In February, the Centers for Medicare & Medicaid Services (CMS) released a proposed regulation outlining a series of changes to the Affordable Care Act (ACA) insurance standards and Marketplace operations. The proposed Notice of Benefit and Payment Parameters (NBPP) for plan year 2027 follows a series of federal-level policy changes in 2025 affecting the ACA Marketplaces, including the expiration of enhanced premium tax credits, newly restrictive eligibility rules, and new paperwork burdens for consumers. Those changes, combined, are expected to reduce Marketplace enrollment by up to 57% and contribute to an average 21.7% individual market premium increase for 2026. This proposed rule would double down on many of the recent policy changes and, by CMS’ own estimates, would reduce Marketplace enrollment by up to 2 million people and federal spending on premium tax credits by $10.4 billion in 2027. For a detailed summary of the proposed rule, see the Health Affairs Forefront articles here, here, and here.
Although CMS provided a short 30-day window for the public to comment on the NBPP, the agency received 2,857 comments. CHIR reviewed a sample of comments from four stakeholder groups to better understand how these organizations view the impact of the proposed policy changes. This third blog in our 4-part series summarizes comments from a sample of consumer and patient advocate organizations. We previously summarized comments from insurers and brokers and from state insurance regulators and Marketplaces. For this post, we reviewed comments submitted by:
American Association of Retired Persons (AARP)
American Cancer Society, Cancer Action Network (ACS-CAN)
Asian & Pacific Islander American Health Forum (APIAHF)
United States of Care (USofCare)
Center on Budget and Policy Priorities (CBPP)
National Health Law Program (NHeLP)
Overarching Comments
Consumer and patient advocates in our sample offered a critical review of the proposed rule. While nearly all organizations supported provisions to strengthen agent and broker accountability and crack down on deceptive marketing, they expressed unified opposition to the rule’s novel policy ideas and rollbacks of current standards. Commenters noted that these proposals are being introduced at a precarious time for the Marketplaces, arriving as the market adjusts to the expiration of enhanced premium tax credits and the impacts of H.R. 1. Advocates also shared concerns about the limited 30-day comment window, arguing it was inadequate to respond to a rule that is estimated to drive millions of people out of the Marketplace.
Rolling Back Simplified Choice
CMS proposes to discontinue the standardized health plans currently available through the federally facilitated Marketplace (FFM) and lift limits on the number of non-standardized plan options an insurer can offer. Every organization in our review strongly opposed these rollbacks, arguing that standardized designs have been highly successful, with enrollment in such plans growing to include one-third of the market just two years after their rollout. AARP noted: “Standardized plans enhance the enrollee’s experience by allowing a clearer comparison of plans among various insurance companies, simplifying the arduous plan selection process.” Consumer groups also cautioned that removing plan limits allows for “silver spamming,” a tactic where insurers flood search results with look-alike plans to crowd out competitors and confuse shoppers, ultimately resulting in “choice overload.”
The Risk of “Non-Network” Health Plans
CMS proposes to enable the certification of “non-network” plans. These products do not maintain a contracted provider network and instead set fixed payment amounts, requiring enrollees to find providers willing to accept that benefit as payment in full or pay the difference between the provider’s billed charge and the plan’s chosen payment level.
Advocates expressed deep alarm over this model, noting that it shifts the burden of price negotiation from the insurer to the patient. Commenters argued that these plans lack basic consumer protections and demand an unrealistic level of “medical and insurance literacy” from consumers. Several groups highlighted the high risk of balance billing, where a provider accepts the plan’s fixed payment but bills the patient for the remaining balance. Furthermore, advocates warned that non-network plans could lead to significant access gaps and continuity-of-care disruptions, as providers may simply refuse to treat enrollees at the set rates. There is also a fear among groups like the National Health Law Program (NHeLP) and Community Catalyst that these plans will bifurcate the market, attracting healthy enrollees with lower premiums while leaving those with chronic conditions in a destabilized and more expensive traditional risk pool.
Concerns Over Higher Financial Burdens and Catastrophic Coverage
The proposed rule includes several provisions that would increase the financial exposure of Marketplace enrollees. CMS proposes allowing catastrophic and bronze-level plans to exceed statutory maximum out-of-pocket (MOOP) limits to maintain required actuarial value levels. Furthermore, the agency seeks to expand eligibility for catastrophic plans and allow them to be marketed as multi-year products.
These proposals were met with collective alarm regarding the potential costs for consumers. Advocates pointed out that, under the proposal, MOOP limits could reach $15,600 for individuals and $31,200 for families in 2027—costs they argue are directly contrary to the statutory requirements of the ACA. Highlighting the high clinical stakes of these costs, ACS-CAN warned that “[a]n astronomical deductible would be a barrier to care for someone with cancer – or for someone who needs to be tested for cancer.” Consumer organizations also pointed out that locking people into long-term catastrophic plans is impractical because individual health needs and financial situations change frequently, making a decade-long insurance commitment risky for the consumer.
Increased Red Tape and Administrative Barriers
To reduce what the agency alleges are improper enrollments, the proposed rule would require the FFM to conduct pre-enrollment verification for at least 75 percent of all individuals seeking to enroll through a Special Enrollment Period (SEP). Advocates in our sample criticized this move toward increased red tape. They argued that these administrative barriers will disproportionately cause healthy, younger people to drop out of the enrollment process, resulting in destabilized risk pools. The National Health Law Program (NHeLP) stressed that “… the burden of imposing pre-enrollment verification requirements on individuals and families seeking Marketplace coverage outweighs HHS’s concern about fraudulent enrollment and program integrity.”
For all Marketplaces, including the state-based Marketplaces (SBM), CMS proposes to require consumers to submit additional paperwork in the event of a data matching issue (DMI). Under this policy, if data sources indicate an applicant has an income above 100 percent of the federal poverty level, or for applicants for whom there is no available tax data, the applicant would be required to submit additional documentation to verify their eligibility. Advocates argued that these expanded DMI requirements create a significant redistribution of burden onto low-income families and those with variable incomes, who may lack the traditional paperwork needed to satisfy these new federal mandates.
The Risks of Privatized Enrollment
In a significant shift toward the privatization of state operations, CMS proposes a SBM-Enhanced Direct Enrollment (SBE-EDE) option, which would allow SBMs to forgo a centralized website and rely exclusively on private web brokers to facilitate eligibility and enrollment. This proposal was met with universal opposition among the advocate organizations in our review. Commenters argued that because private brokers are profit-motivated, there is a significant risk that they will steer shoppers toward non-compliant “junk” plans that may offer higher commissions but fewer consumer protections. These groups also expressed concern that a privatized model lacks the impartial guidance found on government-run platforms. USofCare further argued that “…EDE continues to raise concerns about privacy and security of consumer information, the potential for fraud, and the possibility that EDE could lead to consumers receiving inaccurate or misleading information that might affect eligibility determinations and consumer choice.” Furthermore, advocates noted that this shift could undermine the ACA’s “no wrong door” policy, as private brokers often lack the financial incentive to help low-income individuals enroll in Medicaid or CHIP, potentially leaving eligible families without a clear pathway to coverage.
Oversight of Network Adequacy and Essential Community Provider (ECP) Changes
The 2027 NBPP proposes to change how plan networks are monitored, moving away from federal oversight in favor of state-led reviews. CMS proposes to remove the current requirement that SBMs maintain quantitative network adequacy standards at least as stringent as those used by the federal Marketplace. For plans offered via the FFM, the agency would defer to state programs that demonstrate an “Effective Provider Access Review Program.” Furthermore, CMS proposes to lower the Essential Community Provider (ECP) contracting threshold, including for Federally Qualified Health Centers (FQHCs) and family planning providers, from 35 percent to just 20 percent of available providers.
Advocates expressed deep concern that these relaxed standards will reduce meaningful access in communities where provider availability is already constrained. Families USA and Community Catalyst noted that shifting toward state deference without strong federal backstops creates a “patchwork of protections” that could leave enrollees in some states with inadequate networks. Groups also criticized the removal of documentation requirements for insurers who fail to meet ECP thresholds, arguing that this lack of accountability will further isolate low-income and rural populations from the safety-net providers they rely on for specialized care.
Requiring States to Defray the Cost of Mandated Benefits
CMS proposes that any state-mandated benefit enacted after December 31, 2011, be considered “in addition to [essential health benefits],” (EHB) regardless of whether it was previously embedded in a state’s benchmark plan. Under this proposal, states would be required to pay for the costs of these benefits directly, and related premium increases would be subtracted from the determination of federal premium tax credits.
Several groups, including USofCare and Community Catalyst, argued that this new defrayal framework would financially penalize states for being innovative. USofCare noted that it has “…long recognized the unique role states play in proposing and enacting creative and innovative policies…” and warned that the requirement could force states to roll back important benefit expansions for services like hearing aids or fertility treatments.
Request for Comment on Medical Loss Ratio (MLR) Standards
The rule includes a request for comment on whether the federal government should adjust the ACA’s Medical Loss Ratio (MLR) standards, and if so, the best process for doing so. The agency further asked whether it should be permitted to make adjustments to a state’s MLR in the absence of a state request.
Consumer advocates in our review expressed skepticism regarding this potential shift in authority. Groups like Families USA and the Center on Budget and Policy Priorities (CBPP) cautioned that federal intervention in MLR adjustments could lead to lower standards that prioritize insurer profits over enrollee value. Advocates argued that any adjustment to the MLR threshold reduces the rebates enrollees receive when plans fail to meet spending requirements, and they urged CMS to ensure that any future changes to this framework are governed by objective, data-driven triggers rather than political or industry pressure.
Note on Our Methodology
This blog is intended to provide a summary of comments submitted by consumer and patient advocate organizations. This is not intended to be a comprehensive review of all comments on every provision in the proposed rule, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/document/CMS-2026-0496-0002/comment.