In February, the Trump administration proposed new rules for how Affordable Care Act (ACA) marketplaces will operate in 2027. This annual regulatory proposal, the Notice of Benefit and Payment Parameters (NBPP), arrives in the wake of other federal policy changes affecting the ACA Marketplaces, including the expiration of enhanced premium tax credits (PTCs), more restrictive eligibility for help with ACA premiums, and new enrollment paperwork requirements that will result in fewer eligible individuals purchasing coverage on the Marketplaces. The Centers for Medicare & Medicaid Services (CMS) estimates that the sweeping changes proposed in the 2027 NBPP would cause up to 2 million people to lose Marketplace insurance and reduce federal spending on PTCs by $10.4 billion in 2027. Detailed summaries of the proposed rule, which the Administration will finalize sometimes this spring, are available here, here, and here.
The CHIR team has reviewed a sample of comments submitted by certain stakeholder groups in response to the proposed NBPP. The first blog in this four-part series looked at comments from insurers and brokers; subsequent blogs examined comments from state agencies, including departments of insurance and state-based marketplaces, and consumer and patient advocates. This final installment analyzes comments submitted by health care providers, including hospital associations, physician organizations, and safety-net providers. Specifically, we reviewed comments from:
America’s Essential Hospitals (AEH)
American Academy of Family Physicians (AAFP)
American College of Obstetricians and Gynecologists (ACOG)
American Hospital Association (AHA)
American Medical Association (AMA)
Federation of American Hospitals (FAH)
National Association of Community Health Centers (NACHC)
The provider organizations in our sample shared significant concerns with the proposed rule. Most of their comments focused on changes to QHP requirements that would make it more difficult for consumers to identify, afford, and enroll in health plans that meet their needs. In some cases, these proposed changes—such as changes to network adequacy requirements and the inclusion of state-mandated benefits in EHB—could also undermine current provider protections and interests. An overview of the provider groups’ comments follows.
Changes to Plan Requirements
The proposed rule includes a number of changes to requirements for Marketplace-participating health plans. Generally speaking, these changes would reverse Biden-era regulations designed to protect consumers by ensuring qualified health plans (QHPs) offer an adequate provider network and provide consumers with meaningful and easy-to-understand differences between their Marketplace plan choices. The proposed rule would also enable insurers to offer additional plans that place greater financial risk on enrollees.
Network Adequacy and Essential Community Providers
All of the provider groups in our sample offered comments on CMS’s proposed changes to network adequacy requirements for qualified health plans (QHPs). These proposals include eliminating the current requirement that state-based Marketplaces (SBMs) and SBMs that use the federal platform (SBM-FP) apply quantitative time and distance requirements that are at least as rigorous as the standards used by the federally facilitated Marketplace (FFM), and allowing FFM states that meet certain criteria to do their own network adequacy assessments. A closely related proposal would reduce the threshold percentage of essential community providers (ECPs) that QHPs must include in their networks from 35 percent to 20 percent.
In general, the provider groups in our sample were highly critical of these proposals. The AAFP, for example, noted patients may still face “long travel distances, closed panels, ghost networks, and delays that disrupt continuity of care” with networks that originally “appear” adequate based on simple provider counts. The FAH pointed out that other proposals within the NBPP, such as the creation of non-network plans and plan designs that would increase consumers’ out-of-pocket costs, make it particularly important that consumers have the “assurance and consistency [they] need to evaluate new plans with increasingly complex benefit designs and cost-sharing structures,” including the same minimum standards of network adequacy that currently apply to Medicare Advantage and Medicaid plans. Other groups, such as NACHC, also focused on changes to the proportion of ECPs plans must include in their networks, arguing that the proposal, which reverses a Biden Administration rule that increased the ECP threshold, is “premature” given that CMS, states, and stakeholders have not assessed how the current 35 percent threshold affects access, plan participation, and enrollee outcomes, particularly for the low-income and medically underserved individuals community health centers (CHCs) serve.
Non-Network Plans
Many of the provider groups in our sample weighed in on CMS’s proposal to enable plans that do not have a provider network to offer coverage on ACA Marketplaces. Under this proposal, non-network plans would attest that they have a sufficient number of providers, including ECPs, willing to accept their proposed payment rates as payment-in-full. Hospital groups such as the AHA were “deeply concerned” about this approach, noting that “attestations alone are not enough” and offered alternative regulatory frameworks should CMS decide to move forward with the creation of non-network plans. The FAH opined that non-network plans would leave patients without the financial security offered by conventional health plans, providing merely “illusory benefits” if few providers furnish services at the stated benefit amount. Health care professionals also voiced profound skepticism about this proposal, with the AMA and the AAFP observing that non-network plans would shift administrative burdens and financial uncertainty from health plans to patients and physicians.
Changes to Standardized Plan Requirements
The proposed rule would no longer require insurers in the FFM and in SBM-FPs to offer standardized health plans, and it would no longer provide preferential display on HealthCare.gov for any standardized plans insurers choose to offer. CMS also proposes removing current rules that limit insurers to offering no more than two non-standardized plans per product type at each metal level. The majority of the provider groups in our sample commented on this proposal, with most groups urging CMS to drop these proposals altogether. Providers who opposed changes to standardized plan requirements uniformly noted how rules requiring standardized plan designs, meaningful differences between plan offerings, and limits on the overall number of plan variations help consumers choose appropriate coverage. The AMA, which also expressed concern about the proposed rule’s changes to standardized plan requirements, offered compromise positions—such as requiring plans to offer a single standardized plan in only the bronze and silver coverage tiers and raising, but not eliminating, the limit on the number of non-standardized plans an issuer could offer.
Catastrophic Plans and Higher Maximum Out-of-Pocket Limits
The proposed rule would enable insurers to sell more catastrophic plans by expanding the types of people eligible for these very high-deductible plans, permitting insurers to design and market catastrophic plans as multi-year products, and allowing catastrophic and bronze-level plan designs—which also have significant deductibles—to exceed the annual maximum out-of-pocket (MOOP) cost-sharing liability enshrined in the ACA statute. CMS also asks for comment on whether catastrophic plans should continue to be rated in a separate risk pool from the metal-level plans. All of the provider groups in our sample commented on at least some aspects of these proposals.
Several provider groups, including NACHC, FAH, ACOG, and AHA, opposed policy changes to create greater availability of catastrophic plans and to loosen other requirements that could affect consumers’ access to affordable care. These groups urged CMS not to finalize these proposals. The provider groups expressed grave concerns about consumers’ financial exposure and potential underinsurance in catastrophic plans, which would only become more severe should CMS finalize the proposal to increase MOOP. The AHA, for example, observed that “the deductible amount itself could easily be considered catastrophic for many individuals” who may be tempted to enroll in catastrophic plans.
Other provider groups, however, offered different perspectives. The AAFP shared many of their peer organizations’ concerns about catastrophic plans, but noted that CMS has advanced these proposals in an affordability environment that is markedly changed by the expiration of enhanced PTCs at the end of 2025. Millions of consumers are therefore newly exposed to the full premium or significantly higher net premiums for Marketplace coverage and risk going without coverage. The AAFP therefore offered a series of recommendations for implementing enhanced access to lower-premium catastrophic plans, focusing on consumer support and information related to enrollment choices and consumer protections for catastrophic plan enrollees, such as prohibitions against the averaging of MOOP and deductibles across multi-year catastrophic plans. The AAFP also endorsed CMS’s proposal to allow insurers to use value-based insurance design to cover additional pre-deductible preventive services in multi-year catastrophic plans.
Finally, the EAH, noting that “any health coverage is better than none,” endorsed CMS’s catastrophic plan proposals and requested that CMS expand hardship exemption eligibility for catastrophic plans for individuals over age 30 who experience a change in income.
Proposals to Reduce Eligibility and Enrollment
In alignment with 2025 federal policy changes in the Marketplace Integrity Regulation and the One Big, Beautiful Bill Act, the NBPP includes several proposals that would reduce Marketplace enrollment, such as by creating new paperwork burdens for potential Marketplace enrollees, and excluding individuals who fail to reconcile their PTC amounts through their federal tax filing.
Paperwork Burdens
CMS proposes requiring Marketplace applicants to both the FFM and SBMs to provide additional proof of income if external data sources suggest they have an income below 100% of the federal poverty level (FPL) or if tax data is unavailable for the applicant—an additional verification requirement that could discourage applicants from completing enrollment. CMS also proposes expanding pre-enrollment verification to at least 75 percent of all applicants seeking a Special Enrollment Period (SEPs) for FFM states. Both NACHC and AAFP express concern that these provisions are likely to result in consumers who are eligible for PTCs going without health insurance because they cannot navigate paperwork requirements and procedural barriers. For example, NACHC notes that tax data may be unavailable for perfectly legitimate reasons—such as income that falls below the standard deduction for the taxpayer’s filing status—common to many enrollees served by CHCs. AAFP urges CMS to use administrative discretion to avoid coverage gaps while eligibility is under review, such as providing provisional coverage during this time or creating an SEP for individuals whose enrollment is delayed by HHS verification processes.
Failure to Reconcile
The NBPP will also require Marketplaces to implement a one-year failure-to-reconcile policy in 2027, while delaying implementation to 2028 for SBMs that do not have the capacity to move to a one-year policy in time for the 2027 plan year. Currently, individuals lose their PTC eligibility if they fail to file a federal income tax return and reconcile their advance PTCs to their income for two consecutive years. ACOG, NACHC, AMA, and AAFP register their objections to this policy change, with ACOG noting that implementing a one-year policy reconciliation policy for the 2027 plan year does not provide consumers with enough time to reconcile their advance PTCs before losing eligibility. The AMA notes that low-income consumers who are not otherwise required to file taxes may not be aware that they need to reconcile their PTCs or risk losing coverage, and suggests that CMS provide a multi-faceted educational campaign to inform affected consumers and choose not to finalize the shorter reconciliation window requirement a year earlier than required by statute.
State Mandated Benefits
CMS proposes that states be required to defray the cost of any state-mandated benefits that are: (1) required by the state after December 31, 2011; (2) applicable to the small-group and/or individual market; (3) specific to required care, treatment, or services; and (4) not required by the state to comply with federal standards.
Approximately half of the provider groups in our sample offered comments on this proposal. The AAFP argues that CMS lacks the statutory authority to make this change, citing language at section 1311(d)(3)(B) of the ACA, which authorizes defrayal only for benefits that are “truly additional to EHB.” AAFP notes that, following a long-established process, CMS has approved benchmark updates for opioid use disorder treatment, diabetes, and weight-loss management treatment for obesity and points out that reclassifying such services already embedded in EHB would shift significant costs to the states. The AMA observes that this policy will hurt consumers, while NACHC argues that many of the benefits targeted by this proposal support chronic disease management, behavioral health treatment, and other outpatient services their patients rely on.
Note on Our MethodologyThis blog is intended to provide a summary of comments submitted by health care provider 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.