Seismic Changes To ACA and Exchanges Proposed
Building on changes in the One Big Beautiful Bill Act (OBBBA) and other regulatory changes in 2025, the Trump administration’s 2027 Affordable Care Act (ACA) and Exchange rule aims to make additional seismic changes in healthcare.
Among the major changes include:
- Eliminating a Biden administration rule that limited insurers to two non-standard plan designs per metal level on the Exchanges.
- Eliminate requirements that plans offer standardized options on the Exchanges, with the option to continue current standardized options.
- Changing the permissible cost-sharing parameters for Bronze plans and to update cost-sharing requirements for catastrophic plans, beginning in PY 2027. These proposals would improve consumers’ access to affordable healthcare coverage and provide consumers the flexibility to tailor their coverage to their needs.
- Allowing insurers to offer catastrophic coverage in one-year terms or in longer terms of up to 10 years.
- Allowing multi-year catastrophic plans to be permitted to utilize value-based insurance designs to cover preventive services over and above those that currently must be covered under certain recommendations and guidelines (before an enrollee satisfies a deductible or hits an out-of-pocket maximum).
- Allowing more people over 30 to choose a catastrophic plan if they want to.
- Expanding affordable options by allowing lower deductibles but higher out-of-pocket maximums.
- Allowing certain innovative, non-network plans to obtain qualified health plan status if they can demonstrate a broad enough slate of provider options.
- Tightening citizenship limits and eligibility verification.
- Proposing stronger eligibility and income checks alongside stronger enforcement policies to protect against improper enrollments and unauthorized plan changes.
- Instituting new legal requirements around eligibility for tax credits and other assistance for immigrants as well as suggesting that states’ improper payments measurement programs evaluate how state-based Exchanges are handling premium tax credit payments.
- Implementing stronger standards for brokers and agents to deter fraud and misleading marketing.
- Outlining prohibited marketing practices, such as offering cash equivalents to prompt enrollment, falsely claiming no premiums and enrollment timelines and deadlines.
- Allowing federally facilitated Exchange states to carry out their own provider access reviews and granting state-based Exchanges more discretion with network adequacy.
- Shifting 2027 HHS risk adjustment models and harnessing improved HHS-RADV error estimation methodology.
- Easing the transition to a state-based Exchange.
- Permitting state-based Exchanges to use a “private sector-based approach” by relying on web brokers to manage consumer-facing websites.
- Preventing adult routine dental work to be considered an essential health benefit.
- Establishing stricter parameters around cost defrayal of state-mandated benefits.
- Maintaining the prohibition on the 150% federal poverty line special enrollment period.
Proponents argue the changes are needed to reduce costs and provide more affordable options. Critics argue the changes will simply erode the Exchanges financial position and increase risk.
Additional articles: https://www.fiercehealthcare.com/regulatory/cms-plans-roll-back-limits-non-standard-aca-plan-options and https://www.beckerspayer.com/payer/aca/cms-proposes-aca-implementation-rule/ and https://www.cms.gov/newsroom/press-releases/cms-proposes-regulations-lower-health-care-costs-expand-consumer-choice-protect-taxpayers and https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-payment-parameters-2027-proposed-rule
#exchanges #healthcare #coverage #trump #cms #regulations
https://www.modernhealthcare.com/politics-regulation/mh-aca-exchange-rule-2027-standardized-coverage
Kaiser Reports Good Financials
Kaiser Permanente reported good financial news for Q4 and 2025. It tripled its operating income although operating expenses surged. It reported operating income of $1.4 billion last year, up from $569 million in 2024. The turnaround is tied to investments in operational improvements. Kaiser Permanente and its subsidiaries wrapped 2025 with a 10.3% bump in operating revenues and more than $9.3 billion of total gains.
Additional article: https://www.healthcaredive.com/news/kaiser-bumped-operating-income-2025-despite-rising-expenses/811674/
#kaiserpermanente #margins
Cigna To Lay Off 2,000
After reasonably good financials for Q4, Cigna plans to cut about 2,000 positions by the end of February. The reductions are about 3% of the healthcare company’s global workforce. Cigna also offered voluntary retirement to an undisclosed number of employees.
Another article examines Molina’s decision to exit mainstream Medicare Advantage (MA) plans and focus just on Special Needs Plans (SNPs). Big plans have announced additional contractions, and smaller plans are more likely to leave the program given struggles. Molina’s non-SNP plans were largely a result of acquisitions that never quite fit into the company’s business plan.
Additional article: https://www.modernhealthcare.com/insurance/mh-cigna-layoffs-february-voluntary-separation/
(Articles may require a subscription.)
#medicareadvantage #cigna #molina #margins
https://www.modernhealthcare.com/insurance/mh-molina-medicare-advantage-medicaid
ACHP Urges Further Risk Adjustment Scrutiny
Alliance of Community Health Plans President and CEO Ceci Connolly says the Trump administration is taking risk adjustment overpayments in Medicare Advantage (MA) seriously and sees important momentum. ACHP has made a strong case that big national plans have aggressively coded and created a disadvantage for smaller, community-based plans. Connolly advocates for a far simpler risk adjustment system focused on demographic data, social risk factors, and high-impact, high-cost diagnoses.
#riskadjustment #medicareadvantage #overpayments
TrumpRx Not Always Cheaper
While the new TrumpRx website does offer cheaper drugs than previous brand drug list prices, two criticisms have emerged. One, brand drugs could still be cheaper via insurance. Two, some brand discounts on certain drugs that have generics can be well more than generic prices. STAT News found that at least 18 brand name drugs on TrumpRx have cheaper generics available via GoodRx or Mark Cuban’s Cost Plus Drugs. In some cases, consumers could save hundreds of dollars by going with the exact same generic medicine.
Overall, it does not take away from Trump’s track record on drug price reform as a whole.
#drugpricing #branddrugmakers #trumprx
https://www.statnews.com/2026/02/06/trumprx-discount-drug-website-undercut-by-cheaper-generics/
Trump Admin Barred From Blue State Cuts
A federal judge has extended a preliminary injunction blocking the Trump administration from slashing funds to social service programs in five Democrat-led states. The states receive more than $10 billion a year from the federal government for its child care and family assistance programs.
#trump #hhs
Oz Says Maine Fraud Rivals Minnesota
Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz says that alleged fraud in Maine’s social services programs may be on par with the welfare fraud scandal in Minnesota.
#hhs #cms #fwa
https://thehill.com/homenews/state-watch/5728249-trump-oz-allege-maine-fraud
— Marc S. Ryan
