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Á¿×Ó×ÊÔ´Íø Insights—including briefs, webinars, and our podcast—gives you easy access to Á¿×Ó×ÊÔ´Íøâ€™s deep expertise, helping you stay current on the latest healthcare trends and topics. Search for a topic of interest or browse the latest insights below.

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What Medicaid Policy Changes Should Healthcare Leaders Be PayingÌýAttention toÌýRight Now?Ìý

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What Medicaid Policy Changes Should Healthcare Leaders Be PayingÌýAttention toÌýRight Now?Ìý

Medicaid policy is undergoing a massive regulatory shift driven by theÌýOne Big Beautiful Bill Act (OBBBA)Ìý±ô±ð²µ¾±²õ±ô²¹³Ù¾±´Ç²Ô.Ìý

ToÌýmaintainÌýfinancial stability, compliance, and continuity of care during these Medicaid policy changes, healthcare leaders must focus their attention on fourÌýhighly critical, interconnected policy domains.Ìý

Changes toÌýSection 1115 Demonstration Waivers

The federal approach to approving, extending, and evaluating Section 1115 waivers is experiencing a significant pivot, holding space for true innovation and pilots.

Shifting Federal Alignments:ÌýCMS is reshaping the criteria for waiverÌýflexibilities. For instance, recent guidance has rolled back certainÌýpreviousÌýpathways used to cover health-related social needs (HRSNs) under Section 1115 authority.Ìý

Strategic Scenario Planning:ÌýAs outlined in Á¿×Ó×ÊÔ´Íø’s analysis onÌýThe Medicaid Pivot: New Developments in Section 1115 Demonstration Policy, state changes or extensions will trigger comprehensive CMS reviews. Leaders must transition toward alternative authorities (such as 1915(c) or managed care options) whileÌýmonitoringÌýemerging federal priorities around substance use disorders (SUD) and carceral reentry initiatives

UpdatedÌýEligibility & Community Engagement/Work Requirements

TheÌýeligibilityÌýpathÌýforÌýMedicaidÌýenrollees is tightening dramatically, introducingÌýsignificantÌýrisks of coverage disruptionÌýthatÌýwill create coverageÌýchurn inÌýstate insurance markets.Ìý

Mandatory Community Engagement:ÌýUnder federal mandates, able-bodied adults without young children mustÌýdemonstrateÌýat leastÌý80 hoursÌýper monthÌýof qualifying activities (employment, education, or community service).Ìý

Accelerated Churn Risks:ÌýAs evaluated in Á¿×Ó×ÊÔ´Íø’s report on theÌýMedicaid Community Engagement Interim Final Rule, states are shifting to an accelerated six-month redetermination cycle for expansion populations. Managed care organizations (MCOs) and health systems face immediate operational hurdles to track compliance and prevent massive lapses in continuous enrollment.Ìý

Focus onÌýManaged Care Oversight & Program IntegrityÌýto ReduceÌýFraud, Waste,Ìý& Abuse

Federal regulators are pairing stricter oversight with direct financial consequences toÌýreduceÌýadministrative inefficiencies and improper paymentsÌýandÌýcrack down onÌýfraud and abuse.Ìý

Error Rate Financial Sanctions:ÌýBeginning in FY 2030, states exceedingÌýaÌý3% eligibility error rateÌýface severe pullbacksÌýin federal funding for files lacking insufficient verification data.Ìý

Aggressive Auditing and MCO Risk:ÌýEnhanced program integrity frameworks require monthly network audits to root outÌýterminatedÌýproviders and quarterly data matching for deceased enrollees. Healthcare leaders mustÌýbrace forÌýtighter risk adjustments, standardized plan requirements, and intensive fraud, waste, and abuse (FWA) strategies.

Changes toÌýState Directed Payments (SDPs) &ÌýReimbursementÌý

CMS is fundamentally altering provider reimbursement limits and closing localized financing mechanisms to ensure a more regulated environment.Ìý

Medicare-Linked Caps:ÌýMoving away from average commercial rate benchmarks, CMS isÌýestablishingÌýrigid ceilings. As captured in Á¿×Ó×ÊÔ´Íø’s brief onÌýProposed Changes to Medicaid State Directed Payments, new limits cap SDPs atÌý100% of Medicare ratesÌýfor expansion states andÌý110% of Medicare ratesÌýfor non-expansion states.Ìý

Choking Provider Tax Revenue:ÌýEffective October 2026, states are restricted from implementing new provider taxes beyond July 2025 thresholds. Furthermore, as detailed in Á¿×Ó×ÊÔ´Íø’s commentary onÌýMedicaid State Directed Payments: CMS Proposes Major Changes to Financing and Oversight, existing provider taxes in expansion states will steadily choke down from 6% toÌý5.5% in 2028, andÌýultimately downÌýtoÌý3.5% by 2032, forcing health systems to rapidly recalibrate their financial baselines.Ìý

How Á¿×Ó×ÊÔ´Íø Helps Leaders RespondÌý

Á¿×Ó×ÊÔ´Íø (Á¿×Ó×ÊÔ´Íø) turns high-stakes statutory mandates into functional, compliant operational strategies. We offer end-to-end strategic guidance, actuarial analytics, and technicalÌýassistance:

  • Strategic Planning & Financing Modeling: Developing innovative strategies to model state-directed payment caps, analyze provider tax restrictions, and structure financial baseline adjustments.
  • Operational & Workflow Overhauls:ÌýRedesigning eligibility systems to execute 6-month redeterminations and building automated tracking platforms for community engagement.Ìý
  • Program Integrity & Compliance:ÌýAligning FWA shielding strategies and conducting pre-audit assessments to mitigate the risk of eligibility error-rate penalties.Ìý
  • Workforce & Stakeholder Alignment:ÌýDelivering targeted training and managing cross-functional change management to ensure seamless communication between state agencies, MCOs, and providers.Ìý

With a deep bench that includesÌý10Ìýformer Medicaid and CHIP directorsÌýand active project experience acrossÌýmore than 35 state programs, Á¿×Ó×ÊÔ´Íø equips healthcare leaders to navigate this shifting regulatory landscape with absolute confidence.Ìý

Final 2027 Notice of Benefit and Payment Parameters Notice: What States and Issuers Need to Know

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What are the changes in the payment notice for 2027? On May 15, 2026, the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) released the final Notice of Benefit and Payment Parameters (NBPP) for 2027, setting key rules for the individual and small group health insurance markets. This report explains the most important 2027 Payment Notice changes for health care payers, issuers, state regulators, and state-based exchanges—including what CMS finalized, what changed from the proposed rule, what takes effect in 2026, 2027, and 2028, and what the rule signals for future marketplace policy. Topics include ACA marketplace operations, eligibility and enrollment, marketing oversight, plan design flexibility, cost-sharing, Essential Health Benefits, QHP certification, and state authority. According to HHS, the final rule could reduce marketplace enrollment by 1.2 million to 2.0 million people, making it essential for decision makers to understand the operational, financial, and compliance implications now.

Need to understand how the final 2027 NBPP affects your organization? Connect with the report authors to discuss implications for pricing, product strategy, exchange operations, compliance, and state marketplace oversight. Whether you are evaluating operational changes, preparing for upcoming requirements, or assessing market impact, our experts can help you turn the final payment notice into a clear action plan. .

Medicaid Community Engagement Interim Final Rule:ÌýKey Implications for States, Payers, and Providers

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Á¿×Ó×ÊÔ´Íøâ€™s issue brief on the Medicaid Community Engagement Interim Final Rule provides a clear, actionable summary of new Medicaid work requirements and community engagement requirements for states, Medicaid health plans, providers, community-based organizations, and technology vendors. The report explains key policy changes issued by CMS on June 1, 2026, including exemptions such as medical frailty, verification and reporting expectations, enrollee notification requirements, and the state systems changes needed to prepare for the January 1, 2027 implementation deadline. If you are searching for a summary of Medicaid work requirements, a summary of Medicaid community engagement requirements, the medical frailty definition, or guidance on Medicaid work requirements state systems changes, this brief helps translate complex federal regulation into practical next steps to support compliance, reduce coverage loss risk, and inform implementation strategy.

Please fill out this form to receive a copy of the issue brief.

Medicaid State Directed Payments: CMS Proposes Major Changes to Financing and Oversight

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The Centers for Medicare & Medicaid Services (CMS) proposed changes to state directed payments mark a significant inflection point for Medicaid financing. For states, plans, and providers, the coming months will be critical in understanding the rule’s final shape—and how they can position themselves for a more constrained and standardized payment environment.

Federal Medicaid policy is entering a period of rapid change. Policymakers are advancing a series of interconnected proposals—including Medicaid community engagement (work) requirements, program integrity initiatives, and new scrutiny of financing mechanisms that shape how dollars flow through the program. 

Among the most significant developments: the CMS’s proposed changes to Medicaid state directed payments (SDPs). As outlined in Á¿×Ó×ÊÔ´Íøâ€™s recent Issue Brief, the proposal signals a meaningful shift in how federal policymakers approach provider reimbursement, managed care financing, and oversight of supplemental payment arrangements. 

Á¿×Ó×ÊÔ´Íø (Á¿×Ó×ÊÔ´Íø) will further examine these developments in future articles, briefs, and its Medicaid summer webinar series, which will focus on SDPs, work requirements, and program integrity—three policy areas now moving in parallel and reshaping the Medicaid landscape. This article provides an executive overview of the SDP rule

What are Medicaid State Directed Payments? 

State directed payments (SDPs) are a key Medicaid financing tool that allows states to direct how managed care organizations reimburse providers. 

States use SDPs to: 

  • Increase provider payment levelsÌý
  • Target specific provider types or servicesÌý
  • Support delivery system reformsÌý

Over time, SDPs have become a central component of Medicaid managed care financing. As the Á¿×Ó×ÊÔ´Íø issue brief emphasizes, their growing scale and complexity have drawn increased federal scrutiny. 

What Does CMS Propose to Change? 

The CMS proposed rule implements the statutory changes approved in the 2025 budget reconciliation act (P.L. 119-21, which CMS refers to as the Working Families Tax Cut Act, or WFTCA). The rule introduces a new framework for how SDPs are structured, regulated, and reviewed. Based on Á¿×Ó×ÊÔ´Íøâ€™s analysis, the proposal advances several core policy shifts: 

  1. ExpandedÌýFederal Limits on Payment Levels.ÌýCMS proposes new constraints on how much states can direct plans to pay providers, extending payment limits across a broader range of services and delivery systems. Specifically, CMS proposes to lower the payment ceiling for all SDPs to either 100 percent of Medicare for states administering Affordable Care Act (ACA) expansion programs or 110 percent of Medicare for states without an ACA expansion program. CMS plans to grandfather certain SDPs at levels above Medicare and provide a transition period with an annual 10 percent reduction until the payments are reduced to Medicare levels. In addition, this rule proposesÌýlimiting SDPs to the total published Medicare payment rate at the service level—a departure even from Medicaid fee-for-service (FFS) upper payment limits, which are limited to a reasonable estimate of what Medicare would pay but are calculated at the aggregate level by ownership class.Ìý
  2. Extends LimitsÌýAcross ProgramsÌýand Delivery Systems.ÌýThe proposalÌýseeksÌýto alignÌýthe limitations on practitioner payments underÌýfee-for-serviceÌýwith the new limitations on SDPs. If a state makes payments to a subset of targeted practitioners, the new proposed limit would be actual Medicare payment rates applicable to the practitioner or provider for the sameÌýtime periodÌýas the Medicaid state plan rate year.ÌýThe crosswalk of Medicaid payment rates to Medicare willÌýlikely beÌýadministratively burdensome—especially for states that set Medicaid rates using an entirely differentÌýmethodologyÌýthan Medicare’s. Applying the Medicare payment limit at the service level will limit states’ ability to incentivize certain service types that may need enhanced reimbursement amounts to preserve access to care (e.g., primary care, neonatal, etc.).Ìý
  3. Broader Applicability Across Providers.ÌýThe changes extend beyond a narrow set of provider types, affecting a wider range of stakeholdersÌýparticipatingÌýin Medicaid financing and delivery.ÌýFor example, the WFTCAÌýcalled for the reduced payment ceiling to be applied to the specified four classes of providers. This rule proposes that all providers be limited to the same ceiling and that the revised limits also apply to US territories.Ìý

Why Is CMS Focusing on State Directed Payments Now? 

As highlighted in the Á¿×Ó×ÊÔ´Íø Issue Brief, federal policymakers are increasingly focused on the growth and complexity of SDPs as well as the role of SDPs in broader Medicaid financing strategies. In addition, CMS policy officials are prioritizing program integrity and fraud, waste, and abuse and have couched the current SDP policies as inefficient use of taxpayer dollars. 

These priorities align with a broader shift toward tighter federal oversight of Medicaid funding mechanisms. 

What Are the Implications for States, Plans, and Providers? 

The proposed changes have wide-ranging implications across the Medicaid ecosystem. 

States: SDPs have been a flexible tool for shaping payment policy and directing resources. New federal parameters may limit that flexibility and require states to reassess existing financing strategies. 

Health Plans: Plans may face a more standardized and regulated environment for implementing SDP arrangements, with less variation driven by state policy choices. 

Providers: Many providers rely on SDPs to supplement base Medicaid payment rates. Changes to these payments could affect reimbursement levels and financial stability, particularly for organizations serving large Medicaid populations. 

As the Á¿×Ó×ÊÔ´Íø brief underscores, the impact will vary significantly by state, depending on how SDPs are currently structured. 

How This Fits into Broader Medicaid Policy Changes 

CMS is advancing a broader recalibration of how SDPs fit within Medicaid policy. However, the SDP proposal is also part of a larger set of federal Medicaid policy developments, including: 

  • Medicaid community engagement (work) requirementsÌýand other changes to eligibility and redetermination rulesÌýincluded inÌýa June 1, 2026,Ìýinterim final ruleÌý
  • Program integrity and oversight initiativesÌý
  • Changes to financing structures and supplemental paymentsÌý

Taken together, these policies signal a transition toward greater federal standardization and increased oversight of funding flows. 

What Should Stakeholders Watch Next? 

CMS’s proposed changes to Medicaid state directed payments mark a turning point in Medicaid financing policy. 

Stakeholders should expect continued movement toward greater oversight, tighter payment parameters, and increased consistency across the program. They should begin planning now for a more constrained and standardized payment environment. Key questions center on: 

  • How CMS will implement and phase in payment limits across statesÌý
  • The extent to which existing arrangements will be grandfatheredÌýinÌýor phased downÌý
  • How states respond in redesigning Medicaid payment strategiesÌý

The proposed SDP rule is open for public comment through July 21, 2026, with final policy decisions expected following federal review. As pending issues are resolved, stakeholders across the Medicaid landscape will need to reassess financial models, policy approaches, and operational strategies. 

Stakeholders should begin evaluating potential impacts now, as the policy direction is clear, even if final details are still evolving. 

Staying Ahead of Medicaid Financing Changes 

Given the pace and breadth of these developments, staying informed is critical. Á¿×Ó×ÊÔ´Íøâ€™s upcoming Medicaid summer webinar series will provide timely analysis of the SDP proposal alongside related policy changes, including community engagement and work requirements and program integrity initiatives. These sessions are designed to help states, plans, and providers understand policy changes and prepare for operational and financial implications, identify compliance gaps, and address sustainability issues. Register for one or multiple webinars here.  

To understand how these Medicaid policy changes affect your organization, contact one of Á¿×Ó×ÊÔ´Íøâ€™s Medicaid experts

Ground Ambulance Payment Landscape: Challenges and Policy Options

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Ground ambulance transport is a critical piece of the US healthcare infrastructure and is currently facing several challenges, which may result in the loss of patient access to care. These life-saving services play a vital role in the patient care continuum and significantly impact acute care and long-term recovery. Often, at critical and tense moments before the patient is able to reach hospital care, ground ambulance paramedics and emergency medical technicians (EMTs) are the first point of healthcare contact for the patient. These medical professionals stabilize and treat patients to ensure they begin their care pathway smoothly and recover rapidly.

To address the challenges that the ground ambulance industry is experiencing today and lessen the impact of the various emerging issues, this report offers several recommendations for policymakers and stakeholders to consider.

A Summer Webinar Series: How New Program Integrity Expectations Affect Medicaid Payments

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As federal regulators introduce new Medicaid program integrity expectations to reshape the landscape, states, providers, and insurers across the country are facing intense pressure to adapt to changing eligibility and enrollment rules and financing policies while sustaining access to services and improving outcomes.

This webinar series will deliver timely analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.

Webinar Replay – Summer Webinar Series: The Future of Medicaid State Directed PaymentsÌý

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This webinar was held on June 10, 2026.

As federal regulators seek to reshape the Medicaid landscape, states, providers, and insurers across the country are facing intense pressure to adapt to changing eligibility and enrollment rules and financing policies while sustaining access to services and improving outcomes.

This webinar series deliver timely analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.

A Summer Webinar Series: Understanding Work and Community Engagement RequirementsÌý

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As federal regulators seek to reshape the Medicaid landscape, understanding work and community engagement requirements has become crucial. States, providers, and insurers across the country are facing intense pressure to adapt to changing eligibility and enrollment rules and financing policies while sustaining access to services and improving outcomes.

This webinar series will deliver timely analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.

Proposed Changes to Medicaid State Directed Payments and Targeted Practitioner Payments

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On May 20, 2026, the Centers for Medicare & Medicaid Services (CMS) released the Medicaid Managed Care State Directed Payments and Medicaid Fee-For-Service Targeted Medicaid Practitioner Payments Proposed Rule.

This proposed regulation outlines critical updates to Medicaid provider reimbursement, directly addressing federal mandates from the One Big Beautiful Bill Act (the Working Families Tax Cut legislation enacted on July 4, 2025). Notably, the rule extends payment limitations to additional healthcare providers operating under both Medicaid managed care models and fee-for-service (FFS) delivery systems.

To help healthcare organizations, state agencies, and health plans navigate these complex regulatory shifts, Á¿×Ó×ÊÔ´Íø (Á¿×Ó×ÊÔ´Íø) experts have developed a comprehensive compliance and impact overview.

The proposed changes to Medicaid state directed payments are highly complex. The Á¿×Ó×ÊÔ´Íø consulting team is actively analyzing the regulatory text and stands ready to assist organizations with impact evaluations, policy interpretation, and strategic response planning.


Don’t Miss Our Upcoming Webinar: The Future of Medicaid State Directed Payments
Wednesday, June 10, 2026 | 12:00 PM ET

As federal regulators move to reshape the Medicaid landscape, states, providers, and insurers face intense pressure to adapt. Join Á¿×Ó×ÊÔ´Íø subject matter experts as they deliver timely, up-to-the-moment analysis on federal guidance, waiver activity, and litigation shaping the operational environment.

👉 Register for the webinar to secure your spot and gain actionable insights for your organization.

Connecting the Dots: Key Trends, Plan Shifts, and 2027 NBPP Changes Affecting ACA Marketplace Enrollment

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Explore how 2026 ACA Marketplace enrollment shifts, plan selection trends, and the 2027 NBPP changes are impacting affordability, market stability, and state strategies. 

Recent Á¿×Ó×ÊÔ´Íø (Á¿×Ó×ÊÔ´Íø) webinars and reports discussed that Affordable Care Act (ACA) Marketplace enrollment trends are evolving rapidly and the takeaways go beyond total enrollment numbers. In addition in May, the Centers for Medicare and Medicaid Services (CMS) finalized the 2027 Notice of Benefit and Payment Parameters (NBPP), introducing new flexibility for plans and states alongside stronger program integrity requirements. 

To understand how these changes are reshaping the ACA Marketplace,  Andrea Maresca spoke with Zach Sherman, Managing Director for Coverage Policy and Program Design at Á¿×Ó×ÊÔ´Íø as well as , PhD, Principal at Wakely, and , Principal at Leavitt Partners, both Á¿×Ó×ÊÔ´Íø companies.

Q: The recent Wakely analysis has been central to understanding what’s happening with ACA enrollment. What should people be paying closest attention to? 

Michael Cohen: The key takeaway is that ACA Marketplace trends are about much more than the enrollment numbers. The plans consumers choose, how long they maintain coverage over the course of 2026, and the evolving picture of the morbidity and demographics of the enrolled population are all critical factors for understanding the ACA Marketplace.

°¿³Ü°ùÌý°ù±ð³¦±ð²Ô³ÙÌýÌýfound thatÌýonly about 86 percent of enrollees paid their firstpremiumÌýinÌý2026.ÌýThat’sÌýa strong indicator that affordability pressures are already affecting coverageÌýstability.ÌýÌý

Q: Where are these enrollment changes showing up most clearly?  

Michael Cohen: One data point that stood out is the number of new consumers in 2026, which was down 13 percent compared with prior years.  

The impact also shows up in coverage losses and consumer plan selection. Some consumers are dropping coverage altogether, while others are making tradeoffs to stay covered. These consumers are moving to lower-premium products—particularly from silver to bronze plans—which offer less robust coverage and higher out-of-pocket costs. Both trends matter, especially when thinking about access and financial risk. 

Q: How are enrollment shifts affecting broader ACA Marketplace stability? 

Zach Sherman: It varies by state, but there are notable trends. States that are using the Federally Facilitated Exchange (FFE) and expanded Medicaid saw the largest enrollment declines.  

Notably, non-expansion states on the FFE significantly outperformed expansion states. This was surprising because, with enhanced subsidies ending, the biggest net premium hit consumers would feel is at the lowest income levels, yet that’s where we saw most enrollment growth. 

Across the individual states, the enrollment shifts have real implications for stability. When healthier individuals leave the market—or shift to less comprehensive coverage—it can put pressure on premiums and risk pools. Issuers are taking this information to begin to make estimates for their 2027 pricing and what this means for their 2026 performance.  

At the same time, CMS is introducing new flexibilities in the final 2027 Notice of Benefit and Payment Parameters. 

Q: What are the most important changes in the 2027 final rule? 

Zach Sherman: Broadly, the rule makes a clear push toward increased flexibility for consumers, plans, and state regulators. 

One of the categories of changes is around expanded availability of lower premium plans with higher out-of-pocket costs. For example, catastrophic plans can now be offered for up to 10 years. 

CMS also removed certain requirements for standardized plans and relaxed limits on non-standard plan offerings. That gives issuers more room for plan design innovation, but it also means a more complex landscape and plan selection experience for consumers. 

One of the most notable changes is the introduction of non-network plans as qualified health plans. These plans don’t rely on traditional provider networks, which could lower costs while introducing new considerations for access and consumer experience.  

We’re seeing a shift toward allowing more tailored options and potentially less standardized marketplace programs. It will require a different approach from regulators, and it creates a different type of experience for consumers.  

Q: CMS is intensely focused on addressing fraud, waste and abuse. How is that playing out in the Marketplace program? 

Zach Sherman: Program integrity is a central theme in the 2027 final rule, too. It includes stronger eligibility verification, increased oversight of brokers and marketing practices, and new safeguards to reduce improper enrollments. So while there’s more flexibility in plan design, CMS is pairing it with more scrutiny on how the system operates. 

Q: Where do states fit in all of this? 

Zach Sherman: The final rule gives states more authority in key areas, including oversight of plan network adequacy and essential community provider compliance. We’re deep into discussions with states and health plan issuers about the changes they’re interested in exploring for their state. States will have to decide how to use that flexibility to balance affordability, access, and stability. 

Although many of the provisions take effect in the 2027 plan year, regulators and plans are receiving this information fairly late in the cycle which will make it difficult to incorporate some of the flexibilities. We’re anticipating robust discussions to continue next year and expect to see more variation starting in plan year 2028. 

Differences and Alignment in Federal ACA Marketplace Policy Discussions  

Q: Stepping back from the 2027 NBPP, what should interest-holders know about the evolution of the broader policy landscape? 

Liz Wroe: Members of Congress will need to see the 2027 rates being filed before they consider taking action. Even then, there’s no consensus on several key issues that prevented a bipartisan deal to bring back enhanced subsidies in 2025. 

Instead everyone has transitioned to a larger affordability conversation, and we’ll spend this year working on the policies with a goal of moving forward in 2027.  

There are different approaches to affordability and coverage that are driven by fundamentally different philosophies on how to structure the market. Some proposals focus on expanding subsidies, reducing cost sharing, and strengthening ACA protections. Others emphasize consumer-directed models like defined contributions, health savings accounts, and expanded use of ICHRAs [Individual Coverage Health Reimbursement Accounts] as well as broader access to lower premium plans. 

There are also several areas of bipartisan alignment. Prior authorization reform is a big one. There’s broad agreement that the current system creates administrative burden and delays in care. 

We’re also seeing common interest in policy approaches to strengthen medical loss ratio [MLR] requirements, expand price transparency, and address provider consolidation. 

Even if there is divided government after the November elections, these are areas where policy action may be more likely. States, health plans, providers, and other interest holders will want to monitor these issues now for signals of what may move forward later this year or in the next Congress. 

Stakeholder Opportunities to Inform Marketplace Programs 

Q: What should stakeholders be focused on right now? 

Michael Cohen: For issuers, it’s about understanding how these changes affect pricing, enrollment, and risk. There’s more uncertainty in how plans should be priced. 

Zach Sherman: For states, the focus should be on strategy. The choices they make now on plan oversight, market structure, and consumer protections will shape outcomes for several years. Additionally, there were several proposed Marketplace policies that CMS did not finalize in the 2027 rule—State-Based Exchange Enhanced Direct Enrollment Model—that CMS is likely to revisit in future rules, including the 2028 NBPP.   

Liz Wroe: Broadly, stakeholders should recognize that we’re in a transition period. The market is evolving, and policy is still catching up. 

Connecting the Dots: Enrollment, Rules, Regulators, and the ACA Marketplace 

For stakeholders across the healthcare landscape, navigating this environment requires both technical expertise and strategic insight. 

Á¿×Ó×ÊÔ´Íø works across policy, actuarial, and operational domains to help states, health plans, and other stakeholders translate these developments into actionable strategies—whether that means evaluating market risk, designing programs, or preparing for future policy scenarios. 

To explore these issues in more detail, access Á¿×Ó×ÊÔ´Íøâ€™s webinar discussions and briefs, including: 

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