The Affordable Care Act (ACA) Marketplaces enable individuals and families who do not have access to employer-sponsored coverage or public health insurance programs to purchase guaranteed, comprehensive health coverage. Marketplace plans currently provide financial protection and facilitate access to critical health services for 24.3 million enrollees. In March, the Centers for Medicare & Medicaid Services (CMS) released proposed revisions to federal Marketplace standards and insurance rules. These proposals, which CMS estimates would result in 750,000 to 2 million people losing health coverage, would restrict Marketplace eligibility and enrollment processes and change some of the health benefits Marketplace plans must offer.
The CHIR team has reviewed a sample of comments submitted by select stakeholder groups in response to the proposed rule. The first blog in this four-part series focused on comments submitted by health plans and heath insurance brokers. In this second blog, we discuss comments from health care providers. Specifically, we reviewed comments from:
American Academy of Family Physicians (AAFP)
American College of Obstetricians and Gynecologists (ACOG)
American Medical Association (AMA)
American Psychological Association Services (APA Services)
Association of Academic Medical Colleges (AAMC)
Greater New York Hospital Association (GNYHA)
National Association of Community Health Centers (NACHC)
While these organizations offered comments on a broad range of issues, this summary of provider comments focuses on five topics: 1) open enrollment and special enrollment periods; 2) coverage denials for past-due premiums; 3) Marketplace eligibility for Deferred Action for Childhood Arrivals (DACA) recipients; 4) coverage of gender-affirming care; and 5) affordability.
In general, health care providers shared concerns about or clearly opposed provisions in the proposed rule that would reduce eligibility for, and enrollment in, Marketplace coverage. Provider groups also largely endorsed CMS’s proposal to codify the “preponderance of the evidence” standard of proof for the adjudication of cases involving broker misconduct and urged CMS to take further action to address fraud among agents and brokers. Finally, some provider organizations, such as the American Hospital Association, chose to forgo detailed comments on the proposed rule and instead expressed their deep concern about the anticipated coverage losses that would accrue from the overall regulation, with substantial consequences for individuals’ access to care and providers’ financial stability.
Open and Special Enrollment Periods
The proposed rule would shorten the annual open enrollment period (OEP) for Marketplace coverage. Under current regulations, the OEP runs from November 1 through January 15, with state-based marketplaces (SBMs) allowed to extend the OEP beyond this timeframe. Under this proposal, the OEP would be limited to November 1 through December 15 for all Marketplaces, including SBMs—a reduction of more than 30 days. CMS would also eliminate a special enrollment period (SEP) for individuals and families with annual incomes below 150 percent of the federal poverty level (FPL), or almost $40,000 a year for a family of three. Under current rules, these individuals and families may enroll in Marketplace coverage throughout the year.
Shortening OEP
Almost all of the provider organization comments we examined opposed CMS’s proposal to shorten the OEP, citing the likely loss of coverage that would result. Providers noted that a 75-day open enrollment period is essential for consumers who need to evaluate new premium prices and understand their coverage options, while several noted that consumers will need additional time to navigate the added verification requirements also included in the proposed rule. In addition, the AMA suggested that a shorter enrollment timeframe would deter healthier individuals from enrolling in Marketplace coverage, thus destabilizing the risk pool. Two hospital groups, GNYHA and America’s Essential Hospitals, also opposed the application of this shorter timeframe to SBMs, suggesting that these states have established enrollment procedures, including OEPs, that best meet their enrollees’ needs and should continue to have this flexibility. The AAFP also noted that new limitations on the OEP timeframe would cost states 4000 hours of employee time and $7.8 million to implement.
Eliminating the Low-income SEP
Several provider groups—NACHC, ACOG, and the AMA—also shared their concerns about the elimination of the Low-Income SEP for individuals and families with annual incomes below 150 FPL. For example, ACOG noted that this monthly SEP serves as an “important safety net,” increasing the opportunities to enroll in Marketplace coverage for individuals who lose Medicaid eligibility. The AMA offered alternative approaches to the complete elimination of the Low-Income SEP for CMS’s consideration, such as limiting this SEP to individuals and families who can demonstrate a change in income and a delay in implementation until plan year 2027.
SEP for Pregnancy
ACOG and the AMA also asked CMS to create greater access to Marketplace coverage during pregnancy by making pregnancy a qualifying life event for a SEP. Both organizations note that current regulations can leave pregnant people who are uninsured or lack coverage for maternity care without an avenue to access Marketplace coverage, resulting in delayed prenatal care, greater risk of poor birth outcomes, and significant financial risk for families and the larger health system.
Coverage Denials for Past Due Premiums
The proposed rule includes a provision that would permit insurers to deny an applicant insurance if the person had past-due premiums from a previous policy. This proposal is similar to but stricter than the first Trump Administration’s policy on past due premiums, which also allowed insurers to deny coverage but limited the look-back period for past due premiums to 12 months. In contrast, this proposal permits insurers to deny coverage if the applicant has past-due premiums from any point in time.
Several providers noted their concerns with this proposal. NACHC, for example, highlighted that the low-income patient population served by community health centers may face financial barriers to paying their premiums and posited that existing guardrails, such as short grace periods for non-payment prior to cancellation of coverage, already deter consumers from abusing guaranteed issue requirements. Similarly, ACOG argued that prospective enrollees “should not be punished for past hardships when seeking coverage presently.” The AMA raised implementation questions related to this policy that CMS did not address in the proposed rule, such as whether an enrollee would be given a grace period to retrospectively make up premium payments and how health services would be paid during this timeframe.
Marketplace Eligibility for DACA Recipients
The proposed rule would exclude DACA recipients—certain undocumented individuals who entered the United States as children who are protected from deportation—from the definition of “lawfully present” for purposes of health coverage, thus making DACA recipients in all states ineligible for Marketplace coverage, premium subsidies, and cost-sharing assistance. This proposal reverses a 2024 Biden Administration regulation that extended the definition of “lawfully present” to DACA recipients and enabled these individuals to enroll in Marketplace plans. (Litigation against this rule has blocked DACA recipients from enrolling in Marketplace plans in 19 states.)
All but one provider group in our sample addressed this proposed change in policy. These groups expressed their ongoing support for providing DACA recipients with access to Marketplace plans, premium subsidies, and cost-sharing assistance; some groups specifically and strongly opposed CMS’s proposal to exclude DACA recipients from the definition of “lawfully present.” APA Services, for example, shared their “unqualified opposition” to this provision, noting that immigrants experience “unique stressors” including trauma, displacement, and cultural adjustment, which can lead to increased vulnerability to chronic medical conditions. ACOG’s comment cites their members’ commitment to supporting all patients seeking obstetric and gynecological care without regard to immigration status as the basis of their opposition to this proposal.
Coverage of Gender-Affirming Care
The proposed rule would prohibit insurers from covering gender-affirming care, such as the items and services that treat gender dysphoria (referred to in the rule as “sex trait modification”), as part of essential health benefits. States would still be permitted to mandate such coverage, but would need to defray the costs of such coverage using state funds.
Several of the organizations in our sample expressed concerns with or opposed this proposal outright, with reasons ranging from the critical nature of gender-affirming care for people with gender dysphoria, to concerns about the scope of services encompassed within this exclusion, to the lack of a clear definition for and clinical specificity of the term “sex trait modification.” The AAFP, for example, stated that “gender-affirming health care is part of comprehensive primary care for gender-diverse patients,” while ACOG found it “imperative” to note that many services for gender affirming care are also routinely covered for non-transgender people for indications such as endocrine disorders, menopause, and cancer treatment or prevention. While some provider groups noted that CMS’s term “sex trait modification” is “medically inaccurate and clinically meaningless” and asked CMS to “leave such considerations to the scientific and medical communities,” others urged CMS to craft a clear and comprehensive definition of this term should they move forward with this proposal.
Changes to Premium and Benefit Affordability
The proposed rule would adjust the methodology for determining the amount Marketplace enrollees contribute to their premium. This same methodology also determines the maximum annual out-of-pocket cost for people in both individual and group market health plans, including employer-based coverage. If finalized as proposed, deductibles and other cost-sharing for the typical family could increase by $900 in 2026 (including for those with employer-sponsored insurance). Families enrolled in the Marketplace could face an additional $313 in premiums. Additionally, CMS proposes to give insurers more flexibility to offer plans at each metal level within a wider range of actuarial values (AV) than permitted under current rules.
Two of the provider associations in our sample submitted comments on these provisions. The AMA expressed strong opposition to proposals that would negatively affect coverage affordability, including greater flexibility on AV ranges and CMS’s proposed revisions to premium contributions. The AMA flagged that both of these proposals would lead to higher out-of-pocket costs for enrollees with chronic conditions and urged CMS to monitor affordability issues and coverage disruptions if CMS finalizes this proposal. NACHC noted that the proposed changes would result in premium contributions that are likely too high for the patients that health centers serve and urged CMS to “reconsider” these proposals.
Note on Our Methodology
This blog is intended to provide a summary of comments submitted by health care providers. 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/.
