Pending Changes to Marketplace Plans Could Increase Cost Sharing for Consumers
Changes to Marketplace plans recently finalized by the Centers for Medicare and Medicaid Services (CMS) may incentivize insurers to make their plans less generous. With less generous plans, consumers could face higher out-of-pocket costs. However, these changes could also lower premiums for those who don’t qualify for premium assistance (roughly 8% of Marketplace enrollees). Plans sold on the Affordable Care Act (ACA) Marketplaces and sold in the small group market are grouped into metal tiers—bronze, silver, gold, and platinum—based on their actuarial value (AV), or the average share of health care costs the plan covers for a standard population. Bronze plans require the highest cost sharing, paying only 60% of expected costs, followed by silver plans (70%), gold plans (80%), and platinum plans (90%). “Expanded” bronze plans have a somewhat higher actuarial value and are required to cover some services before the deductible is met.
Issuers are given flexibility in meeting these actuarial value targets. In rules issued in effect from the 2023 plan year, standard on-exchange bronze (except expanded bronze), silver, gold, and platinum plans are required to be within +2/-2 percentage points of their AV targets, a range known as the de minimis range. Individual market standard silver plans have an allowable range of +2/0 percentage points; silver plans offered with cost-sharing reductions for lower-income enrollees are required to have a narrower range (+1/0 percentage points).
CMS has finalized expanding the de minimis range as part of a broader Program Integrity Rule starting in plan year 2026. The finalized rule reverts to the range used between 2018-2022 and gives issuers more flexibility to lower the AV of plans while maintaining their metal level. Individual and small-group market plans may vary from the target AV by up to +2/-4 percentage points (except for expanded bronze plans). For silver plans that include cost-sharing reductions, the allowable range is expanded to +1/-1 percentage points. The One Big Beautiful Bill Act, as passed by the House of Representatives, would codify these ranges into law.
An illustrative silver plan can be used to illustrate the potential impacts of widening the allowable range of AVs. Under current rules, a silver plan with 15% coinsurance for enrollees across all services and a $4,000 combined medical and drug deductible has an actuarial value of 70%. That calculation is based on the actuarial value calculator issued by the federal government. Under the new finalized rule, a plan with a deductible $1,750 higher or a coinsurance 25 percentage points higher could still be classified as silver, with an AV of just over 66%. How much more any given consumer would pay out-of-pocket would depend on their use of services.
Insurers may choose to configure plan designs in this wider range by some combination of increased copays, coinsurance, maximum out-of-pocket amounts, or cost sharing for specific services to decrease the AV. Many Marketplace plans currently have AVs near the lower end of the allowed range: In 2025, the average AV for silver plans was 70.3%.
Standardized plans (designated “easy pricing” plans on HealthCare.gov) were created to simplify cost-sharing arrangements and allow consumers to easily compare plans. For the 2026 plan year, standardized plans have an actuarial value of 70.0% in most states. Allowing a wider range of actuarial values to be classified as the same metal level may increase the challenges of shopping. If insurers choose to offer non-standardized plans with lower AVs, consumers may have difficulty identifying the decreased coverage provided by these plans compared to standardized ones.
While insurers are not required to lower AVs, the finalized rule could create an incentive to do so—effectively reducing the value of coverage for Marketplace enrollees. The finalized rule cites increased cost sharing as a potential benefit, lowering overall premiums, and encouraging more people without a subsidy to purchase coverage. However, those who are eligible for premium tax credits – which make up the vast majority of Marketplace enrollees – would not pay lower premiums and may face higher cost sharing.