HealthCare.gov managers prepare for possible 2026 crash

Congress could crush 2026 HealthCare.gov sales.

If sales plummet, health insurers will have to pay higher user fees on the health plans they still manage to sell through HealthCare.gov, HealthCare.gov managers warn in a draft version of the notice describing how HealthCare.gov and other Affordable Care Act health insurance programs will work in 2026.

The web-based health insurance supermarket now charges health insurers a user fee equal to 2.2% of the monthly premiums in states where it provides all ACA exchange services.

The user fee is set to fall to 1.5% of the monthly premiums for 2025 coverage.

If Congress hits HealthCare.gov by failing to renew the current, relatively generous ACA premium tax credit subsidies, falling volume will increase per-enrollee costs and force HealthCare.gov to push the user fee up to 2.5% of total monthly premiums, officials say.

But, if Congress renews the current level of subsidies by March 31, 2025, then the user fee in states where HealthCare.gov provides all exchange services could range from 1.8% to 2.2%, officials say.

Related: HealthCare.gov managers expect to work with 90,000 agents

The fate of the premium tax credit subsidies could also affect many other enrollment-based HealthCare.gov calculations and payments, officials say.

The Centers for Medicare and Medicaid Services, the arm of the U.S. Department of Health and Human Services that oversees ACA health insurance programs, posted a preview version of the Notice of Benefit and Payment Parameters for 2026 and Basic Health Program notice on the web Friday.

The Federal Register plans to publish the draft Oct. 10. Comments on the draft, including the proposed March 31, 2025, date for finalizing the 2026 user fee, will be due 30 days after the official publication date.

What it means for the benefits community: ACA exchange programs sell a significant number of small-group plans in states like California and Colorado.

In August, Covered California was administering health plan accounts for 8,927 small employers with 76,475 participants.

ACA exchange rules could also affect the ability of brokers and employers to try relatively new types of “cash for coverage” arrangements, such as the individual coverage health reimbursement arrangement and the qualified small employer HRA.

ICHRAs and QSEHRAs depend on workers having guaranteed access to major medical insurance through the ACA public exchange system or the ordinary, off-exchange individual health insurance market.

The history: Drafters of the two bills that created the Affordable Care Act created the Affordable Care Act public exchange system in an effort to fend off policymakers who wanted the United States to shift to a purely government-run health finance system.

The public exchange system is supposed to make it possible for health insurers to sell individual and small-group health insurance without medical underwriting, by creating a simple way for consumers to use ACA premium tax credit subsidies to shop for coverage and pay for the coverage.

Some states and the District of Columbia run their own ACA public exchange programs and set their own user fees and other parameters.

The U.S. Department of Health and Human Services set up HealthCare.gov to provide exchange services in the states that are unwilling or unable to handle all exchange services. HealthCare.gov now provides full exchange services in 29 states and exchange support services in three states.

HealthCare.gov now administers exchange plan accounts and tax credit subsidy access for about 16 million people.

When the ACA exchange system came to life, in 2014, Congress made tax credit subsidies available only to people with modified adjusted gross income under 400% of the federal poverty level.

In response to the COVID-19 pandemic, Congress adopted emergency rules that made subsidies available to people at any income level if the cost of coverage would eat up too much of their household income.

The current “affordability percentage” limit is 8.39%. The affordability percentage is set to increase to 9.02% for 2025 coverage.

The subsidy expansion extension fight: The looming expiration of the current high health insurance subsidy has created a new battlefield for ACA system supporters and ACA system opponents.

Analysts at the Paragon Health Institute, a research center popular with Republicans, have argued that the ACA premium tax credit system is deeply flawed, encourages people to lie about their income to increase their subsidies, and encourages health insurers to provide terrible coverage aimed at consumers who focus solely on the premiums.

Supporters contend that the cost of keeping the current ACA subsidy rules in place is comparable to the cost of the tax breaks already offered for employer-sponsored health benefits.

The Urban Institute, a group popular with Democrats, predicted that letting the current subsidies lapse would increase the number of uninsured people and people without major medical insurance to 31 million, from 27 million people, and might increase the number of people with employer-sponsored coverage to 151 million, from 147 million.

The Congressional Budget Office has predicted that keeping the expanded premium tax credit subsidies in place would cost the federal government about $251 billion over 10 years.

Subsidy expansion would cost less than Biden administration proposals for expanding access to child care and paid family and medical level, and it would cost more than administration proposals for expanding access to preschool and increasing Pell grant awards for college students.

Other parameters notice documents: In addition to talking about the HealthCare.gov user fee in the ACA 2026 parameters document, the Centers for Medicare and Medicaid Services also talk about topics such as possible plan design changes for 2026, changes to the risk-adjustment system, rules for letting plans avoid canceling coverage for enrollees who owe less than $5 in unpaid premiums, and new rules for making lead HealthCare.gov agents take responsibility for the actions of other agents.