But the authors of the new ICHRA paper say insurers, ICHRA services providers and other players should create an off-exchange enrollment pathway for ICHRA users.

One reason is that, to make the tax rules for ICHRA plans the same as the tax rules for traditional group health plans, "enrollments must occur outside the public exchanges," according to Kyle Estep of Take Command, Lori Koehler of zizzl and Johnna Barnard of Remodel Health.

Today, if the employees buy coverage through an ACA public exchange, they have to pay their share of the premiums with the earnings left over after payroll taxes and income taxes have been withheld, the executives write.

If employees can buy the coverage through an off-exchange Section 125 cafeteria plan, then the employees can pay the premiums with pre-tax earnings, the executives say.

HealthCare.gov and state-based ACA public exchanges, like Covered California, help administer the ACA premium tax credit health insurance subsidies. But the federal ICHRA rules won't let ICHRA get premium tax credits. That means there is no practical reason to put HealthCare.gov or a state-based exchange between an ICHRA plan and the health insurers, the executives write.

The backdrop: The authors of the new HRA Council paper estimate that U.S. employers may be offering ICHRA plans and another type of cash-for-coverage plan, the qualified small employer health reimbursement arrangement, to about 200,000 employees.

Related: ICHRA adoption challenges: Employee flexibility vs. coverage quality

ICHRA plans have been around for several years, but most employers were focusing on efforts to cope with the COVID-19 pandemic. Last year was the first year when typical employers had a long enough post-crisis lead time to try a new type of plan.

This year, Centene and Oscar Health are examples of health insurers courting ICHRA program managers. Investment firms have been investing in ICHRA services providers.

Paper details: Estep, Koehler and Barnard also have many other ideas for other ways to streamline ICHRA plan enrollment and administration, such as:

◆ Persuading all states to start and stop individual major medical enrollment periods on the same dates.

◆ Having insurers share plan, rate and provider network data with health plan information services.

◆ Letting ICHRA plans submit off-exchange enrollment applications for many different ICHRA users from the same plan in bulk.

◆ Adding a field to health insurance application and enrollee data file records to indicate whether enrollees are using ICHRAs or other types of health accounts to pay for the coverage.

◆ Adding fields to enrollee data files to indicate when premium cash is coming from the employer and when the premium cash is coming from an employee.

◆ Making it easier for enrollees to update coverage payment information during the plan year.

Estep, Koehler and Barnard suggest that insurers, ICHRA services providers and technology firms may need to create a new, expanded version of the existing American National Standards Institute X12 834 electronic data interchange enrollment file standards to support ICHRAs.