Health Insurance Exchanges and Qualified Health Plans: Overview and Policy Updates

Overview of Health Insurance Exchanges
March 17, 2023
Health Insurance Exchanges and Qualified Health Plans: Overview and Policy Updates Updated May 6, 2025 (R44065) Jump to Main Text of Report

Contents

• Introduction
• Overview
• Types and Administration of Exchanges
• Individual and SHOP Exchanges
• State-Based and Federally Facilitated Exchanges
• Exchange Administration
• Qualified Health Plans
• Standardized Plans
• Individual Exchanges
• Eligibility and Enrollment
• Interaction with Medicaid, CHIP, and Medicare
• Open and Special Enrollment Periods
• Enrollment Data
• Enrollment Trends
• Covered Benefits
• Premiums, Cost Sharing, and Subsidies
• Premiums
• Cost Sharing, Actuarial Value Levels, and Maximum Out-of-Pocket Limits
• Premium Tax Credits and Cost-Sharing Reductions
• Premium, APTC, and CSR Data
• Provider Networks
• Exchange Provider Network Data
• Insurer Participation
• SHOP Exchanges
• Eligibility and Enrollment
• Enrollment Periods
• Enrollment Processes and Options
• Enrollment Data
• Congressional Member and Staff Enrollment via the DC SHOP Exchange
• Benefits, Premiums, and Cost Sharing
• Small Business Health Care Tax Credit
• Provider Networks
• Insurer Participation
• Exchange Enrollment Assistance
• Navigators and Other Exchange-Based Enrollment Assistance
• Brokers, Agents, and Other Third-Party Assistance Entities
• Exchange Funding
• Initial Grants for Exchange Planning and Establishment
• Ongoing Federal Funding for Exchange Operations
• Funding Sources for Federal Exchange Spending
• User Fees Collected from Participating Insurers
• Other Federal Funding Sources
• State Financing of the Exchanges
• American Rescue Plan Act Grants for Exchange Modernization

Figures

• Figure 1. Individual and SHOP Exchange Types by State, Plan Year 2025
• Figure 2. Maximum Annual Limitations on Cost Sharing, by Plan Year
• Figure 3. Plan Year 2025 Insurer Participation in the Individual Exchanges, by County
• Figure 4. Private Health Insurance Market Concentration in the Individual Exchanges and Other Markets, 2022
• Figure 5. Federal User Fees for Insurers Participating in Specified Types of Individual Exchanges, by Plan Year

Tables

• Table 1. Nationwide Individual Exchange Enrollment, by Plan Year
• Table 2. Examples of Standardized Plan Requirements for QHP Issuers in Most FFE and SBE-FP States, Plan Year 2025
• Table 3. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing Reductions Nationwide, by Plan Year
• Table A-1. Exchange Types and Key Details by State, Plan Year 2025
• Table B-1. Types of Plans Offered Through the Exchanges
• Table C-1. CMS Funding for the Exchanges, by Source, by Year
• Table C-2. CMS Funding for the Exchanges, by Activity, by Year
• Table D-1. HHS "Notice of Benefit and Payment Parameters," Final Rule by Year
• Table D-2. Selected Federal Resources on the Exchanges

Appendixes

• Appendix A. Exchange Information by State
• Appendix B. Types of Plans Offered Through the Exchanges
• Appendix C. Exchange Funding Details from CMS Budget Justifications
• Appendix D. Additional Resources

Summary

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) required The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) required
health insurance exchanges to be established in every statehealth insurance exchanges to be established in every state and the District of Columbia. Exchanges are virtual marketplaces . Exchanges are virtual marketplaces
Vanessa C. Forsberg
in which consumers and small business owners and employees can shop for and purchase private in which consumers and small business owners and employees can shop for and purchase private
Analyst in Health Care
health insurance coverage and, where applicable, be connected to public health insurance health insurance coverage and, where applicable, be connected to public health insurance
Financing
programs (e.g., Medicaid).programs (e.g., Medicaid).

In general, states must have two types of exchanges: an In general, states must have two types of exchanges: an individual exchange and aand a small business

health options programSmall Business Health Options Program (SHOP) exchange.. Exchanges may be established either by the state Exchanges may be established either by the state
itself as a itself as a state-based exchange (SBE) or by the Secretary of Health and Human Services (HHS) as a or by the Secretary of Health and Human Services (HHS) as a federally facilitated
exchange (FFE). SomeA few states have states have SBE-FPs: they have SBEsa state-based exchange using the federal platform (SBE-FP): they administer their exchange but use the federal information technology platform but use the federal information technology platform (FP),
, including the federal exchange website www.HealthCare.govincluding the federal exchange website www.HealthCare.gov.
. SHOP exchanges may be administered as SB-SHOPs or FF-SHOPs, but there are no SB-FP-SHOPs. A primary function of the exchanges is to facilitate enrollment. This generally includes operating a web portal that allows for A primary function of the exchanges is to facilitate enrollment. This generally includes operating a web portal that allows for
the comparison and purchase of coverage; making determinations of eligibility for coverage and financial assistance; and the comparison and purchase of coverage; making determinations of eligibility for coverage and financial assistance; and
offering different forms of enrollment assistance, including Navigators and a call center. Exchanges also are responsible for offering different forms of enrollment assistance, including Navigators and a call center. Exchanges also are responsible for
several administrative functions, including certifying the plans that will be offered in their marketplaces.several administrative functions, including certifying the plans that will be offered in their marketplaces.
The ACA generally requires that the private health insurance plans offered through an exchange are The ACA generally requires that the private health insurance plans offered through an exchange are qualified health plans
(QHPs). To be a certified as a QHP, a plan must be offered by a state-licensed health insurance issuer and must meet To be a certified as a QHP, a plan must be offered by a state-licensed health insurance issuer and must meet
specified requirements, including covering the specified requirements, including covering the essential health benefits (EHB). QHPs sold in the individual and SHOP . QHPs sold in the individual and SHOP
exchanges must comply with the same state and federal requirements that apply to QHPs and other health plans offered exchanges must comply with the same state and federal requirements that apply to QHPs and other health plans offered
outside of the exchanges in the individualoutside of the exchanges in the individual (also called nongroup) market and small-group and small-group marketsmarket, respectively. Additional requirements apply only to , respectively. Additional requirements apply only to
QHPs sold in the exchanges. QHPs sold in the exchanges. ExchangesExchange insurers also may offer variations of QHPs, such as child-only or catastrophic plans, and also may offer variations of QHPs, such as child-only or catastrophic plans, and non-
QHP dental-only plans.
they may also offer exchange-certified dental plans. Consumers and small businesses must meet certain eligibility criteria to purchase coverage through the individual and SHOP Consumers and small businesses must meet certain eligibility criteria to purchase coverage through the individual and SHOP
exchanges, respectively. There is an annual exchanges, respectively. There is an annual open enrollment period (OEP) during which any eligible consumer may purchase during which any eligible consumer may purchase
coverage via the individual exchanges; otherwise, consumers may purchase coverage only if they qualify for a coverage via the individual exchanges; otherwise, consumers may purchase coverage only if they qualify for a special
enrollment period (SEP). In general, small businesses may enroll at any time during the year. There are plans available in all In general, small businesses may enroll at any time during the year. There are plans available in all
individual exchanges, and individual exchanges, and about 16.3 million people obtained health insurance through the individual exchanges during the
2023 open enrollment period20.8 million people were enrolled in health insurance through the individual exchanges as of February 2024. Data available at the time of this report indicate that over 24 million consumers selected a plan during the 2025 OEP. Nationwide SHOP exchange enrollment estimates are not regularly released; in addition, there . Nationwide SHOP exchange enrollment estimates are not regularly released; in addition, there
are no SHOP exchange plans available in more than half of states in are no SHOP exchange plans available in more than half of states in 20232025, similar to , similar to 2022.
recent years. Plans sold through the exchanges, like private health insurance plans sold off the exchanges, have premiums and out-of-Plans sold through the exchanges, like private health insurance plans sold off the exchanges, have premiums and out-of-
pocket (OOP) costs. Consumers who obtain coverage through the individual exchanges may be eligible for federal financial pocket (OOP) costs. Consumers who obtain coverage through the individual exchanges may be eligible for federal financial
assistance with premiums and OOP costs in the form of assistance with premiums and OOP costs in the form of premium tax credits and and cost-sharing reductions. Small businesses . Small businesses
that use the SHOP exchangesthat use the SHOP exchanges may be eligible for may be eligible for small business health insurance tax credits that assist with the cost of that assist with the cost of
providing health insurance coverage to employees.providing health insurance coverage to employees.
The federal government spent an estimated $2.09 billion on the operation of exchanges in FY2022, projected $2.38 billion in
spending for FY2023, and proposed $2.31 billion for FY2024. Federal government funding for the operation of the exchanges was $2.44 billion for FY2023 (final), $2.47 billion for FY2024 (CR), and was requested to be $2.34 billion for FY2025. Much of the federal spending on the exchanges is funded by Much of the federal spending on the exchanges is funded by
user fees paid by the insurers who participate in FFE and SBE-FP exchanges. States with SBEs finance their own exchange paid by the insurers who participate in FFE and SBE-FP exchanges. States with SBEs finance their own exchange
administration; states with SBE-FPs also finance certain costs (e.g., their own Navigator programs).administration; states with SBE-FPs also finance certain costs (e.g., their own Navigator programs).
This report provides This report provides an overview of key aspects of the health insurance exchanges,overviews of and data on key topics including types and administration of including types and administration of
exchanges, eligibility and enrollment, exchanges, eligibility and enrollment, plan costs and financial assistancequalified health plan features (benefits, costs, and financial assistance), provider networks, insurer participation, , insurer participation, enrollment assistance, and exchange financing. It and exchange financing. It
also includes information about policy changes enacted under the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2)
and the budget reconciliation measure known as the Inflation Reduction Act (), as well as recent administrative policy
changes, including those made in response to the Coronavirus Disease 2019 (COVID-19) pandemic and related economic
recession.

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Contents
Introduction ..................................................................................................................................... 1
Overview ......................................................................................................................................... 2
Types and Administration of Exchanges ................................................................................... 2
Individual and SHOP Exchanges ........................................................................................ 2
State-Based and Federally Facilitated Exchanges .............................................................. 3
Exchange Administration .................................................................................................... 5
Qualified Health Plans .............................................................................................................. 6
Standardized Plans .............................................................................................................. 7
Individual Exchanges ...................................................................................................................... 8
Eligibility and Enrollment ......................................................................................................... 8
Interaction with Medicaid, CHIP, and Medicare ................................................................. 9
Open and Special Enrollment Periods ................................................................................ 9
Enrollment Estimates ........................................................................................................ 13
Premiums, Cost Sharing, and Subsidies .................................................................................. 14
Premiums .......................................................................................................................... 14
Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels ................... 14
Premium Tax Credits and Cost-Sharing Reductions ......................................................... 16
Premium, APTC, and CSR Data ....................................................................................... 17
Insurer Participation ................................................................................................................ 19
SHOP Exchanges ........................................................................................................................... 21
Eligibility and Enrollment ....................................................................................................... 21
Enrollment Periods............................................................................................................ 22
Enrollment Processes and Options .................................................................................... 22
Enrollment Estimates ........................................................................................................ 23
Congressional Member and Staff Enrollment via the D.C. SHOP Exchange ................... 24
Premiums and Cost Sharing .................................................................................................... 24
Small Business Health Care Tax Credit ............................................................................ 24
Insurer Participation ................................................................................................................ 25
Exchange Enrollment Assistance .................................................................................................. 26
Navigators and Other Exchange-Based Enrollment Assistance .............................................. 26
Brokers, Agents, and Other Third-Party Assistance Entities ................................................... 28
Exchange Spending and Funding .................................................................................................. 28
Initial Grants for Exchange Planning and Establishment ........................................................ 28
Ongoing Federal Spending on Exchange Operation ............................................................... 28
Funding Sources for Federal Exchange Spending .................................................................. 29
User Fees Collected from Participating Insurers .............................................................. 29
Other Federal Funding Sources ........................................................................................ 30
State Financing of the Exchanges ........................................................................................... 30
American Rescue Plan Act Grants for Exchange Modernization ........................................... 31

Figures
Figure 1. Individual and SHOP Exchange Types by State, Plan Year 2023 .................................... 5
Figure 2. Plan Year 2023 Insurer Participation in the Individual Exchanges, by County ............. 20
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Figure 3. Federal User Fees for Insurers Participating in Specified Types of Individual
Exchanges, by Plan Year ............................................................................................................ 30

Tables
Table 1. Nationwide Individual Exchange Enrollment Estimates, by Plan Year ........................... 13
Table 2. Maximum Annual Limitations on Cost Sharing, by Plan Year ........................................ 16
Table 3. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing Reductions
Nationwide, by Plan Year ........................................................................................................... 18

Table A-1. Exchange Types and Key Details by State, Plan Year 2023 ........................................ 32
Table B-1. Types of Plans Offered Through the Exchanges .......................................................... 36
Table C-1. CMS “Health Insurance Marketplaces Transparency Table,” Recent Years ................ 39
Table C-2. CMS Federal Exchange Funding Sources, Recent Years ............................................ 40
Table D-1. HHS “Notice of Benefit and Payment Parameters,” Final Rule by Year .................... 41

Appendixes
Appendix A. Exchange Information by State ................................................................................ 32
Appendix B. Types of Plans Offered Through the Exchanges ...................................................... 36
Appendix C. Exchange Spending and Funding Details from CMS Budget Justifications ............ 38
Appendix D. Additional Resources ............................................................................................... 41

Contacts
Author Information ........................................................................................................................ 42

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link to page 17 Overview of Health Insurance Exchanges

Introduction
also includes information about recent statutory and administrative policy changes and current policy issues related to the exchanges and QHPs.

Introduction

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) required The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) required health
insurance exchanges (also known as (also known as marketplaces) to be established in every state) to be established in every state. and the District of Columbia.¹ The ACA The ACA
exchanges are virtual marketplaces in which consumers and small businesses can shop for and exchanges are virtual marketplaces in which consumers and small businesses can shop for and
purchase private health insurance coverage and, where applicable, be connected to public health purchase private health insurance coverage and, where applicable, be connected to public health
insurance programs (e.g., Medicaid).insurance programs (e.g., Medicaid).12 Certain consumers and small employers are eligible for Certain consumers and small employers are eligible for
financial assistance for private health insurance purchased (only) through the exchanges. financial assistance for private health insurance purchased (only) through the exchanges.
Exchanges are intended to simplify the experience of obtaining health insurance. They are not Exchanges are intended to simplify the experience of obtaining health insurance. They are not
intended to supplant the private market outside of the exchanges but rather to provide an intended to supplant the private market outside of the exchanges but rather to provide an
additional source of private health insurance coverage options.additional source of private health insurance coverage options.
The exchanges may be administered by state governments and/or the federal government. The exchanges may be administered by state governments and/or the federal government.
Regardless, the major functions of the exchanges are (1) to facilitate consumersRegardless, the major functions of the exchanges are (1) to facilitate consumers’' and small and small
businesses’businesses' purchase of coverage (by operating a web portal, making determinations of eligibility purchase of coverage (by operating a web portal, making determinations of eligibility
for coverage and any financial assistance, and offering different forms of enrollment assistance) for coverage and any financial assistance, and offering different forms of enrollment assistance)
and (2) to certifyand (2) to certify, recertify, and otherwise monitor the plans that are offered in those and otherwise monitor the plans that are offered in those
marketplaces.marketplaces.
Although a relatively small proportion of people in the U.S. obtain their coverage through the
exchanges,2 the administration and functioning of these marketplaces are ongoing topics of
interest to congressional audiences and other stakeholders. An understanding of the exchanges
can provide context for current health policy discussions and proposals related to health care
coverage and costs, the roles of the public and private sectors in the provision of health coverage,
and more.
This report provides an overview of key aspects of the health insurance exchanges This report provides background on key aspects of the health insurance exchanges and the private health insurance plans sold within the exchanges, which are called qualified health plans (QHPs). It begins with . It begins with
summary information about types and administration of exchanges and summary information about types and administration of exchanges and the plans sold in them.
an overview of QHPs. Sections on the individual and small business exchanges discuss eligibility and enrollment, plan Sections on the individual and small business exchanges discuss eligibility and enrollment, plan
costsfeatures (benefits, premiums, cost sharing, and financial assistance available to eligible consumers and small businesses and financial assistance available to eligible consumers and small businesses), provider networks, insurer , insurer
participation, and other topics. The final sections participation, and other topics. The final sections of the report describe types of enrollment assistance available describe types of enrollment assistance available
to exchange consumers and provide information on federal funding for the exchanges.to exchange consumers and provide information on federal funding for the exchanges.
Appendixes offer further details, including exchange types by state.
The report includes information about policy changes enacted under the American Rescue Plan
Act of 2021 (ARPA; P.L. 117-2) and the budget reconciliation measure known as the Inflation
Reduction Act (P.L. 117-169), as well as recent administrative policy changes, including those
made in response to the Coronavirus Disease 2019 (COVID-19) pandemic and related economic
recession.

1 In this report, the terms consumers and individuals generally are used interchangeably, often to refer to consumers
purchasing coverage directly from insurers for themselves and/or their families via the individual exchanges. Similarly,
small businesses and small employers may be used interchangeably, often in reference to such employers and/or their
employees purchasing coverage via the SHOP exchanges.
2 For example, about 16.3 million people obtained health insurance through the individual exchanges during the 2023
open enrollment period (November 1, 2022, through January 15, 2023, in most states). This figure is approximately
4.88% of the U.S. population of about 334.4 million people as of February 2023. See Table 1 regarding exchange
enrollment estimates and sources. The U.S. population estimate is part of a series of monthly projections made by the
U.S. Census Bureau based upon the 2020 Census, at https://www.census.gov/popclock/.
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Overview
Types and Administration of Exchanges
Individual and SHOP Exchanges
Relevant data are provided throughout (e.g., individual exchange enrollment by year). Appendices offer further details, including exchange types by state and federal funding for the exchanges by year.

Throughout the report, there are also updates and insights on recent statutory and regulatory policy changes related to the exchanges and QHPs, and current policy and programmatic issues of interest. This includes discussions of standardized plan requirements, network adequacy requirements, direct enrollment options, special enrollment periods, temporary enhancements to premium tax credits, and requirements on exchange plan agents and brokers.

Although a relatively small proportion of people in the U.S. obtain their coverage through the exchanges,³ the administration and functioning of these marketplaces are ongoing topics of interest to congressional audiences and other stakeholders. An understanding of the exchanges can provide context for current health policy discussions and proposals related to health care coverage and costs, the roles of the public and private sectors in the provision of health coverage, and more.

Overview Types and Administration of Exchanges Individual and SHOP Exchanges The ACA required health insurance exchanges to be established in all states and the District of The ACA required health insurance exchanges to be established in all states and the District of
Columbia.Columbia.34 In general, the health insurance exchanges began operating in October 2013 to allow In general, the health insurance exchanges began operating in October 2013 to allow
consumers to shop for health insurance plans that began as soon as January 1, 2014.consumers to shop for health insurance plans that began as soon as January 1, 2014.
There are two types of exchanges—There are two types of exchanges—individual exchanges and and small business health options
programSmall Business Health Options Program (SHOP) exchanges..45 These exchanges are part of the nongroup and small-group These exchanges are part of the nongroup and small-group
segments of the private health insurance market, respectively.segments of the private health insurance market, respectively.5 6 In an individual exchange, eligible In an individual exchange, eligible
consumers can compare and purchase nongroup insurance for themselves and their families and consumers can compare and purchase nongroup insurance for themselves and their families and
can apply for premium tax credits and cost-sharing reductions (PTCs and CSRs) that are available can apply for premium tax credits and cost-sharing reductions (PTCs and CSRs) that are available
only through the exchanges (see only through the exchanges (see "“Premium Tax Credits and Cost-Sharing Reductions”).
"). In a SHOP exchange, small businesses can compare and purchase small-group insurance and can In a SHOP exchange, small businesses can compare and purchase small-group insurance and can
apply for small business health insurance tax credits (see apply for small business health insurance tax credits (see "“Small Business Health Care Tax
Credit”Credit"); in addition, employees of small businesses can enroll in plans offered by their ); in addition, employees of small businesses can enroll in plans offered by their
employers on a SHOP exchange.employers on a SHOP exchange.
Each exchange covers a whole state.Each exchange covers a whole state.67 Within an exchange, private insurers may offer plans that Within an exchange, private insurers may offer plans that
cover the whole state or only certain areas within the state (e.g., one or more counties). Plans sold cover the whole state or only certain areas within the state (e.g., one or more counties). Plans sold
within a given exchange may cover services offered by providers located in more than one state.within a given exchange may cover services offered by providers located in more than one state.
In general, consumers and small businesses may obtain coverage within their stateIn general, consumers and small businesses may obtain coverage within their state’'s individual or s individual or
SHOP exchange, respectively, or they may shop in the nongroup or small-group health insurance SHOP exchange, respectively, or they may shop in the nongroup or small-group health insurance
markets outside of the exchanges, which existed prior to the ACA and continue to exist.7 Outside
of the ACA exchanges, consumers can purchase coverage through agents or brokers, or they can
purchase it directly from insurers. In addition, there were and still are privately operated websites
that allow the comparison and purchase of coverage sold by different insurers, broadly similar in
concept to the ACA exchanges.8

3 The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) also gave the territories the option
of establishing exchanges, but none elected to do so, by the statutory deadline of October 1, 2013. See 42 U.S.C.
§18043.
4 The term individual exchange is used for purposes of this report. It is not defined in exchange-related statute or
regulations.
5 Broadly, private health insurance includes group plans (largely, employer-sponsored insurance) and nongroup plans
(i.e., plans that consumers purchase directly from insurers). The group market is divided into small- and large-group
market segments; a small group is typically defined as a group of up to 50 individuals (e.g., employees), and a large
group is typically defined as one with 51 or more individuals.
6 There is an option for states to coordinate in administering regional exchanges or for a single state to establish
subsidiary exchanges that serve geographically distinct areas (see 45 C.F.R. §155.410), but none have done so.
7 However, plans are not available in all small business health options program (SHOP) exchanges in 2023.
8 An example of a privately owned website that allows for comparison and purchase of coverage from different insurers
is ehealthinsurance.com. Note that some types of coverage sold outside of the federal and state exchanges, potentially
including some types of coverage available on private sites like this one, are not subject to some or all federal health
insurance requirements. For more information, see CRS Report R46003, Applicability of Federal Requirements to
Selected Health Coverage Arrangements.
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State-Based and Federally Facilitated Exchanges
markets outside of the exchanges, which existed prior to the ACA and continue to exist.⁸

There are different ways of obtaining coverage on the exchange, including via the exchange website or via agents or brokers or Navigators, as discussed later in this report.⁹ Outside of the ACA exchanges, consumers and small businesses can purchase coverage through agents or brokers, or they can purchase it directly from insurers. In addition, there were and still are privately operated websites that allow the comparison and purchase of coverage sold by different insurers, broadly similar in concept to the ACA exchanges.¹⁰

State-Based and Federally Facilitated Exchanges A state can choose to establish its own A state can choose to establish its own state-based exchange (SBE). If a state opts not to (SBE). If a state opts not to
administer its own exchange, or if the Department of Health and Human Services (HHS) administer its own exchange, or if the Department of Health and Human Services (HHS)
determines the state is not in a position to do so, then HHS is required to establish and administer determines the state is not in a position to do so, then HHS is required to establish and administer
the exchange in the state as a the exchange in the state as a federally facilitated exchange (FFE).(FFE).
There is one variation on the SBE approach: a state may have a There is one variation on the SBE approach: a state may have a state-based exchange using a
federal platform (SBE-FP), which means the state oversees the exchange but uses the federally (SBE-FP), which means the state oversees the exchange but uses the federally
facilitated information technology (IT) platform, or facilitated information technology (IT) platform, or federal platform (FP) (i.e., HealthCare.gov). (FP) (i.e., HealthCare.gov).
There is also a variation on the FFE approach: a state may have a There is also a variation on the FFE approach: a state may have a state partnership FFE, which , which
allows the state to manage certain aspects of its exchange while HHS manages the remaining allows the state to manage certain aspects of its exchange while HHS manages the remaining
aspects and has authority over the exchange. In early guidance on this option, HHS indicated a aspects and has authority over the exchange. In early guidance on this option, HHS indicated a
state could elect to perform some plan management and/or certain consumer assistance functions, state could elect to perform some plan management and/or certain consumer assistance functions,
and HHS would perform other functions, including facilitating enrollment through the federal and HHS would perform other functions, including facilitating enrollment through the federal
HealthCare.gov platform and funding Navigator entities in the state.HealthCare.gov platform and funding Navigator entities in the state.911 In federal and private In federal and private
resources that track exchange data, this variation may not be reported on separately, but rather resources that track exchange data, this variation may not be reported on separately, but rather
may be included in overall counts of FFEs, which is the model this report generally follows.may be included in overall counts of FFEs, which is the model this report generally follows.
Direct Enrollment Exchange Types In rulemaking finalized January 19, 2021 (the 2022 Notice of Benefit and Payment Parameters, or In rulemaking finalized January 19, 2021 (the 2022 Notice of Benefit and Payment Parameters, or
“Payment NoticePayment Notice”1012), HHS and the Department of the Treasury established new ), HHS and the Department of the Treasury established new “"direct direct
enrollment”enrollment" variations of the exchange types: FFE-DE, SBE-DE, and SBE-FP-DE. States electing variations of the exchange types: FFE-DE, SBE-DE, and SBE-FP-DE. States electing
these options would these options would “"adopt a private sector-based enrollment approach as an alternative to the adopt a private sector-based enrollment approach as an alternative to the
consumer-facing enrollment website operated by the Exchange (for example, HealthCare.gov for consumer-facing enrollment website operated by the Exchange (for example, HealthCare.gov for
the FFEs).” In other words, consumers would enroll in exchange plans via private agents or
brokers, rather than on an exchange website like HealthCare.gov. The exchange would still have
to “make available a website listing basic [qualified health plan] QHP information for
comparison,” but this website would direct consumers to “approved partner websites for
consumer shopping, plan selection, and enrollment activities.”the FFEs)."¹³ Per the final rule, this would have Per the final rule, this would have
been an option for SBEs as of plan year (PY) 2022, and for FFEs and SBE-FPs as of PY2023. been an option for SBEs as of plan year (PY) 2022, and for FFEs and SBE-FPs as of PY2023.
The final rule was published but did not take effect before the presidential transition. The Biden The final rule was published but did not take effect before the presidential transition. The Biden
Administration subsequently repealed the establishment of these DE exchange type options.11
“Direct Enrollment” (DE) and the Exchanges
Although current regulations do not allow states to adopt a direct enrol ment exchange type (e.g., FFE-DE), there
are ongoing uses of DE approaches and systems in the exchanges. In general, DE can be a way for consumers to
enrol in an exchange plan directly on an insurer’s or web-broker’s website or otherwise with an agent or broker,
rather than enrol ing on an exchange website (e.g., HealthCare.gov).

9 See Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight
(CCIIO), “General Guidance on Federally Facilitated Exchanges,” May 16, 2012, at https://www.cms.gov/CCIIO/
Resources/Fact-Sheets-and-FAQs/Downloads/ffe-guidance-05-16-2012.pdf. Also see CMS, CCIIO, “Guidance on
State Partnership Exchange,” January 3, 2013, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/
Downloads/partnership-guidance-01-03-2013.pdf. For more information about Navigators, see “Navigators and Other
Exchange-Based Enrollment Assistance” in this report.
10 See 2022 Payment Notice, “Part 1,” starting page 6143, regarding information in this paragraph. The Notice of
Benefit and Payment Parameters, or Payment Notice, is an annually published rule that includes updates and policy
changes related to the exchanges and private health insurance. Because different parts of the Final 2022 Payment
Notice were published in January 2021, May 2021, and September 2021, the informal references “Part 1,” Part 2,” and
“Part 3” are used to distinguish them in this report. See Table D-1 for Payment Notice citations.
11 2022 Payment Notice, “Part 3,” starting on page 53424.
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In the individual exchanges, consumers can enrol on their exchange website and may also have DE options. In FF-
SHOP and some SB-SHOP exchanges, DE is the only enrol ment option. See “Enrol ment Processes and Options”
in the SHOP section of this report, and “Brokers, Agents, and Other Third-Party Assistance Entities” in the
Exchange Enrol ment Assistance section, for more information.
For PY2023, 30 states have FFEs, 18 states have SBEs, and three states have SBE-FPs.12 A few
Administration subsequently repealed the establishment of these DE exchange type options.¹⁴ Per rulemaking finalized in April 2024, an exchange must "operate a centralized eligibility and enrollment platform" on its website (state exchange website or HealthCare.gov), and exchanges are prohibited from "solely relying on non-Exchange entities" to make eligibility determinations.¹⁵

Although current regulations do not allow states to adopt a direct enrollment exchange type (e.g., FFE-DE), these regulations do not preclude other existing uses of DE approaches and systems in the exchanges, as discussed later in this report. For example, in the individual exchanges, consumers can enroll on their exchange website and there may also be DE options for them to enroll directly on an insurer's or web-broker's website.¹⁶ In FF-SHOP and some SB-SHOP exchanges, DE is the only enrollment option.¹⁷

Exchange Types by State

For PY2025, 28 states have FFEs, 20 states have SBEs, and three states have SBE-FPs.¹⁸ A few states have changed approaches one or more times (e.g., initially worked to create an SBE but states have changed approaches one or more times (e.g., initially worked to create an SBE but
then switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of then switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of
whether the state moved toward more or less federal involvement, but in several cases, a state whether the state moved toward more or less federal involvement, but in several cases, a state
transitioned from a fully state-based approach to an SBE-FP (i.e., transitioned toward more transitioned from a fully state-based approach to an SBE-FP (i.e., transitioned toward more
federal involvement). Recent and ongoing transitions federal involvement). Recent and ongoing transitions are generallyhave been in the direction of less federal in the direction of less federal
and more state involvement.and more state involvement. For example, as of PYs 2020-23, the following states have
19 From PY2020 to PY2025, nine states transitioned from FFE to SBE-FPtransitioned from FFE to SBE-FP, and/or from SBE-FP to SBE: and/or from SBE-FP to SBE: Georgia, Illinois, Nevada, New Jersey, Nevada, New Jersey,
Pennsylvania, Maine, Virginia, Kentucky, and New Mexico.Pennsylvania, Maine, Virginia, Kentucky, and New Mexico.13 After pursuing an alternative
approach in recent years, Georgia is now seeking to transition from FFE to SBE.14
In the same time period, no states transitioned to an FFE. See Appendix A for more information about current exchange types and transitions over time. SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP).SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP).15 Most
states’20 Most states' individual and SHOP exchanges are administered in the same way (e.g., both state-based individual and SHOP exchanges are administered in the same way (e.g., both state-based
or both federally facilitated). However, in or both federally facilitated). However, in about half of the28 states, no insurers are offering medical states, no insurers are offering medical
plans in the SHOP exchange, meaning there is effectively no SHOP exchange there.plans in the SHOP exchange, meaning there is effectively no SHOP exchange there.1621 For PY2025 For
PY2023, there are , there are 828 FF-SHOPs FF-SHOPs and 15 SB-SHOPs(6 with medical plans with medical plans), 22 SB-SHOPs (16 with , 27 states with no SHOP
medical plansmedical plans), and , and one1 state exempted from operating a SHOP exchange. state exempted from operating a SHOP exchange.17
22 See Figure 1 for individual and SHOP exchange types by state in for individual and SHOP exchange types by state in PY2023PY2025, and see, and see Table Table A-1 for for
additional information, including on state transitions to different exchange types.

12 In tallies throughout this report, the District of Columbia is counted as a state.
13 For some considerations regarding such transitions, see Sabrina Corlette et al., States Seek Greater Control, Cost-
Savings by Converting to State-Based Marketplaces, Robert Wood Johnson Foundation, October 2019, at
https://www.rwjf.org/en/library/research/2019/10/states-seek-greater-control-cost-savings-by-converting-to-state-
based-marketplaces.html.
14 In 2020, Georgia received approval through the Section 1332 state innovation waiver process to shift to its own
Georgia Access Model, essentially a direct enrollment exchange type, beginning in PY2023. However, the Georgia
Access Model component of the waiver was suspended for PY2023 in 2022. For more information about the 1332
waiver process, which allows states to waive specified ACA provisions, including provisions related to the
establishment of health insurance exchanges and related activities, see CRS Report R44760, State Innovation Waivers:
Frequently Asked Questions. In February 2023, Georgia indicated its intention to transition to an SBE approach. See
State of Georgia Office of Commissioner of Insurance and Safety Fire, Letter to CCIIO, February 14, 2023, at
https://oci.georgia.gov/document/document/georgia-sbe-blueprint-letter-cms/download.
15 As of June 2018, states could no longer select a state-based SHOP using the federal IT platform (SB-FP-SHOP)
approach, except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According
to CMS, those states no longer use that model. See “Enrollment Processes and Options” in the SHOP section of this
report for more information.
16 See “Insurer Participation” in the SHOP section of this report for more information.
17 Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange. Initially set to expire after
PY2021, the waiver was extended through PY2026 in December 2021.
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Figure 1. Individual and SHOP Exchange Types by State, Plan Year 2023

Source: CRS il ustration. See data sources in Table A-1.
Notes: SHOP = small business health options program; IT = information technology. Counts of “states”additional information, including on state transitions to different exchange types.

Figure 1. Individual and SHOP Exchange Types by State, Plan Year 2025 Source: CRS illustration. See data sources in Table A-1. Notes: IT = information technology; SHOP = Small Business Health Options Program. Counts of "states" include include
the District of Columbia. In the individual exchanges, the District of Columbia. In the individual exchanges, plan year is generally the calendar year, but group plan is generally the calendar year, but group plan
years, including in the SHOP exchanges, may start at any time during a calendar year. See years, including in the SHOP exchanges, may start at any time during a calendar year. See report “Overview”
report "Overview" regarding individual and SHOP exchanges, and federal and state administration of exchanges.regarding individual and SHOP exchanges, and federal and state administration of exchanges.
In about In more than half of the states, no insurers are offering medical plans in the SHOP exchange, meaning there is half of the states, no insurers are offering medical plans in the SHOP exchange, meaning there is
effectively no SHOP exchange there.effectively no SHOP exchange there. See “"Insurer Participation” in" in the SHOP section of this report for more the SHOP section of this report for more
information. There are medical plans available in all individual exchanges.information. There are medical plans available in all individual exchanges.
Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange. For more information, Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange. For more information,
see CRS Report R44760, see CRS Report R44760, State Innovation Waivers: Frequently Asked Questions. .
Exchange Administration
Whether state-based or federally facilitated, exchanges are required by law to fulfill certain Whether state-based or federally facilitated, exchanges are required by law to fulfill certain
minimum functions. ACA provisions related to the establishment and operation of the exchanges minimum functions. ACA provisions related to the establishment and operation of the exchanges
are codified at 42 U.S.C. §§18031 et seq. Other federal provisions also are relevant, for example are codified at 42 U.S.C. §§18031 et seq. Other federal provisions also are relevant, for example
regarding the requirements for plans that may be sold through the exchanges.regarding the requirements for plans that may be sold through the exchanges.18
23 A primary function of the exchanges is to provide a way for consumers and small businesses to A primary function of the exchanges is to provide a way for consumers and small businesses to
compare and purchase health plan options offered by participating insurers.compare and purchase health plan options offered by participating insurers.1924 This generally This generally
includes operating a web portal that allows for comparing and purchasing coverage, making includes operating a web portal that allows for comparing and purchasing coverage, making
determinations of eligibility for coverage and financial assistance, and offering different forms of determinations of eligibility for coverage and financial assistance, and offering different forms of
enrollment assistance.enrollment assistance.
Exchanges also are responsible for several administrative functions, including certifying the plans Exchanges also are responsible for several administrative functions, including certifying the plans
that will be offered in their marketplaces.that will be offered in their marketplaces.2025 This includes annually certifying or recertifying plans This includes annually certifying or recertifying plans
to be sold in their exchanges as to be sold in their exchanges as qualified health plans (QHPs, discussed below). QHP (QHPs, discussed below). QHP
certification involves a review of various factors, including the plancertification involves a review of various factors, including the plan’'s benefits, cost-sharing s benefits, cost-sharing

18 See “Qualified Health Plans” in this report.
19 42 U.S.C. §18031(b)(1)(A).
20 42 U.S.C. §18031(d)(4).
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structure, provider network, premiums, marketing practices, and quality improvement activities, structure, provider network, premiums, marketing practices, and quality improvement activities,
to ensure compliance with applicable federal and state standards.to ensure compliance with applicable federal and state standards.2126 The QHP certification process The QHP certification process
is to be completed each year in time for insurers to market their plans and premiums during the is to be completed each year in time for insurers to market their plans and premiums during the
exchanges’exchanges' annual open enrollment period (see annual open enrollment period (see "“Open and Special Enrollment Periods”).
Exchanges’"). Exchanges' other administrative activities include collecting enrollment and other data, reporting other administrative activities include collecting enrollment and other data, reporting
data to and otherwise interacting with the Departments of HHS and the Treasury, and working data to and otherwise interacting with the Departments of HHS and the Treasury, and working
with state insurance departments and federal regulators to conduct ongoing oversight of plans.with state insurance departments and federal regulators to conduct ongoing oversight of plans.
Qualified Health Plans
In general, health insurance plans offered through exchanges must be In general, health insurance plans offered through exchanges must be qualified health plans
(QHPs).(QHPs).2227 A QHP is a A QHP is a health plan offered by a state-licensed insurer that is certified to be sold in that plan offered by a state-licensed insurer that is certified to be sold in that
state’state's exchange, covers the s exchange, covers the essential health benefits (EHB) package, and meets other specified (EHB) package, and meets other specified
requirements.requirements.23 28 Covering the EHB package means covering 10 broad categories of benefits,Covering the EHB package means covering 10 broad categories of benefits,
29 complying with limits on consumer cost sharing on the EHB, and meeting certain generosity complying with limits on consumer cost sharing on the EHB, and meeting certain generosity
requirements (in terms of requirements (in terms of actuarial value or AV).).2430 As discussed later in this report, an AV is As discussed later in this report, an AV is an
estimate of the “percentage of total average costs for covered benefits” to be paid by a plan.the "percentage paid by a health plan of the percentage of the total allowed costs of benefits."³¹ Plan Plan
AVs are associated with metal levels (90% AV for platinum plans, 80% for gold, 70% for silver, AVs are associated with metal levels (90% AV for platinum plans, 80% for gold, 70% for silver,
and 60% for bronze), and the higher the AV percentage, the lower the cost sharing, on average.and 60% for bronze), and the higher the AV percentage, the lower the cost sharing, on average.25
QHPs are subject to the same state and federal requirements that apply to health plans offered
outside of exchanges.2632

Following are several key points about QHP requirements, as compared to requirements on other private health insurance plans:³³

Requirements on private health insurance plans sold in the nongroup and small-group markets are applicable both in and out of the exchanges.³⁴ Thus, a QHP offered through an individual exchange must comply with Thus, a QHP offered through an individual exchange must comply with
state and federal requirements applicable to individual market (or nongroup market) plans; a QHP state and federal requirements applicable to individual market (or nongroup market) plans; a QHP
offered through a SHOP exchange must comply with state and federal requirements applicable to offered through a SHOP exchange must comply with state and federal requirements applicable to
small-group market plans. For example, the requirement to cover the EHB applies to small-group market plans. For example, the requirement to cover the EHB applies to individual
nongroup and small-group plans both in and out of the exchanges.and small-group plans both in and out of the exchanges.
There are additional requirements that apply only to QHPs sold in the exchanges.There are additional requirements that apply only to QHPs sold in the exchanges.27 35 For example, For example,
an insurer wanting to sell QHPs in an exchange must offer at least one silver-level and one gold-an insurer wanting to sell QHPs in an exchange must offer at least one silver-level and one gold-
level plan in all of the areas in which the insurer offers coverage within that exchange. In
addition, QHPs that use provider networks must meet network adequacy standards, including
maintaining provider networks that are “sufficient in number and types of providers” and include
essential community providers (i.e., certain types of providers that serve predominantly low-
income and medically underserved individuals). As of PY2023, QHP issuers in FFEs must meet

21 42 U.S.C. §18031(c)(1); 42 U.S.C. §18031(e). For more information, also see CMS, CCIIO, 2023 Final Letter to
Issuers in the Federally Facilitated Exchanges, April 28, 2022, at https://www.cms.gov/CCIIO/Resources/Regulations-
and-Guidance/Downloads/Final-2023-Letter-to-Issuers.pdf. Hereinafter referred to as “CMS, 2023 Final Letter to
Issuers.”
22 42 U.S.C. §18031(d)(2)(B).
23 42 U.S.C. §18021(a)(1).
24 42 U.S.C. §18022.
25 See “Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels” for more information.
26 For more information about federal requirements applicable to different types of plans, see CRS Report R45146,
Federal Requirements on Private Health Insurance Plans. This report also addresses states’ roles as the primary
regulators of health insurance.
27 See, for example, 42 U.S.C. §§18021, 18023, and 18031; and 45 C.F.R. §§156.200 et seq. Also see CMS, 2023 Final
Letter to Issuers.
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“time and distance” standards related to network adequacy requirements.28 Also aslevel plan in all of the areas in which the insurer offers coverage within that exchange. Exchange plans also are subject to certain network adequacy requirements, as discussed in the "Provider Networks" section of this report.

There are multiple data reporting requirements on QHPs, some of which also apply to plans outside the exchanges. Per exchange requirements, QHPs must report data on claims payment policies and practices, claims denials, enrollment, cost sharing, premium rating practices, and other topics.³⁶ Other private health insurance plans are subject to some of these requirements.³⁷ Starting in 2026, QHPs in FFEs will be subject to additional reporting requirements regarding prior authorization, including a list of items and services requiring prior authorization and data on prior authorization request approvals, denials, and appeals.³⁸ These requirements will not apply to other private health insurance plans.

As of PY2023, of PY2023,
QHP issuers in FFEs and SBE-FPs must offer standardized QHP issuers in FFEs and SBE-FPs must offer standardized plansplan options, as explained below. , as explained below.
A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be
offered outside of exchanges, as well. offered outside of exchanges, as well. Besides standard QHPs, other types of plansIn addition to typical QHPs, certain QHP variations may be may be
available in a given exchange, including child-only plans, catastrophic plans, consumer operated available in a given exchange, including child-only plans, catastrophic plans, consumer operated
and oriented plans (CO-OPs), and and oriented plans (CO-OPs), and multi-statemultistate plans (MSPs). Stand-alone dental plans (SADPs), also sometimes referred to as qualified dental plans (QDPs), are the only non-health plans offered in the exchanges. They are subject to certain modified QHP requirements.³⁹ See plans (MSPs). Technically, these are also QHPs.
Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges. See Table B-
1 for more informationfor more information.
about types of plans offered in the exchanges. Under federal law, insurers are not required to offer plans in the exchanges, just as they are not Under federal law, insurers are not required to offer plans in the exchanges, just as they are not
required to offer plans in markets outside the exchanges. If an insurer does want to offer a plan in required to offer plans in markets outside the exchanges. If an insurer does want to offer a plan in
an exchange, it must meet applicable federal and state requirements, as discussed in this section an exchange, it must meet applicable federal and state requirements, as discussed in this section
and the prior one on and the prior one on "“Exchange Administration.”". Insurer participation in the individual and Insurer participation in the individual and
SHOP exchanges is discussed SHOP exchanges is discussed in the sections below.
later in this report. Standardized Plans
In the 2023 Payment NoticeIn the 2023 Payment Notice, finalized in May 2022, HHS indicated that insurers offering QHPs in finalized in May 2022, HHS indicated that insurers offering QHPs in
most FFEs and SBE-FFEs and SBE-FPs29 areFPs were required to offer required to offer “standardized plans”"standardized" plans starting in PY2023. starting in PY2023. In general, a
non-standardized plan40 The 2024 through 2026 Payment Notices have modified certain requirements for standardized plans and provided limits on the offering of non-standardized plans.⁴¹ These requirements do not apply in SBEs, although in the 2025 Payment Notice, HHS suggested that over half of SBEs have their own standardized plan requirements.⁴² The requirements do not apply in SHOP exchanges. In general, a non-standardized plan is one that meets the requirements outlined above (i.e., QHP and other is one that meets the requirements outlined above (i.e., QHP and other
applicable federal or state requirements), but otherwise may vary in terms of benefits, cost applicable federal or state requirements), but otherwise may vary in terms of benefits, cost
sharing, and/or other features. A sharing, and/or other features. A standardized plan also meets those requirements, and meets also meets those requirements, and meets
certain other parameters—particularly in terms of cost-sharing requirements—outlined by HHS in certain other parameters—particularly in terms of cost-sharing requirements—outlined by HHS in
the 2023 Payment Notice.regulations and guidance.⁴³ Standardized plans may still vary in other ways. Standardized plans may still vary in other ways.
On HealthCare.gov, standardized plans are identified to consumers as "easy pricing" plan options. Specifically, HHS designed a standardized plan option for each metal level of plan offered in the Specifically, HHS designed a standardized plan option for each metal level of plan offered in the
exchanges, and specified variations of themexchanges. For each of these standardized plans, cost-sharing . For each of these standardized plans, cost-sharing
requirements are set for certain categories of benefits and overall (e.g., the planrequirements are set for certain categories of benefits and overall (e.g., the plan’'s deductible and s deductible and
annual out-of-pocket limit). annual out-of-pocket limit). QHP issuers must offer a standardized plan “Examples are shown in Table 2, in the cost-sharing section of this report. In general, FFE and SBE-FP QHP issuers are required to "offer in the individual market at least one standardized plan "at every product at every product
network type ...network type ... , at every metal level, and throughout every service area that , at every metal level, and throughout every service area that they offerit also offers non- non-
standardized QHP optionsstandardized QHP options in the individual market.”30, including, for silver plans, for the income-based cost-sharing reduction plan variations."⁴⁴ For example, if an insurer offers For example, if an insurer offers a a non-
standardized gold health maintenance organization (HMO) QHP in a given service area, such gold health maintenance organization (HMO) QHP in a given service area, such
insurer must also offer a insurer must also offer a standardized gold HMO QHP throughout that service area.gold HMO QHP throughout that service area.31
For tables outlining the cost-sharing requirements, and for other details, including on exchanges’
and other entities’ displays of standardized plan options, see the 2023 Payment Notice. Other

28 QHP network adequacy standards, including time and distance requirements, are at 45 C.F.R. §156.230. Essential
community provider requirements are at 45 C.F.R. §156.235.
29 2023 Payment Notice, starting on page 27310; codified at 45 C.F.R. §156.201. This policy does not apply in SBEs,
although some states with SBEs already do or plan to require QHP issuers to offer standardized plans. This policy also
does not apply in FFEs or SBE-FPs where a state has its own requirements for standardized plans as of January 1, 2020
(Oregon), and there are variations of the requirements to accommodate certain states’ cost-sharing laws (Delaware and
Louisiana).
30 2023 Payment Notice, page 27312.
31 CMS, HHS Notice of Benefit and Payment Parameters for 2023 Final Rule Fact Sheet, April 28, 2022, at
https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2023-final-rule-fact-sheet. A
plan’s service area is the geographic area – generally a whole county or group of counties – in which it is available to
consumers. See HealthCare.gov, “Service area,” at https://www.healthcare.gov/glossary/service-area/. Also see 45
C.F.R. §155.1055.
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resources provide further background on this issue, including prior federal rulemaking on
standardized plans and certain state approaches.32
Individual Exchanges
Eligibility and Enrollment
Consumers may purchase health insurance plans for themselves and their families in their state’s
individual exchange. Consumers may enroll 45 As of PY2024, QHP issuers are not required to offer standardized plans at the "non-expanded bronze" metal level, and as of PY2026, QHP issuers that offer "multiple standardized plan options within the same product network type, metal level, and service area must meaningfully differentiate these plans," as specified.⁴⁶

As of PY2025, issuers are generally limited to offering two non-standardized plan options per product network type and per metal level, although there are exceptions as specified in regulations (e.g., "if issuers demonstrate that these additional non-standardized plans have specific design features that will substantially benefit consumers with chronic and high-cost conditions").⁴⁷ Variations are also allowed with regard to inclusion of adult dental, pediatric dental, and adult vision benefit coverage.

According to an HHS issue brief, standardized plan requirements (and limits on non-standardized plans) are intended to help consumers understand their plan options and reduce "choice overload." This brief and other resources provide further background on standardized plans, including prior federal rulemaking and certain state approaches.⁴⁸ Individual Exchanges Eligibility and Enrollment Qualified individuals may purchase health insurance plans for themselves and their families in their state's individual exchange.⁴⁹ Consumers are qualified individuals—i.e., eligible for exchange coverage—as long as they (1) meet state residency as long as they (1) meet state residency
requirements;requirements;3350 (2) are not incarcerated, except individuals in custody pending the disposition of (2) are not incarcerated, except individuals in custody pending the disposition of
charges; and (3) are U.S. citizens, U.S. nationals, or charges; and (3) are U.S. citizens, U.S. nationals, or “"lawfully presentlawfully present”" residents. residents.34
51 Undocumented individuals are prohibited from purchasing coverage through the exchanges, even Undocumented individuals are prohibited from purchasing coverage through the exchanges, even
if they were to pay the entire premium without financial assistance. if they were to pay the entire premium without financial assistance.
Consumers can use their state Consumers can use their state’'s exchange website (HealthCare.gov or a state-run site) to apply for s exchange website (HealthCare.gov or a state-run site) to apply for
coverage and financial assistance and to compare and enroll in plans. The ACA requires coverage and financial assistance and to compare and enroll in plans. The ACA requires
exchanges to provide a exchanges to provide a “"single, streamlinedsingle, streamlined" form form” that consumers can use to apply for that consumers can use to apply for “"all all
applicable State health subsidy programs within the State.applicable State health subsidy programs within the State.”35"⁵² This means that through one form, This means that through one form,
consumers can be determined eligible for exchange financial assistance (see consumers can be determined eligible for exchange financial assistance (see "“Premium Tax
Credits and Cost-Sharing Reductions”" in this report), as well as Medicaid and the State in this report), as well as Medicaid and the State
Children’Children's Health Insurance Program (CHIP), as discussed below.s Health Insurance Program (CHIP), as discussed below.3653 The exchange website The exchange website
displays all exchange plans available to a consumer, with estimates of the consumerdisplays all exchange plans available to a consumer, with estimates of the consumer’'s costs, s costs,
including monthly premiums that reflect the application of any federal financial assistance for including monthly premiums that reflect the application of any federal financial assistance for
which they are eligible.which they are eligible.
In addition to using their exchange website, consumers can apply and enroll by phone, by mail, in In addition to using their exchange website, consumers can apply and enroll by phone, by mail, in
person, and/or via approved partner websites (i.e., via direct enrollment), as available by state. person, and/or via approved partner websites (i.e., via direct enrollment), as available by state.
Enrollment assistance is available for those who want it (e.g., through exchange Navigators or Enrollment assistance is available for those who want it (e.g., through exchange Navigators or
through agents or brokers).37

32 See, for example, HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), Facilitating Consumer
Choice: Standardized Plans in Health Insurance Marketplaces, December 28, 2021, at https://aspe.hhs.gov/reports/
standardized-plans-health-insurance-marketplaces. Also see Katie Keith, “Final 2023 Payment Rule, Part 2: Standard
Plans And Other Exchange Provisions,” Health Affairs Forefront, April 30, 2022, at https://www.healthaffairs.org/do/
10.1377/forefront.20220430.953129/.
33 State residency may be established through a variety of means, including actual or planned residence in a state, actual
or planned employment in a state, and other circumstances. See 45 C.F.R. §155.305.
34 U.S. citizens and U.S. nationals are eligible for coverage through the exchanges. Lawfully present immigrants are
also eligible for coverage through the exchanges. Examples of lawfully present immigrants include those who have
qualified non-citizen immigration status without a waiting period, humanitarian statuses or circumstances, valid non-
immigrant visas, and legal status conferred by other laws. See 45 C.F.R. §155.305 and HealthCare.gov, “Coverage for
Lawfully Present Immigrants,” at https://www.healthcare.gov/immigrants/lawfully-present-immigrants/.
35 42 U.S.C. §18083, 45 C.F.R. §155.405.
36 Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as
long-term services and supports, to a diverse low-income population, including children, pregnant women, adults,
individuals with disabilities, and people aged 65 and older. CHIP is a means-tested program that provides health
coverage to targeted low-income children and pregnant women in families that have annual income above Medicaid
eligibility levels but have no health insurance. The “applicable State health subsidy programs” also include the Basic
Health Program, which is operational in two states: Minnesota and New York.
37 See “Exchange Enrollment Assistance” in this report for information on Navigators, agents and brokers, and
approved web brokers and other technology providers.
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through agents or brokers).⁵⁴ Interaction with Medicaid, CHIP, and Medicare
In conjunction with the streamlined application mentioned above, exchanges must have In conjunction with the streamlined application mentioned above, exchanges must have "screen and enroll" systems systems
for coordinating with the Medicaid and CHIP programs on eligibility determinations and for coordinating with the Medicaid and CHIP programs on eligibility determinations and
enrollment into those programs, for eligible consumers. These systems may vary by state.enrollment into those programs, for eligible consumers. These systems may vary by state.38
55 Consumers who are eligible for Medicaid or CHIP may choose to buy exchange coverage instead, Consumers who are eligible for Medicaid or CHIP may choose to buy exchange coverage instead,
but they would not be eligible for financial assistance for exchange coverage (i.e., PTCs or cost-but they would not be eligible for financial assistance for exchange coverage (i.e., PTCs or cost-
sharing reductions).sharing reductions).
There are some limitations on the sale of exchange plans to Medicare-eligible or Medicare-There are some limitations on the sale of exchange plans to Medicare-eligible or Medicare-
enrolled individuals.enrolled individuals.3956 In short, it is generally illegal to sell an individual exchange plan to In short, it is generally illegal to sell an individual exchange plan to
someone enrolled in or entitled to Medicare because it would duplicate coverage.someone enrolled in or entitled to Medicare because it would duplicate coverage.
Open and Special Enrollment Periods
Consumers may enroll in coverage through the exchanges only during specified Consumers may enroll in coverage through the exchanges only during specified “open” and
“special”"open" and "special" enrollment periods. enrollment periods.
Open Enrollment Periods
Anyone eligible for exchange plan coverage may newly enroll (or make changes to existing Anyone eligible for exchange plan coverage may newly enroll (or make changes to existing
coverage) during an annual coverage) during an annual open enrollment period (OEP).40open enrollment period (OEP).⁵⁷ The OEP typically takes place in fall The OEP typically takes place in fall
of the year preceding the of the year preceding the plan year (PY; the calendar year in the individual exchanges) during (PY; the calendar year in the individual exchanges) during
which the coverage is which the coverage is effective.
in effect. The annual federal OEP is November 1 to January 15, for FFE and SBE-FP states.The annual federal OEP is November 1 to January 15, for FFE and SBE-FP states.4158 This means, This means,
for example, that the OEP for for example, that the OEP for PY2023PY2025 was November 1, was November 1, 20222024, to January 15, , to January 15, 2023.422025.⁵⁹ This is also This is also
the default OEP for SBEs, but states with SBEs may extend their OEPs, and they may also choose
to offer a shorter OEP than is federally offered, as long as the SBE’s OEP is at least November
1-December 15.43

38 45 C.F.R. Part 155, Subpart D, including §155.302. Regarding FFE and SBE-FP states, also see Section 2.1.2 of
CMS, Federally-facilitated Exchange (FFE) and Federally-facilitated Small Business Health Options Program (FF-
SHOP) Enrollment Manual, July 28, 2022, at https://www.cms.gov/files/document/ffeffshop-enrollment-manual-
2022.pdf. Hereinafter referred to as “CMS, FFE and FF-SHOP Enrollment Manual (2022).” Regarding SBE states,
also see Sara Rosenbaum et al., Streamlining Medicaid Enrollment: The Role of the Health Insurance Marketplaces
and the Impact of State Policies, Commonwealth Fund, March 30, 2016, at https://www.commonwealthfund.org/
publications/issue-briefs/2016/mar/streamlining-medicaid-enrollment-role-health-insurance.
39 Social Security Act §1882(d)(3)(A)(i). Medicare is a federal program that pays for covered health care services for
most people aged 65 and older and for certain permanently disabled individuals under the age of 65. The prohibition on
selling an individual exchange plan to someone enrolled in or entitled to Medicare does not apply to employment-based
coverage, including coverage sold in the SHOP exchanges. See CMS, “Medicare and the Marketplace,” updated
December 2021, at https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/
Overview1.html. Also see Section 3.4.8 of CMS, FFE and FF-SHOP Enrollment Manual (2022). Information for
consumers is at Medicare.gov, “Medicare & the Marketplace,” at https://www.medicare.gov/about-us/medicare-the-
marketplace.
40 45 C.F.R. §155.410.
41 These annual OEP dates were updated via rulemaking, effective as of the PY2022 OEP (in fall 2021). See the 2022
Payment Notice, “Part 3,” starting on page 53429. See prior year OEPs at 45 C.F.R. §155.410(b) and (e).
42 Consumers enrolling by December 15 of a given OEP are to have coverage beginning January 1. Consumers
enrolling December 16-January 15 are to have coverage beginning February 1.
43 For PY2023 SBE OEPs, see CMS, “State Exchange OE Chart PY 2023,” at https://www.cms.gov/files/document/
state-exchange-open-enrollment-chart.pdf. For PY2022 and prior year SBE OEP information, see the CMS page of
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the default OEP for SBEs, but states with SBEs may extend or otherwise modify their OEPs, subject to federal regulations.⁶⁰ Before and during an OEP, consumers already enrolled in coverage through an exchange should Before and during an OEP, consumers already enrolled in coverage through an exchange should
receive notification from the exchange and from their insurer about the opportunity to make any receive notification from the exchange and from their insurer about the opportunity to make any
updates to their application data and/or coverage choices. Insurers must notify consumers of updates to their application data and/or coverage choices. Insurers must notify consumers of
changes to their plans such as premiums, benefit coverage, or provider networks.changes to their plans such as premiums, benefit coverage, or provider networks.4461 If an existing If an existing
exchange plan enrollee does not take any action during the OEP, they generally will be exchange plan enrollee does not take any action during the OEP, they generally will be
automatically reenrolled in the same plan for the upcoming plan year.automatically reenrolled in the same plan for the upcoming plan year.45
62 Special Enrollment Periods
Outside of an OEP, consumers may only enroll in coverage Outside of an OEP, consumers may only enroll in coverage (or switch plansor switch plans) via the exchange if via the exchange if
they qualify for a they qualify for a special enrollment period (SEP). Generally, consumers qualify for SEPs due to (SEP). Generally, consumers qualify for SEPs due to
a a qualifying life event (QLE), also called a (QLE), also called a triggering event..4663 This includes, for example: This includes, for example:
 Loss of qualifying coverage, which includes most types of comprehensive which includes most types of comprehensive
coverage (e.g., coverage (e.g., Medicare, Medicaid, and group and nongroup private Medicaid, and group and nongroup private
insurance).insurance).4764 This SEP also applies when a dependent turns 26 and is no longer This SEP also applies when a dependent turns 26 and is no longer
eligible to be covered on a parenteligible to be covered on a parent’'s plan. This SEP doess plan. This SEP does notnot apply in certain apply in certain
circumstances, such as loss of coverage due to failure to pay premiums, or circumstances, such as loss of coverage due to failure to pay premiums, or
voluntarily ending coverage during a plan year.voluntarily ending coverage during a plan year.48
 65 Change in household size, for example due to a change in marital status or , for example due to a change in marital status or
number of dependents, or due to a death in the family.number of dependents, or due to a death in the family.4966 Regarding dependents, Regarding dependents,
birth and adoption (and other specified scenarios) are QLEs that trigger SEPsbirth and adoption (and other specified scenarios) are QLEs that trigger SEPs, but but
generally not pregnancy.50

marketplace public use files at https://www.cms.gov/research-statistics-data-systems/marketplace-products/2022-
marketplace-open-enrollment-period-public-use-files.
44 See Section 3.2.5 of CMS, FFE and FF-SHOP Enrollment Manual (2022); its “Reenrollment Communications to
Enrollees” section cites CMS, Updated Federal Standard Renewal and Product Discontinuation Notices in the
Individual Market (Required for Notices Provided in Connection with Coverage Beginning in the 2021 Plan Year), July
31, 2020, at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Updated-Federal-Standard-
Notices-for-coverage-beginning-in-the-2021-plan-year.pdf. There, see “Instructions for Attachment 2,” item 20.
45 For more information about plan renewal options and processes, including automatic renewals of enrollees in their
existing plans or in alternate plans if their existing ones will no longer be available, see Section 3.2 of CMS, FFE and
FF-SHOP Enrollment Manual (2022). Although this manual describes processes for HealthCare.gov states, SBEs also
have processes for automatic reenrollment.
46 In addition to the examples and their regulatory citations shown here, see HealthCare.gov information on SEPs at
https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ and
https://www.healthcare.gov/sep-list/. Also see 45 C.F.R. §147.104 regarding SEPs applicable to the individual and
group markets overall.
47 45 C.F.R. §155.420(d)(1), (e)(1). Qualifying coverage generally means the types of minimum essential coverage
(MEC) that are identified in the Internal Revenue Code (IRC) Section 5000A and its implementing regulations.
48 While exchange plan enrollees may voluntarily terminate their coverage at any time during the plan year, this would
not necessarily trigger an SEP through which someone could select a new plan.
49 45 C.F.R. §155.420(d)(2).
50 There is no federal SEP specifically for pregnant individuals, but there are pregnancy-related SEPs in at least eight
SBEs: Colorado (as of 2024), Connecticut, Maine, Maryland, New Jersey, New York, Vermont, and Washington, DC.
In addition, see 45 C.F.R. §155.420(d)(1)(iii), which specifies that the loss of certain other pregnancy-related coverage
(e.g., via Medicaid) would trigger a federal exchange SEP.
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 generally not pregnancy.⁶⁷ Becoming newly eligible for exchange coverage (e.g., by becoming a U.S. for exchange coverage (e.g., by becoming a U.S.
citizen or leaving incarceration), citizen or leaving incarceration), and/or having a change in income that affects that affects
eligibility for federal subsidies for coverage.eligibility for federal subsidies for coverage.51
 68 Change in residence, such as moving to a new state (or new ZIP code or county such as moving to a new state (or new ZIP code or county
within a state), including moves for school or seasonal work.within a state), including moves for school or seasonal work.52
 69 Certain other situations, including errors or misrepresentations made by including errors or misrepresentations made by
exchanges and/or plans,exchanges and/or plans,5370 and other exceptional or complex circumstances. and other exceptional or complex circumstances.54
71 HHS also may choose to offer SEPs or extend an OEP for some or all consumers due to broadly HHS also may choose to offer SEPs or extend an OEP for some or all consumers due to broadly
applicable circumstances, or otherwise make SEP changes (subject to statutory requirements).applicable circumstances, or otherwise make SEP changes (subject to statutory requirements).55
72 For example, due in part to the COVID-19 pandemic, HHS created an SEP to allow all exchange-For example, due in part to the COVID-19 pandemic, HHS created an SEP to allow all exchange-
eligible consumers to newly enroll or update their enrollment in an exchange plan from February eligible consumers to newly enroll or update their enrollment in an exchange plan from February
15, 2021, to August 15, 2021.56 In addition, for the duration of the COVID-19 emergency
declared by the Federal Emergency Management Agency (FEMA), if someone otherwise
qualifies for another SEP, but misses their SEP enrollment deadline (generally a 60 day period)
due to the impacts of COVID-19, they might still qualify to enroll.57
Federal SEPs apply to FFEs, SBE-FPs, and generally to SBEs. However, SBEs have flexibility
regarding implementation of some SEPs.58 SBEs also may create their own SEPs, subject to
applicable federal and state laws. SEPs for the individual exchanges may or may not apply to the
federal SHOP exchanges and/or to the nongroup market outside the exchanges.59
Eligibility for Medicaid or CHIP may be determined at any point during the calendar year and has
no connection to an applicant’s state’s exchange OEP.

51 45 C.F.R. §155.420(d)(3, 6).
52 45 C.F.R. §155.420(d)(7). Note, per HealthCare.gov, that “moving only for medical treatment or staying somewhere
for vacation doesn’t qualify you for a Special Enrollment Period.”
53 45 C.F.R. §155.420(d)(4, 5, 12).
54 45 C.F.R. §155.420(d)(8-15). These include SEPs related to gaining or maintaining status as an Indian, being a
victim of domestic abuse or spousal abandonment, having access to an Individual Coverage Health Reimbursement
Account (ICHRA) or being enrolled in COBRA continuation coverage, and more.
55 Statutory requirements for exchange SEPs are at 42 U.S.C. §18031(c)(6), and Secretarial authority to establish
standards for the exchanges is at 42 U.S.C. §18041(a). Also see 45 C.F.R. §155.420(d)(9) regarding SEPs for
“exceptional circumstances.” Examples of certain administrative changes made to SEPs are in the HHS final rule,
“Patient Protection and Affordable Care Act; Market Stabilization,” 82 Federal Register 18346, April 18, 2017, at
https://www.federalregister.gov/documents/2017/04/18/2017-07712/patient-protection-and-affordable-care-act-market-
stabilization.
56 This SEP was initially set to end May 15, 2021, and was later extended to August 15, 2021. See CMS, “2021 Special
Enrollment Period in response to the COVID-19 Emergency,” January 28, 2021, at https://www.cms.gov/newsroom/
fact-sheets/2021-special-enrollment-period-response-covid-19-emergency, and CMS, “Extended Access Opportunity to
Enroll in More Affordable Coverage Through HealthCare.gov,” March 23, 2021, at https://www.cms.gov/newsroom/
fact-sheets/extended-access-opportunity-enroll-more-affordable-coverage-through-healthcaregov.
57 Regarding this enrollment flexibility, see HealthCare.gov at https://www.healthcare.gov/coverage-outside-open-
enrollment/special-enrollment-period/. Regarding the COVID-19 emergency declared by FEMA (which, as of February
2023 is set to end on May 11, 2023), see CRS Insight IN12088, Effects of Terminating the Coronavirus Disease 2019
(COVID-19) PHE and NEA Declarations.
58 For example, the COVID-19 SEP, described above, was available in all FFEs and SBE-FPs. States with SBEs were
“strongly encouraged” by CMS to take similar action, and all SBEs (15 in PY2021) did so. See page 19 of HHS, 2021
FINAL MARKETPLACE SPECIAL ENROLLMENT PERIOD REPORT, September 15, 2021, at
https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf.
59 For more information about SEPs, see Section 6 of CMS, FFE and FF-SHOP Enrollment Manual (2022).
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Monthly SEP for Certain Low-Income Populations
As discussed later in this report, consumers may be eligible (based on income and other criteria)
15, 2021, to August 15, 2021.⁷³

CMS later announced another temporary SEP for eligible consumers who lost Medicaid or CHIP coverage due to the end of the Medicaid continuous enrollment requirement that was in place during the pandemic.⁷⁴ The SEP was available if consumers applied for coverage or updated their applications between March 31, 2023, and November 30, 2024, and attested to an end of Medicaid or CHIP coverage during that period.⁷⁵ While there is already an SEP based on loss of qualifying coverage, this "Unwinding SEP" temporarily provided additional time for affected individuals to enroll in an exchange plan. In the 2024 Payment Notice, CMS permanently provided a longer SEP for individuals losing Medicaid or CHIP coverage (generally 90 days, as compared to the 60-day SEP applicable to most other QLEs).⁷⁶

Federal SEPs apply to FFEs, SBE-FPs, and generally to SBEs. However, SBEs have flexibility regarding implementation of some SEPs.⁷⁷ SBEs also may create their own SEPs, subject to applicable federal and state laws. SEPs for the individual exchanges may or may not apply to the federal SHOP exchanges and/or to the nongroup market outside the exchanges.⁷⁸

Eligibility for Medicaid or CHIP may be determined at any point during the calendar year and has no connection to an applicant's state's exchange OEP.

Monthly SEP for Certain Low-Income Populations As discussed later in this report, consumers may be eligible based on income and other criteria to receive premium tax credits (PTCs) that reduce the cost of buying certain health plans offered to receive premium tax credits (PTCs) that reduce the cost of buying certain health plans offered
through the exchanges. In through the exchanges. In March 2021, the American Rescue Plan Act (ARPA; P.L. 117-2) temporarily 2021, the American Rescue Plan Act (ARPA; P.L. 117-2) temporarily
enhanced eligibility for and the amount of these PTCs. In August 2022, P.L. 117-169, which is enhanced eligibility for and the amount of these PTCs. In August 2022, P.L. 117-169, which is
commonly known as the Inflation Reduction Act of 2022 (IRA), extended these PTC commonly known as the Inflation Reduction Act of 2022 (IRA), extended these PTC
enhancements through tax year 2025.enhancements through tax year 2025.
Separately, a new federal SEP was created Separately, a new federal SEP was created through rulemaking in September 2021, in September 2021, effective as of
PY2022.60through the 2022 Payment Notice, Part 3.⁷⁹ This is a monthly SEP for consumers who are eligible for the PTC and have expected This is a monthly SEP for consumers who are eligible for the PTC and have expected
household incomes up to 150% of the federal poverty level (FPL). household incomes up to 150% of the federal poverty level (FPL). Specifically, Initially, this SEP allowed such individuals such individuals
mayto newly enroll or switch plans once a month newly enroll or switch plans once a month, only during periods of time when they would qualify during periods of time when they would qualify
for a $0 premium on a benchmark plan due to the PTC.for a $0 premium on a benchmark plan due to the PTC.
In the preamble of the rule finalizing this SEP, HHS stated that the SEP eligibility criteria In the preamble of the rule finalizing this SEP, HHS stated that the SEP eligibility criteria are
were based on the ARPA enhancements to the PTC. Although this SEP was not required by ARPA and based on the ARPA enhancements to the PTC. Although this SEP was not required by ARPA and
iswas not exclusive to ARPA, it not exclusive to ARPA, it iswould have been effective only during times when PTC enhancements are available, effective only during times when PTC enhancements are available,
such as those in ARPA and such as those in ARPA and now in the IRA. In other words, the IRA’s extension of the PTC
enhancements has also effectively extended this SEP.
the IRA.

In the 2025 Payment Notice, finalized April 2024, this SEP was made permanent, with a modification.⁸⁰ The SEP is still for consumers who are eligible for the PTC and have expected household incomes up to 150% of FPL, but the limitation regarding $0 premiums was removed.

Consumers eligible for this SEP have certain enrollment options depending on their current Consumers eligible for this SEP have certain enrollment options depending on their current
enrollment status. For example, current exchange plan enrollees who become eligible under this enrollment status. For example, current exchange plan enrollees who become eligible under this
SEP are only able to change to a silver-level plan, but new enrollees may select any metal-level SEP are only able to change to a silver-level plan, but new enrollees may select any metal-level
plan. These options may be more limited than the enrollment options related to other SEPs.plan. These options may be more limited than the enrollment options related to other SEPs.6181 The The
enrollment options and adverse selection concerns are also summarized in a Health Affairs article enrollment options and adverse selection concerns are also summarized in a Health Affairs article
on the on the final rule.62
September 2021 rule.⁸² This SEP is available in all FFE and SBE-FP statesThis SEP is available in all FFE and SBE-FP states. It, and it is optional for SBEs is optional for SBEs and at least nine SBEs
have implemented it..⁸³ Insurers are not required to offer this SEP outside of the exchanges. Insurers are not required to offer this SEP outside of the exchanges.6384 HHS HHS
also clarified also clarified in the final rule that this that this new SEP and its related enrollment options do not change SEP and its related enrollment options do not change
eligibility for, or enrollment options for, any other exchange SEP.
SEP Related to the Unwinding of Medicaid Continuous Enrollment
In January 2023, CMS announced a new SEP for eligible consumers who lose Medicaid or CHIP
coverage due to the end of these programs’ continuous enrollment conditions, which have been in
place during the COVID-19 pandemic. For consumers using HealthCare.gov, this SEP is to be
available if they apply for coverage or update their applications between March 31, 2023, and
July 31, 2024, and attest to an end of Medicaid or CHIP coverage during that period. This SEP is
available in all FFE and SBE-FP states. It is optional for SBEs.64

60 45 C.F.R. §155.420(d)(16), as added by the 2022 Payment Notice, “Part 3,” starting at page 53432. The discussion of
the effective date starts on page 53438.
61 See 45 C.F.R. §155.420(a)(3-4) for enrollment options (e.g., for enrollees and/or their dependents, and for different
metal level plans) for different SEPs. Plan metal levels are explained in “Cost Sharing, Maximum Out-of-Pocket
Limits, and Actuarial Value Levels” in this report.
62 Katie Keith, “Biden Administration Finalizes First Marketplace Rule, Including New Low-Income Special
Enrollment Period,” Health Affairs Forefront, September 20, 2021, at https://www.healthaffairs.org/do/10.1377/
forefront.20210919.154415/.
63 45 C.F.R. §147.104(b)(2)(i)(G), as added by the 2022 Payment Notice, “Part 3.”
64 For further details, including regarding consumers who may be eligible for more than one SEP, see CMS, Temporary
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Enrollment Estimates
Annual individual exchange enrollment estimates to date are shown in Table 1. eligibility for, or enrollment options for, any other exchange SEP. Enrollment Data Nationwide individual exchange enrollment by year is shown in Table 1. Given the Given the
exchange eligibility determination process, as well as the different time frames of OEPs and exchange eligibility determination process, as well as the different time frames of OEPs and
SEPs, CMS releases data on exchange enrollment in stages. SEPs, CMS releases data on exchange enrollment in stages. Pre-effectuated enrollment is the is the
number of unique individuals who have been determined eligible to enroll in an exchange plan number of unique individuals who have been determined eligible to enroll in an exchange plan
and have selected a plan. These individuals may or may not have submitted the first premium and have selected a plan. These individuals may or may not have submitted the first premium
payment. In general, cumulative and final pre-effectuated enrollment payment. In general, cumulative and final pre-effectuated enrollment estimatesdata are released are released
during, and soon after, an annual open enrollment period. during, and soon after, an annual open enrollment period. As of the date of this report, CMS has
released a 2023 OEP “Final National Snapshot,” estimating that 16.3For example, in March 2024, CMS reported that 21.4 million consumers signed million consumers signed
up for a plan in the individual exchanges nationwide, between November 1, 2022, andup for a plan (or were automatically reenrolled) in the individual exchanges nationwide during the 2024 open enrollment period (November 1, 2023-January 16, 2024 in most states).⁸⁵ In an early 2025 enrollment "snapshot," CMS reported that 24.2 million consumers had selected a plan during the 2025 OEP as of January January
15, 2023.6515, 2025.⁸⁶ Additional pre-effectuated enrollment data will likely be released in spring Additional pre-effectuated enrollment data will likely be released in spring 2023.
2025. Subsequently, Subsequently, effectuated enrollment is the number of unique individuals who have been is the number of unique individuals who have been
determined eligible to enroll in an exchange plan, have selected a plan, and have submitted the determined eligible to enroll in an exchange plan, have selected a plan, and have submitted the
first premium payment for an exchange plan. Effectuated enrollment first premium payment for an exchange plan. Effectuated enrollment estimatesdata generally are generally are
point-in-time and point-in-time and enrollment numbers may change over the coverage year. For example, due to changes in life may change over the coverage year. For example, due to changes in life
circumstances, an individual may disenroll (e.g., if later offered coverage through an employer), circumstances, an individual may disenroll (e.g., if later offered coverage through an employer),
or enroll (e.g., given eligibility for an SEP) in an exchange plan, outside of an OEP.or enroll (e.g., given eligibility for an SEP) in an exchange plan, outside of an OEP.
CMS also releases average effectuated enrollment estimates In July 2024, CMS reported that 20.8 million consumers, or 97% of the OEP 2024 individual exchange enrollees, had effectuated their enrollment as of February 2024.⁸⁷ CMS also releases data on average effectuated enrollment over specified time periods (e.g., over specified time periods (e.g.,
over the first half of an enrollment year or monthly for the previous enrollment year). See the over the first half of an enrollment year or monthly for the previous enrollment year). See the
“"Enrollment StatisticsEnrollment Statistics”" section of CRS Report R46638, section of CRS Report R46638, Health Insurance Exchanges: Sources for
of Statistics, for HHS reports and resources detailing , for HHS reports and resources detailing differentvarious enrollment enrollment estimates by year.
data. Table 1. Nationwide Individual Exchange Enrollment Estimates, by Plan Year
(in millions)(in millions)

2014
2015
2016
2017
2018
2019
2020
2021
2022

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

Pre-effectuated Pre-effectuated
(final for PY (final for PY
OEP)^a

8.0

11.7

12.7

12.2

11.8

11.4

11.4

12.0

14.5

16.4

21.4

Effectuated, early in PY (point-in-time as of date shown)^b NA^c

10.2, Mar. 2015

11.1, Mar. 2016

10.3, Feb. 2017

10.6, Feb. 2018

10.6, Feb. 2019

10.7,Feb. 2020 11.3, Feb. 2021 13.8, Feb. 2022

15.7, Feb. 2023

20.8, Feb. 2024 Effectuated, late in PY (point-in-time or average for month shown)^d 6.3, Dec. 2014 8.8, Dec. 2015 9.1,Dec. 2016 8.9,Dec. 2017 9.2,Dec. 2018 9.1,Dec. 2019

9.9, Dec. 2020

12.2, Dec. 2021

13.5, Dec. 2022

17.4, Dec. 2023

NA^e 8.0
11.7
12.7
12.2
11.8
11.4
11.4
12.0
14.5
OEP)a
Effectuated,
Early
early in PY
2014
10.2,
11.1,
10.3,
10.6,
10.6,
10.7,
11.3,
13.8,
(point-in-time
estimate
Mar.
Mar.
Feb.
Feb.
Feb.
Feb.
Feb.
Feb.
as of date
not
2015
2016
2017
2018
2019
2020
2021
2022
shown)b
found
Dec.
Effectuated,
2022
late in PY
6.3,
8.8,
9.1,
8.9,
9.2,
9.1,
9.9,
12.2,
data
(point-in-time
Dec.
Dec.
Dec.
Dec.
Dec.
Dec.
Dec.
Dec.
expected
or average for
2014
2015
2016
2017
2018
2019
2020
2021
summer
month shown)c
2023
Source: CRS analysis of Department of Health and Human Services (HHS) reports of individual exchange CRS analysis of Department of Health and Human Services (HHS) reports of individual exchange
enrol mentenrollment. Data sources are in CRS Report R46638, . Data sources are in CRS Report R46638, Health Insurance Exchanges: Sources forof Statistics, in report , in report
sections specified in table notes below.

Special Enrollment Period (SEP) for Consumers Losing Medicaid or the Children’s Health Insurance Program (CHIP)
Coverage Due to Unwinding of the Medicaid Continuous Enrollment Condition– Frequently Asked Questions (FAQ),
January 27, 2023, at https://www.cms.gov/technical-assistance-resources/temp-sep-unwinding-faq.pdf.
65 CMS, Marketplace 2023 Open Enrollment Period Report: Final National Snapshot, January 25, 2023, at
https://www.cms.gov/newsroom/fact-sheets/marketplace-2023-open-enrollment-period-report-final-national-snapshot.
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sections specified in table notes below. Notes: OEP = open OEP = open enrol mentenrollment period; PY = plan year. In the individual exchanges, a period; PY = plan year. In the individual exchanges, a plan yearPY is generally the is generally the
calendar year. See calendar year. See "“Open and Special Enrol ment Periods” inEnrollment Periods" in this report for more information. this report for more information.
a. a. Pre-effectuated enrollment is the number of unique individuals who have been determined eligible to is the number of unique individuals who have been determined eligible to enrol in
enroll in an exchange plan and have selected a plan but may or may not have submitted the first premium payment. an exchange plan and have selected a plan but may or may not have submitted the first premium payment.
Final pre-effectuated Final pre-effectuated enrol ment estimatesenrollment data typically are released typically are released fol owingfollowing an OEP and include any broadly an OEP and include any broadly
applicable OEP extensions or longer state-based exchange applicable OEP extensions or longer state-based exchange (SBE) OEPs. For these data sources by year, see OEPs. For these data sources by year, see
the the “"Pre-effectuated Pre-effectuated Enrol ment Data”Enrollment Data" section of the report mentioned above. For example, the 2021 section of the report mentioned above. For example, the 2021
estimateamount is from CMS, is from CMS, Health Insurance Exchanges 2021 Open Enrollment Report, April 2021., April 2021.
b. b. Effectuated enrollment is the number of unique individuals who have been determined eligible to is the number of unique individuals who have been determined eligible to enrol enroll in an in an
exchange plan, have selected a plan, and have submitted the first premium payment for an exchange plan.exchange plan, have selected a plan, and have submitted the first premium payment for an exchange plan.
HHS generally releases effectuated HHS generally releases effectuated enrol ment estimatesenrollment data for a point in time early in the plan year and may for a point in time early in the plan year and may
release additional point-in-time release additional point-in-time estimatesdata during the year. Data sources by year are in the during the year. Data sources by year are in the “"Point-in-Time Point-in-Time
Effectuated Effectuated Enrol ment Data”Enrollment Data" section of the report section of the report mentioned above. For example, the 2020 . For example, the 2020 estimateamount is is
from from CMSCenters for Medicare and Medicaid Services (CMS), , Early 2020 Effectuated Enrollment Snapshot, July 2020.July 2020.
c. See table note (b) regarding effectuated enrol ment and point-in-time estimates. Average estimates c. Early-year effectuated enrollment estimate not found for PY2014. d. Some effectuated enrollment data reflect reflect
an average over a specified time periodan average over a specified time period, in this case one month. For PY2014 and PY2015, quarterly point-in-
time estimates were released, including those shown. Average monthly enrol ment. For PY2016 and on, average monthly enrollment data are provided. Average monthly enrollment data were not provided data were not provided
for those years. For PYs 2016 and on, average monthly enrol ment data are providedfor PY2014 and PY2015, but quarterly point-in-time data were released in those years. Although point-in-. Although point-in-
time and average monthly time and average monthly estimatesenrollment are not the same, they are provided here to show late-year are not the same, they are provided here to show late-year enrol ment
estimatesenrollment across all plan years. across all plan years.) Data sources by year are in the Data sources by year are in the “"Point-in-Time Effectuated Point-in-Time Effectuated Enrol ment Data”
and “Enrollment Data" and "Average Monthly Effectuated Enrolment DataAverage Monthly Effectuated Enrolment Data”" sections of the report mentioned above (e.g., the sections of the report mentioned above (e.g., the 2018
estimate is from the end of the report CMS, Early 2019 Effectuated Enrollment Snapshot, August 2019).
Premiums, Cost Sharing, and Subsidies
2022 amount is from Table 7 in CMS, Early 2023 Snapshot and Fully Year 2022 Average, August 2023). e. Late-year effectuated enrollment data for PY2024 are expected in summer 2025. Enrollment Trends As shown in Table 1, early year effectuated enrollment was around 10-11 million each year until 2021, but it has increased sharply since then. February 2024 enrollment (20.8 million) is 32.5% higher than February 2023 (15.7 million), and 94.4% higher than February 2020 (10.7 million). Changes in exchange enrollment have varied by state. Year-over-year changes in the other types of exchange enrollment data (e.g., pre-effectuated enrollment) generally followed the same pattern. However, when comparing enrollment rates within a given year, it is evident that there were greater shifts in exchange enrollment rates in the early years of the exchanges than there have been in recent years. For example, from 2014 through 2019, there was more than a 20% decrease in each year's late year effectuated enrollment as compared to that year's pre-effectuated enrollment. The greatest changes were in 2016 and 2017, with decreases of 28.3% and 27%, respectively. The changes have varied since 2020, ranging from a 13.2% decrease in 2020 to a 6.1% increase in 2023. See Table 1. Increases or decreases in enrollment within a given year are the net of disenrollments (and those who did not effectuate their initial plan selections) as well as new enrollments throughout the year (e.g., through special enrollment periods).

Increases or decreases in exchange enrollment—including changes over time and within a given year—may be due to numerous factors, including federal and state policy changes as well as market and demographic effects. For example, exchange enrollment increases during and after the COVID-19 pandemic may be attributable, at least in part, to new eligibility for subsidized exchange coverage (discussed later in this report), new special enrollment periods, and changes in income and/or access to other forms of health coverage. Other factors that may affect enrollment include marketing and outreach efforts, plan choices and costs on and off the exchanges, enrollment processes and available assistance, and consumer preferences. It would be difficult to isolate the effects of any particular variable (policy or otherwise) on enrollment, given their interacting effects.⁸⁸

Covered Benefits In and out of the exchanges, covered benefits may differ by private health insurance plan, subject to applicable federal and state requirements. As stated earlier,⁸⁹ private health insurance plans sold in the individual exchanges (i.e., QHPs) are subject to the same federal requirements on benefit coverage as private health insurance plans sold in the nongroup market outside the exchanges. This includes, for example, coverage of 10 categories of essential health benefits (EHB).⁹⁰ Per current federal regulations, states generally specify the benefits to be covered within the 10 categories, so particular EHB benefits vary by state. Other federal requirements that apply both on and off the exchanges include coverage of certain preventive services without cost sharing, mental health parity, and a prohibition on benefit coverage exclusions based on an enrollee's preexisting health conditions.⁹¹ States also may impose requirements on the types of plans they regulate, including those sold on the exchanges.

One distinction regarding QHPs (as compared to plans sold off the exchanges) is related to dental coverage. While EHB coverage includes the category "pediatric services, including oral and vision care," QHPs are exempt from covering pediatric dental benefits if a stand-alone dental plan (SADP) is also available in that exchange. In turn, one requirement on SADPs is that they must cover pediatric dental in accordance with relevant EHB standards.⁹²

Certain ACA provisions address QHP coverage and financing of abortion. The ACA specifies that states may elect to require or prohibit coverage of abortion by QHPs (and other private plans regulated by states).⁹³ If QHPs do cover elective abortion, there are payment segregation requirements, including that a plan cannot use any funds attributable to premium tax credits (discussed below) to pay for such services.⁹⁴ CMS public use files (PUFs) on plans offered in the federal and state exchanges include data on certain benefits covered by QHPs, including benefits covered as EHB.⁹⁵ Premiums, Cost Sharing, and Subsidies Typically, enrollees of private health insurance plans (in or out of the exchanges) pay Typically, enrollees of private health insurance plans (in or out of the exchanges) pay premiums to to
obtain coverage. They also are generally responsible for obtain coverage. They also are generally responsible for out-of-pocket (OOP) costs, or (OOP) costs, or cost
sharing, as they use benefits., as they use benefits.
Premiums
Premiums are set by insurers and are based on their expected medical claims costs (i.e., the Premiums are set by insurers and are based on their expected medical claims costs (i.e., the
payments they expect to make to health care providers for covered health benefits for a given payments they expect to make to health care providers for covered health benefits for a given
group of enrollees)group of enrollees), administrative expenses, taxes, fees, and profit. and associated administrative expenses (including taxes and fees).⁹⁶ The premium-setting process The premium-setting process
is subject to federal and state requirements, as applicable to plans both in and out of the is subject to federal and state requirements, as applicable to plans both in and out of the
exchanges. For example, insurers cannot vary premiums based on health statusexchanges. For example, insurers cannot vary premiums based on health status.66, and insurers are subject to annual state and federal review of their premium rates.⁹⁷ In addition, In addition,
insurers that want to offer plans in the exchanges must submit their proposed premiums insurers that want to offer plans in the exchanges must submit their proposed premiums for
federal or state approval (depending on exchange type) each year.67 If consumers do not pay their
premiums, insurers may terminate their coverage, subject to applicable federal and state
requirements.68
to the exchanges as part of the QHP certification process each year.⁹⁸ Data on exchange premiums are Data on exchange premiums are inin Table 3 at the end of this section.at the end of this section.
Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels
As enrollees receive benefits covered by the plan, the costs for the benefits are paid by the
enrollee and/or the plan, depending on the plan’s terms. In general, enrollee cost sharing includes

66 See CRS Report R45146, Federal Requirements on Private Health Insurance Plans for more information about this
and other requirements related to setting premiums.
67 See “Exchange Administration” in this report.
68 See 45 C.F.R. §156.270 regarding insurer termination of enrollee coverage, including for nonpayment of premiums.
It also addresses the “grace period” of three consecutive months of premium nonpayment for enrollees who receive a
premium tax credit (discussed in the “Premium Tax Credits and Cost-Sharing Reductions” section of this report).
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deductibles, coinsurance, and co-payments, up to an annual limit on consumer out-of-pocket
(OOP) spending.69
Federally-set maximum OOP limits apply to all health plans sold in the exchanges and to all non-
grandfathered nongroup and group plans sold outside the exchanges.70 The maximum OOP limits
are updated each year through HHS rulemaking and/or guidance. See Table 2 for the maximum
limits that apply to most plans. QHP issuers must also offer plan variations with reduced OOP
limits for consumers who qualify for cost-sharing reductions, as discussed in the next section.
And as of PY2023, certain QHP issuers must also offer standardized plans as specified in
rulemaking, some of which would also have lower OOP limits than shown in Table 2.71 Plans
may set their OOP limits lower than the applicable maximums.

Because a premium is the price for coverage, the premium amount generally reflects plan features (e.g., covered benefits, cost-sharing requirements). As the majority of premium revenue pays for medical claims, the relationship of plan features to potential claims costs may directly affect a given premium. For example, a plan that covers many benefits—which has the potential to lead to numerous medical claims—can have higher premiums than a plan that covers few benefits, all else equal.

Changes in premiums may be related to numerous factors, including changes in plan features (e.g., more or fewer benefits covered), changes in the prices insurers pay for covered benefits (e.g., higher or lower provider payments), or changes in enrollee demand for healthcare (e.g., more or fewer number of claims filed). These changes can be affected by federal or state requirements or market dynamics, and they can vary geographically and by plan type.

One analysis suggests that rising health care prices are a key driver of increases in exchange plan premiums for PY2025.⁹⁹ It also points to increased utilization of costly prescription drugs as a factor affecting premiums. Another analysis of 2025 health insurance premium drivers in the nongroup and small group markets (not specific to the exchanges) similarly highlights prescription drug spending as a driver of premium increases.¹⁰⁰ These resources also discuss various recent and ongoing policy changes (e.g., the temporarily enhanced premium subsidies discussed below in this report), and the extent to which there are any indications of their effects on premiums.

Cost Sharing, Actuarial Value Levels, and Maximum Out-of-Pocket Limits

As enrollees receive benefits covered by their plan, the costs for the benefits are paid by the enrollee and/or the plan, depending on the plan's terms. In general, enrollee cost sharing includes deductibles, coinsurance, and co-payments, up to an annual limit on consumer out-of-pocket spending.¹⁰¹ Consumer cost-sharing requirements on covered benefits may vary by QHP, subject to applicable federal requirements as discussed here, and any applicable state requirements.

Actuarial Value and the "Metal Levels" Most health plans sold through the exchanges (and non-grandfathered plans sold in the nongroup Most health plans sold through the exchanges (and non-grandfathered plans sold in the nongroup
and small-group markets off-and small-group markets off-exchange72exchange¹⁰²) must provide coverage in compliance with one of four ) must provide coverage in compliance with one of four
levels of levels of actuarial value (AV), which correspond to a precious metal designation. (AV), which correspond to a precious metal designation.73103 AV is the "percentage paid by a health plan of the AV is an
estimate of the “percentage of percentage of the total total average costs for covered benefits” to be paid by a plan.74 The
four AV levels are 90% for platinum, 80% for gold, 70% for silver, and 60% for bronze.75
allowed costs of benefits."¹⁰⁴ In other words, a plan's AV indicates the average share of the medical costs that it will pay for covered benefits. Given that plans and enrollees collectively pay total costs, AV is the plan counterpart to enrollee Given that plans and enrollees collectively pay total costs, AV is the plan counterpart to enrollee
cost-sharing expenses.cost-sharing expenses. The four AV levels are 90% for platinum, 80% for gold, 70% for silver, and 60% for bronze.¹⁰⁵ The higher the AV percentage, the lower the cost sharing, on average. For The higher the AV percentage, the lower the cost sharing, on average. For
example, a silver plan expects to cover approximately 70% of total costs for covered benefits. example, a silver plan expects to cover approximately 70% of total costs for covered benefits.
Because enrolleesBecause enrollees’' use of such benefits vary, a given silver plan enrollee use of such benefits vary, a given silver plan enrollee’'s actual cost sharing s actual cost sharing
may be more or less than 30% of costs associated with receipt of covered benefits. AV is not a may be more or less than 30% of costs associated with receipt of covered benefits. AV is not a
measure of plan generosity for an enrolled individual or family, nor is it a measure of premiums measure of plan generosity for an enrolled individual or family, nor is it a measure of premiums
or benefits packages.or benefits packages.
With the exception of With the exception of “catastrophic”"catastrophic" plans and stand-alone dental plans ( plans and stand-alone dental plans (seesee Table B-1), plans , plans
sold in the exchanges must have at least 60% AV. An insurer selling plans in an exchange must sold in the exchanges must have at least 60% AV. An insurer selling plans in an exchange must
offer at least a silver and gold plan throughout each service area in which it offers coverage.76

69 In general, beginning with each plan year, an enrollee pays 100% of the costs of their covered benefits until they
meet a threshold amount called a deductible. Exceptions apply. After that, the enrollee pays coinsurance (a percentage
amount) or co-payments (a flat amount) for covered benefits, and the plan pays the rest. If an enrollee’s spending meets
an annual OOP limit, the plan will generally pay 100% of covered costs for the remainder of the plan year.
70 45 C.F.R. §156.130(a). The annual out-of-pocket limit is generally only required to apply to the plan’s covered EHB
that are furnished by an in-network provider, unless otherwise addressed in federal or state law. See CRS Report
R45146, Federal Requirements on Private Health Insurance Plans for more information, including about self-only and
other-than-self-only coverage, as shown in the table.
71 See the “Standardized Plans” section of this report.
72 Grandfathered plans are individual or group plans in which at least one individual was enrolled as of enactment of
the ACA (March 23, 2010) and which continue to meet certain criteria. Plans that maintain their grandfathered status
are exempt from some, but not all, federal requirements. There are no grandfathered plans sold through the exchanges,
but they may be available off the exchanges. For more information, see CRS Report R46003, Applicability of Federal
Requirements to Selected Health Coverage Arrangements, as well as HHS, “Grandfathered Health Insurance Plans,” at
https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/.
73 42 U.S.C. §18022(d).
74 See the definition of actuarial value in the glossary posted on HealthCare.gov at https://www.healthcare.gov/
glossary/actuarial-value/. AV calculations include only costs associated with a plan’s covered EHB that are furnished
by in-network providers, unless otherwise addressed in federal or state law.
75 Regulations allow plans to fall within a specified AV range and still comply with one of the four levels; see 45
C.F.R. §156.140(c)(2).
76 45 C.F.R. §156.200(c)(1).
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Table 2. Maximum Annual Limitations on Cost Sharing, by Plan Year
(federally set maximums; insurers may set lower out-of-pocket limits)

2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Self-Only
$6,350
$6,600
$6,850
$7,150
$7,350
$7,900
$8,150
$8,550
$8,700
$9,100
Coveragea
Coverage
$12,700 $13,200 $13,700 $14,300 $14,700 $15,800 $16,300 $17,100 $17,400 $18,200
Other Than
Self-Onlya
Percentage
N/A
3.9%
3.8%
4.4%
2.8%
7.5%
3.2%
4.9%
1.8%
4.6%
Increase over
Prior Year
Source: CRS analysis of relevant federal rulemaking regarding 45 C.F.R. §156.130(a)(2). These amounts have
generally been updated each year through an HHS rule called the Notice of Benefit and Payment Parameters,
also known as the Payment Notice. Starting with PY2023, these OOP limits and certain other payment
parameters wil be published in guidance instead of future Payment Notices. For PY2023 amounts, see CMS,
Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on
Cost Sharing, and Required Contribution Percentage for the 2023 Benefit Year, December 28, 2021, at
https://www.cms.gov/files/document/2023-papi-parameters-guidance-v4-final-12-27-21-508.pdf. This is also
referenced in the 2023 Payment Notice, page 27305. Annual Payment Notices are cited in Table D-1.
Notes: Once an enrol ee’s cost sharing (including deductibles, coinsurance, and co-payments) meet the plan’s
OOP limit in a plan year, the insurer generally wil pay 100% of covered costs for the remainder of the plan year.
This table shows federally-set OOP limits that apply to most plans, but some plan variations must have lower
OOP limits. See “Standardized Plans” and “Premium Tax Credits and Cost-Sharing Reductions” in this report.
Plans may also set their OOP limits lower than the applicable maximums.
a. If a consumer is solely enrol ed in a plan, the self-only limit applies. If a consumer and one or more
dependents are enrol ed in a plan, both the self-only and the other than self-only limits may apply. See
“Maximum Annual Limitation on Cost-Sharing” in CRS Report R45146, Federal Requirements on Private
Health Insurance Plans for further information.
Premium Tax Credits and Cost-Sharing Reductions
offer at least a silver and gold plan throughout each service area in which it offers coverage.¹⁰⁶

CMS reports on pre-effectuated enrollment include data on enrollment by metal level. During the PY2024 open enrollment period, 31% of individual exchange consumers nationwide selected bronze plans, 54% silver, 13% gold, 1% platinum, and less than 1% catastrophic plans.¹⁰⁷

Maximum Out-of-Pocket Limits

Federally set maximum OOP limits apply to all health plans sold in the exchanges and to all non-grandfathered nongroup and group plans sold outside the exchanges.¹⁰⁸ The maximum OOP limits are updated each year through HHS rulemaking and/or guidance. See Figure 2 for the generally applicable maximum limits by year. For example, the PY2025 maximum OOP limit for self-only coverage is $9,200; the limit is doubled for coverage other than self-only. Plans may set their OOP limits lower than these applicable maximums.

QHP issuers also must offer plan variations with reduced OOP limits for certain standardized plan options and for consumers who qualify for cost-sharing reductions, as discussed below in this section. SADPs are subject to modified OOP limits.¹⁰⁹

Figure 2. Maximum Annual Limitations on Cost Sharing, by Plan Year

(federally set maximums; insurers may set lower out-of-pocket [OOP] limits)

Source: CRS analysis of relevant federal rulemaking and guidance regarding 45 C.F.R. §156.130(a)(2). These amounts have generally been updated each year through an HHS rule called the Notice of Benefit and Payment Parameters, also known as the Payment Notice. Annual payment notices are cited in Table D-1. Starting with PY2023, these OOP limits and certain other payment parameters are published in guidance instead of Payment Notices. For PY2025 amounts, see CMS, Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year, November 15, 2023, https://www.cms.gov/files/document/2025-papi-parameters-guidance-2023-11-15.pdf. See the similarly titled guidance on PY2026 amounts, issued October 8, 2024, https://www.cms.gov/files/document/2026-papi-parameters-guidance-2024-10-08.pdf.

Notes: Once an enrollee's cost sharing (including deductibles, coinsurance, and co-payments) meets the plan's OOP limit in a plan year, the insurer generally will pay 100% of covered costs for the remainder of the plan year. If a consumer is solely enrolled in a plan, the self-only limit applies. If a consumer and one or more dependents are enrolled in a plan, both the self-only and the other than self-only limits may apply. See "Maximum Annual Limitation on Cost-Sharing" in CRS Report R45146, Federal Requirements on Private Health Insurance Plans for further information.

This table shows federally set OOP limits that apply to most plans, but some plan variations must have lower OOP limits. See "Standardized Plans" and "Premium Tax Credits and Cost-Sharing Reductions" in this report. Plans also may set their OOP limits lower than the applicable maximums.

Cost-Sharing Limits for Standardized Plans

As discussed earlier in this report, QHP issuers in FFEs and SBE-FPs are generally required to offer standardized QHPs—with certain cost-sharing limits designed by HHS—in addition to any non-standardized QHPs they offer. Specifically, HHS designed a standardized plan option for each metal level of plan offered in the exchanges. For each of these standardized plans, cost-sharing requirements are set for certain categories of benefits and overall (e.g., the plan's deductible and annual out-of-pocket limit). Examples of such cost-sharing amounts set for PY2025 standardized plans are shown in Table 2 below. The 2025 maximum OOP limit for the standardized expanded bronze plan is the same as the 2025 maximum OOP limit generally applicable to non-standardized plans, as shown in Figure 2 above. Table 2. Examples of Standardized Plan Requirements for QHP Issuers in Most FFE and SBE-FP States, Plan Year 2025 Selected Requirements^a

Expanded Bronze

Standard Silver

Silver 73 CSR

Silver 87 CSR

Silver 94 CSR

Gold

Platinum

Actuarial Value

63.81%

70.01%

73.09%

87.33%

94.14%

78.06%

88.04%

Deductible

$7,500

$5,000

$3,000

$500

$0

$1,500

$0

Maximum OOP Limit

$9,200

$8,000

$6,400

$3,000

$2,000

$7,800

$4,300

ER Services

50%

40%

40%

30%

25%, ND

25%

$100, ND

Inpatient Hospital Services (including MH/SUD)

50%

40%

40%

30%

25%, ND

25%

$350, ND

Primary Care Visit (including MH/SUD Outpatient Office Visits)^b

$50, ND

$40, ND

$40, ND

$20, ND

$0, ND

$30, ND

$10, ND

Specialist Visit

$100, ND

$80, ND

$80, ND

$40, ND

$10, ND

$60, ND

$20, ND

Generic Drugs

$25, ND

$20, ND

$20, ND

$10, ND

$0, ND

$15, ND

$5, ND

Specialty Drugs

$500

$350

$350

$250

$150, ND

$250, ND

$150, ND

Source: 2025 Payment Notice, Table 11, https://www.federalregister.gov/d/2024-07274/p-1472. Also see Table 12 at that link. These requirements do not apply in FFEs or SBE-FPs where a state has its own requirements for standardized plans as of January 1, 2020 (Oregon), and there are variations of the requirements to accommodate certain states' cost-sharing laws (Delaware and Louisiana). Annual payment notices are cited in Table D-1.

Notes: The Department of Health and Human Services designed a standardized plan option for each metal level of plan offered in the exchanges. The metal level plan designations correspond to the plan's actuarial value (AV), which is the "percentage paid by a health plan of the percentage of the total allowed costs of benefits," as defined at 45 C.F.R. §156.20. In general, the four AV levels are 90% for platinum, 80% for gold, 70% for silver, and 60% for bronze. For standardized plans, "expanded bronze" (with a higher AV) is used instead of the typical bronze. There are also standardized plan options for the silver plan cost-sharing reduction (CSR) plan variations, which are available to eligible consumers based on income and other factors. See the following section of this report regarding CSRs.

For specified benefit categories, there are co-payments (flat dollar amounts) or coinsurance (percentages). ER = emergency room; FFE = federally facilitated exchange; MH/SUD = mental health and substance use disorder; ND = the benefit category is not subject to the plan deductible; OOP = Out-of-pocket costs; QHP = qualified health plan; SBE-FP = state-based exchange using the federal information technology (IT) platform.

a. Illustrative examples of standardized plan cost-sharing limits are excerpted here; see source table (2025 Payment Notice, Table 11) for additional rows (e.g., laboratory services, speech therapy, preferred and non-preferred brand drugs). b. In the source table, there is a separate row for "mental health & substance use disorder outpatient office visits," but those limits are the same as provided for primary care visits, so they are combined in this table. The source table included inpatient MH/SUD in the inpatient hospital row. Premium Tax Credits and Cost-Sharing Reductions Consumers purchasing coverage through the individual exchanges may be eligible to receive Consumers purchasing coverage through the individual exchanges may be eligible to receive
financial assistance that effectively reduces their cost of that coverage. Eligibility for such financial assistance that effectively reduces their cost of that coverage. Eligibility for such
assistance is based primarily on income, and assistance is provided in the form of premium tax assistance is based primarily on income, and assistance is provided in the form of premium tax
credits (PTCs) and cost-sharing reductions (CSRs).credits (PTCs) and cost-sharing reductions (CSRs).77
110 As temporarily enhanced (As temporarily enhanced (through the end of 2025; see text box), the PTC generally is available to consumers with see text box), the PTC generally is available to consumers with
household incomes household incomes at or above 100% of the federal poverty level (FPL) and who do not have access to above 100% of the federal poverty level (FPL) and who do not have access to
public coverage (e.g., Medicaid) or employment-based coverage that meets certain standards. public coverage (e.g., Medicaid) or employment-based coverage that meets certain standards.
Some exceptions apply. The credit is designed to reduce an eligible individualSome exceptions apply. The credit is designed to reduce an eligible individual’s's (or family's) cost of cost of
purchasing health insurance coverage through the exchange. The amount of the PTC is based on a purchasing health insurance coverage through the exchange. The amount of the PTC is based on a
statutory formula and varies from person to person. It is designed to provide larger credit amounts statutory formula and varies from person to person. It is designed to provide larger credit amounts
to individuals with lower incomes compared to those with higher incomes. Although the amount to individuals with lower incomes compared to those with higher incomes. Although the amount
of the PTC is based on the second-lowest-cost silver plan (SLCSP) in a consumerof the PTC is based on the second-lowest-cost silver plan (SLCSP) in a consumer’'s local area, s local area,
consumers may apply the credit to any bronze- or higher-metal level plan available to them on consumers may apply the credit to any bronze- or higher-metal level plan available to them on
their statetheir state’'s exchange. s exchange.

77 For more information about these forms of consumer financial assistance, including applicable eligibility criteria and
illustrative examples, see CRS Report R44425, Health Insurance Premium Tax Credit and Cost-Sharing Reductions.
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Individuals who receive PTCs also may be eligible for subsidies that reduce cost-sharing Individuals who receive PTCs also may be eligible for subsidies that reduce cost-sharing
expenses.expenses.78111 These cost-sharing reductions (CSRs) are applied in two ways. First, an insurer must These cost-sharing reductions (CSRs) are applied in two ways. First, an insurer must
reduce the annual OOP limit that otherwise would apply to an eligible individualreduce the annual OOP limit that otherwise would apply to an eligible individual’'s exchange plan. s exchange plan.
Second, the insurer must effectively raise the AV of the eligible individualSecond, the insurer must effectively raise the AV of the eligible individual’'s plan, for example by s plan, for example by
reducing other cost-sharing requirements in addition to the lowered OOP cap. Among other reducing other cost-sharing requirements in addition to the lowered OOP cap. Among other
eligibility requirements, CSRs generally are available to consumers who are eligible for PTCs and eligibility requirements, CSRs generally are available to consumers who are eligible for PTCs and
have incomes between 100% and 250% of the FPL. Although a PTC can be applied to any metal have incomes between 100% and 250% of the FPL. Although a PTC can be applied to any metal
level plan, CSRs are applicable only to silver plans.level plan, CSRs are applicable only to silver plans.
Premium Tax Credit and Cost-Sharing Reductions Under the
American Rescue Plan Act of 2021 and the Inflation Reduction Act of 2022
Several provisions of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) temporarily expanded eligibility Several provisions of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) temporarily expanded eligibility
for and the amount of the premium tax credit (PTC) and cost-sharing reductions (CSRs) for certain individuals. for and the amount of the premium tax credit (PTC) and cost-sharing reductions (CSRs) for certain individuals.
For example, ARPA eliminated the eligibility phase-out for households with annual incomes above 400% of the For example, ARPA eliminated the eligibility phase-out for households with annual incomes above 400% of the
Federal Poverty Level (FPL) and reduced the percentage of annual income used in the credit formula. The Federal Poverty Level (FPL) and reduced the percentage of annual income used in the credit formula. The
temporary formula change benefitted households with incomes between 100% and 150% of FPL the most; such temporary formula change benefitted households with incomes between 100% and 150% of FPL the most; such
individuals may have received individuals may have received ful full subsidies to cover the premiums of certain plans.subsidies to cover the premiums of certain plans.
Enacted in August 2022, P.L. 117-169 (commonly known as the Inflation Reduction Act of 2022) extends Enacted in August 2022, P.L. 117-169 (commonly known as the Inflation Reduction Act of 2022) extends the
certain ARPA PTC enhancementsARPA PTC enhancements – —but not its CSR enhancementsbut not its CSR enhancements – —through tax year 2025.through tax year 2025.
For more information about these PTC changes and for discussion of ARPAFor more information about these PTC changes and for discussion of ARPA’'s CSR changes, see CRS Report s CSR changes, see CRS Report
R44425, R44425, Health Insurance Premium Tax Credit and Cost-Sharing Reductions. See . See "“Monthly SEP for Certain Low-
Income Populations”" in this report for discussion of a special in this report for discussion of a special enrol mentenrollment period related to the PTC enhancements. period related to the PTC enhancements.
Premium, APTC, and CSR Data
Table 3 summarizes nationwide data on premiums, advance premium tax summarizes nationwide data on premiums, advance premium tax credit (APTC) 79,credits (APTCs),¹¹² and and
CSRs by year, as available in relevant HHS reports on effectuated enrollmentCSRs by year, as available in relevant HHS reports on effectuated enrollment.80 in the individual exchanges.¹¹³ The average The average
premium and APTC amounts shown in the table premium and APTC amounts shown in the table mayare provided for general reference, but they obscure wide variations in actual amounts obscure wide variations in actual amounts
per consumer, depending on the plan and metal level an individual chooses and/or the factors by per consumer, depending on the plan and metal level an individual chooses and/or the factors by
which an insurer is able to vary premiumswhich an insurer is able to vary premiums (e.g., age). In addition, the APTC data in the table are . In addition, the APTC data in the table are not
necessarilytypically not final for each year, because when an individual receiving an APTC files his or her tax final for each year, because when an individual receiving an APTC files his or her tax
return for a given year, the total amount of advance payments he or she received in that tax year is return for a given year, the total amount of advance payments he or she received in that tax year is
reconciled with the amount he or she should have received.reconciled with the amount he or she should have received.
Premium and cost-sharing data on all plansPremium and cost-sharing data on all plans offered in the exchanges, as opposed to such data for in the exchanges, as opposed to such data for
plans selected, also are available, including for PY2023.81

78 The ACA requires the HHS Secretary to provide full reimbursements to insurers that provide these cost-sharing
subsidies to their enrollees. However, the ACA did not appropriate funds for such payments. In October 2017, the
Trump Administration halted these payments, effective immediately, until Congress appropriates funds. Insurers still
must provide the subsidies to eligible consumers, but insurers are not reimbursed. See HHS, “Payments to Issuers for
Cost-Sharing Reductions,” October 12, 2017, at https://www.hhs.gov/sites/default/files/csr-payment-memo.pdf.
79 Consumers may choose to receive the credit on a monthly basis, in advance of filing taxes, to coincide with the
payment of insurance premiums (technically, advance payments go directly to insurers). Advance payments
automatically reduce monthly premiums by the credit amount. This option is called the advance premium tax credit, or
APTC. Consumers may instead claim the full credit amount of the PTC when filing their taxes, even if they have little
or no federal income tax liability.
80 In the reports cited in Table 3, certain of these data are also available at the state level. In these HHS reports, and in
other HHS reports (e.g., on pre-effectuated enrollment) some data may also be available on demographics and/or metal
levels of plans. For more information, see CRS Report R46638, Health Insurance Exchanges: Sources for Statistics.
81 For example, regarding premiums and cost sharing on plans offered in FFEs and SBE-FPs in PY2023, see CMS,
CCIIO, Plan Year 2022 Qualified Health Plan Choice and Premiums in HealthCare.gov Marketplaces, October 2022,
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Table 3. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing
Reductions Nationwide, by Plan Year
(based on effectuated enrollment in all individual exchanges)

2014a
2015b
2016b
2017c
2018d
2019
2020
2021
2022
Average total
premium per
N/A
N/A
N/A $470.52 $597.20 $594.17 $576.16 $574.59 $586.56
monthe
Average APTC
$276
$272
$291 $373.06 $519.89 $514.01 $491.53 $485.67 $508.26
per monthf
Percentage of
enrol ees
86%
85%
85%
84%
87%
87%
86%
86%
90%
receiving APTCg
Percentage of
enrol ees
58%
57%
57%
57%
53%
52%
50%
48%
49%
receiving CSRh
Data as of
Dec.
Mar.
Mar.
PY
Feb.
Feb.
Feb.
Feb.
Feb.
2014
2015
2016
2017
2018
2019
2020
2021
2022
plans selected, also are available, including for PY2025.¹¹⁴ Table 3. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing Reductions Nationwide, by Plan Year

(based on effectuated enrollment in all individual exchanges)

Plan Year Average Total Premium per Month^a Average APTC per Month^b Percentage of Enrollees Receiving APTC^c Percentage of Enrollees Receiving CSR^d Dataas of 2014^e

Not available

$276

86%

58%

Dec. 2014

2015^f

Not available

$272

85%

57%

Mar. 2015

2016^f

Not available

$291

85%

57%

Mar. 2016

2017^g

$470.52

$373.06

84%

57%

PY2017

2018^h

$597.20

$519.89

87%

53%

Feb. 2018

2019

$594.17

$514.01

87%

52%

Feb. 2019

2020

$576.16

$491.53

86%

50%

Feb. 2020

2021

$574.59

$485.67

86%

48%

Feb. 2021

2022

$586.56

$508.26

90%

49%

Feb. 2022

2023

$604.78

$527.07

91%

48%

Feb. 2023

2024

$603.04

$535.91

93%

50%

Feb. 2024

Source: CRS analysis based on Department of Health and Human Services (HHS) reports of individual exchange enrollment Source: CRS analysis based on Department of Health and Human Services (HHS) reports of individual exchange
enrol ment in private health insurance plans, as specified in in private health insurance plans, as specified in these table notes and cited at CRS Report R46638, table notes and cited at CRS Report R46638, Health
Insurance Exchanges: Sources forof Statistics in the in the “"Point-in-Time Effectuated Point-in-Time Effectuated Enrol ment Data”Enrollment Data" section. These section. These
PY2022PY2024 estimates, for example, estimates, for example, were point-in-time as ofare point in time for February February 2022, and published in September 2022.
Notes: N/A = not available. PY = plan year. 2024, per CMS, Effectuated Enrollment: Early 2024 Snapshot and Full Year 2023 Average, July 2024, https://www.cms.gov/files/document/early-2024-and-full-year-2023-effectuated-enrollment-report.pdf. Notes: APTCs (advance premium tax credits) and CSRs (cost-sharing APTCs (advance premium tax credits) and CSRs (cost-sharing
reductions) are types of financial assistance that effectively reduce premiums and cost sharing, respectively, for reductions) are types of financial assistance that effectively reduce premiums and cost sharing, respectively, for
eligible consumers obtaining coverage in the individual exchanges. The average premium and APTC amounts eligible consumers obtaining coverage in the individual exchanges. The average premium and APTC amounts
shown above may in the table obscure wide variations in actual amounts per consumer, depending on the metal level plan an obscure wide variations in actual amounts per consumer, depending on the metal level plan an
individual chooses and/or the factors by which an insurer is able to vary premiums (individual chooses and/or the factors by which an insurer is able to vary premiums (see “e.g., age; see "Premiums, Cost Sharing,
and Subsidies”" in this report). In addition, the APTC data in the table in this report). In addition, the APTC data in the table typically are are not not necessarily final, because when an final, because when an
individual receiving an APTC files his or her tax return for a given year, the total amount of advance payments he individual receiving an APTC files his or her tax return for a given year, the total amount of advance payments he
or she received in that tax year is reconciled with the amount he or she should have received.or she received in that tax year is reconciled with the amount he or she should have received.
a. a. This definition, or a non-substantive variation of it, appears in one or more reports: "Average total premium per month is the total premium (including APTC and any premium paid by the policyholder) for the month, divided by the number of individuals who had an active policy for the month." b. This definition, or a non-substantive variation of it, appears in one or more reports: "Average APTC per month is the total amount of APTC for the month for all individuals who received APTC, divided by the number of individuals who received APTC." c. This definition, or a non-substantive variation of it, appears in one or more reports: "APTC enrollment is the total number of individuals who had an active policy in February 2017, who paid their premium (thus becoming effectuated), and who received an APTC subsidy." d. This definition, or a non-substantive variation of it, appears in one or more reports: "CSR enrollment is the total number of individuals who had an active policy in February 2017, who paid their premium (thus effectuating their coverage), and received CSRs." e. Relevant data for PY2014 are available only as of December 2014. These numbers are provided to allow for Relevant data for PY2014 are available only as of December 2014. These numbers are provided to allow for
approximate comparison within the table. Average premium amounts were not provided in this or the approximate comparison within the table. Average premium amounts were not provided in this or the
fol owing year’following year's report. See s report. See March 31, 2015, Effectuated Enrollment Snapshot, June 2015.June 2015.
b. f. Average premium amounts for PY2015 and PY2016 were not provided in those yearsAverage premium amounts for PY2015 and PY2016 were not provided in those years’' or the following years' or the fol owing
years’ reports. See reports. See March 31, 2015 Effectuated Enrollment Snapshot, June 2015June 2015, and and March 31, 2016,
Effectuated Enrollment Snapshot, June 2016, respectively., June 2016, respectively.
c. g. The June 2017 report provided average APTC data but not average premium data for February 2017. The June 2017 report provided average APTC data but not average premium data for February 2017.
However, the July 2018 report provided average monthly premium and APTC data for the 2017 plan year However, the July 2018 report provided average monthly premium and APTC data for the 2017 plan year
(total amounts for the year, divided by the total number of member months). The data in this column, from (total amounts for the year, divided by the total number of member months). The data in this column, from
the July 2018 report, are provided to allow for approximate comparison, but they are average monthly the July 2018 report, are provided to allow for approximate comparison, but they are average monthly
estimates for the year rather than the average estimates for a given month as shown in this table for other estimates for the year rather than the average estimates for a given month as shown in this table for other
years. See 2017 years. See 2017 Effectuated Enrollment Snapshot, June 2017, June 2017, and and Early 2018 Effectuated Enrollment Snapshot,
July 2018.July 2018.
d. h. See See Early 2018 Effectuated Enrollment Snapshot, July 2018. Subsequent year data in this table are from similar July 2018. Subsequent year data in this table are from similar
subsequent year reports.

at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-Choice-Premiums. Hereinafter referred to as “CMS,
QHP Choice, PY2023.” Also see KFF, “Average Marketplace Premiums by Metal Tier, 2018-2023,” not dated, at
https://www.kff.org/health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/; and KFF, “Cost-
Sharing for Plans Offered in the Federal Marketplace, 2014-2023,” February 2023, at https://www.kff.org/slideshow/
cost-sharing-for-plans-offered-in-the-federal-marketplace/.
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e. This definition, or a non-substantive variation of it, appears in one or more reports: “Average total premium
per month is the total premium (including APTC and any premium paid by the policyholder) for the month,
divided by the number of individuals who had an active policy for the month.”
f.
This definition, or a non-substantive variation of it, appears in one or more reports: “Average APTC per
month is the total amount of APTC for the month for all individuals who received APTC, divided by the
number of individuals who received APTC.”
g. This definition, or a non-substantive variation of it, appears in one or more reports: “APTC enrol ment is
the total number of individuals who had an active policy in February 2017, who paid their premium (thus
becoming effectuated), and who received an APTC subsidy.”
h. This definition, or a non-substantive variation of it, appears in one or more reports: “CSR enrol ment is the
total number of individuals who had an active policy in February 2017, who paid their premium (thus
effectuating their coverage), and received CSRs.”
Insurer Participation
As stated earlier (see “Qualified Health Plans”subsequent year reports. Provider Networks

Most plans—in and out of the exchanges—have a provider network, which refers to a set of health care providers and facilities that the insurer has contracted with to furnish covered benefits to plan enrollees at specified prices. In general, insurers can make various decisions about their provider networks, including whether to include out-of-state providers in their networks and whether to provide coverage for benefits furnished by out-of-network providers.

There are no federal requirements generally related to provider network composition that apply to private health insurance plans outside the exchanges,¹¹⁵ but there are certain network adequacy requirements that apply to QHPs in the exchanges.¹¹⁶ Per current regulations on exchange network adequacy requirements, QHP issuers must use provider networks and must ensure their networks are "sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay."¹¹⁷ This is further defined in terms of the following standards:

• As of PY2023, QHP issuers in FFEs generally must meet "time and distance" network adequacy standards set by HHS.¹¹⁸ Plans must provide access to at least one provider in each category listed in guidance, within set time and distance parameters (which vary by provider type and by geography), for at least 90% of enrollees. "For example, for endocrinology in a large metro county, at least 90 percent of enrollees would be required to have reasonable access to at least one provider within 15 miles and 30 minutes." ¹¹⁹
• As of PY2025, QHP issuers in FFEs generally also must meet "appointment wait time" network adequacy standards. For example, enrollees seeking an appointment for routine primary care must be able to schedule an appointment within 15 business days, at least 90% of the time.¹²⁰

These network adequacy requirements also apply in some or all exchanges:

• QHP issuers in all exchanges must include essential community providers (ECPs) in their provider networks, namely a "a sufficient number and geographic distribution of [ECPs], where available, to ensure reasonable and timely access" for low-income and medically underserved individuals.¹²¹ QHP issuers in FFEs are subject to specific ECP standards—for example, that they must offer a contract to at least one ECP in each of eight categories of providers (e.g., federally qualified health centers, mental health facilities, and family planning providers) in each county in the plan's service area and all available Indian Health Care providers in the plan's service area.
• QHP issuers in all exchanges "must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients" and other information as specified, "in a manner that is easily accessible."¹²²

Exchange Provider Network Data CMS PUFs on plans offered in the federal and state exchanges include certain data on QHPs' provider networks—for example, plans' provider network URLs and indications of whether a plan has a nationwide network—but the files do not appear to measure network composition.¹²³

There have been some analyses of QHP provider networks, including estimates of plans' network composition relative to available providers in the area. For example, an August 2024 KFF report estimated the following, regarding the individual exchanges nationwide in 2021:

On average, Marketplace enrollees had access to 40% of the doctors near their home through their plan's network, with considerable variation around the average. Twenty-three percent of Marketplace enrollees were in a plan with a network that included a quarter or fewer of the doctors in their area, while only 4% were in a plan that included more than three-quarters of the area doctors in their network.¹²⁴

These analyses also address some factors that insurers may consider when establishing their networks (e.g., provider availability, market dynamics between insurers and providers, costs and their effect on premiums, consumer preferences regarding access and costs, and applicable federal and state requirements).

Insurer Participation As stated earlier (see "Qualified Health Plans"), insurers are not federally required to participate ), insurers are not federally required to participate
in the exchanges, but they must meet certain requirements if they do want to offer plans in an in the exchanges, but they must meet certain requirements if they do want to offer plans in an
exchange.exchange.
Also as stated earlier (see "Individual and SHOP Exchanges"), insurers offering QHPs—also called QHP issuers—may offer plans that cover the whole state or only certain areas within a state, such as one or more counties. For each plan year to date, at least one insurer has offered an individual exchange plan in each For each plan year to date, at least one insurer has offered an individual exchange plan in each
county in all states. However, there have been concerns about county in all states. However, there have been concerns about “"bare countiesbare counties”" in one or more plan in one or more plan
years, particularly as insurers were making their decisions in 2017 about offering coverage for years, particularly as insurers were making their decisions in 2017 about offering coverage for
PY2018.PY2018.82
125 See Figure 2 3 for CMS projections of insurer participation in all individual exchanges for CMS projections of insurer participation in all individual exchanges (including SBEs) in PY2025. It shows that 18% of counties have one or two QHP issuers, 49% of counties have three or four QHP issuers, and 32% of counties have five or more QHP issuers.¹²⁶

According to a CMS report on the 31 FFE and SBE-FP states in PY25, eight states have more QHP issuers in PY25 than PY24 (Florida, Iowa, Michigan, Nebraska, New Hampshire, Ohio, Texas, and Wyoming) and three states have fewer QHP issuers in PY25 than PY24 (Illinois, Kansas, and Utah).¹²⁷ Additional data on issuer participation and plan availability are provided at the end of this section.

Figure 3. Plan Year 2025 Insurer Participation in the Individual Exchanges, by County Source: CRS adapted from in PY2023.
According to a CMS report on FFE and SBE-FP states only, “out of the 33 PY23 HealthCare.gov
states, 11 states have more QHP issuers participating in PY23 than PY22, and 22 states have
counties with more QHP issuers in PY23 than PY22 due to new issuers entering and existing
issuers expanding service areas.”83

82 See, for example, Erica Teichert, “Last ‘bare’ county in the U.S. scores ACA exchange coverage,” Modern
Healthcare, August 24, 2017, at https://www.modernhealthcare.com/article/20170824/NEWS/170829941/last-bare-
county-in-the-u-s-scores-aca-exchange-coverage.
83 CMS, QHP Choice, PY2023.
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Figure 2. Plan Year 2023 Insurer Participation in the Individual Exchanges, by County

Source: Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance
Oversight (CCIIO), Oversight (CCIIO), “"County by County Plan Year County by County Plan Year 20232025 Insurer Participation in Health Insurance Exchanges, Insurer Participation in Health Insurance Exchanges,”
published" October October 31, 2022, at 25, 2024, https://www.cms.gov/marketplace/about/exchange-coverage-mapshttps://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-
Marketplaces/Health-Insurance-Exchange-Coverage-Maps. This page also has such maps for prior years.. This page also has such maps for prior years.
An insurer might choose to begin, continue, or stop offering coverage in a state or locality, on An insurer might choose to begin, continue, or stop offering coverage in a state or locality, on
and/or off an exchange, for various reasons. In January 2019, the Government Accountability and/or off an exchange, for various reasons. In January 2019, the Government Accountability
Office (GAO) released a report on insurer participation and related issues in the individual Office (GAO) released a report on insurer participation and related issues in the individual
exchanges.exchanges.84128 The report provided background on a range of policy factors that may have affected The report provided background on a range of policy factors that may have affected
insurer participation in various ways, including the following:insurer participation in various ways, including the following:
 the federal requirements imposed by the ACA on plans sold in the nongroup the federal requirements imposed by the ACA on plans sold in the nongroup
market, including the individual exchanges;market, including the individual exchanges;85
 129 the consumer financial assistance available only in the exchanges;the consumer financial assistance available only in the exchanges;86
 130 the three ACA programs—risk corridors, reinsurance, and risk adjustment—the three ACA programs—risk corridors, reinsurance, and risk adjustment—
meant to mitigate insurersmeant to mitigate insurers’' financial risk in the financial risk in the individualnongroup and small-group and small-group
markets, including in the exchanges;87

84 Government Accountability Office (GAO), Health Insurance Exchanges: Claims Costs and Federal and State
Policies Drove Issuer Participation, Premiums, and Plan Design, January 2019, at https://www.gao.gov/products/
GAO-19-215.
85 Several provisions of the ACA, such as guaranteed issue of health insurance, generally have increased higher-risk
individuals’ ability to purchase insurance and restricted insurers’ ability to deny or limit coverage to such individuals.
The ACA created some new requirements and expanded some existing requirements, including by applying
requirements on the nongroup market that previously existed in one or more segments of the group market.
86 See “Premium Tax Credits and Cost-Sharing Reductions” in this report. One of the factors cited in the GAO report as
affecting insurers’ participation was “federal funding changes,” including the ending of federal payments for cost-
sharing reduction subsidies in October 2017.
87 Of the three ACA risk-mitigation programs—risk corridors, reinsurance, and risk adjustment—one was designed to
be permanent. The risk corridors and reinsurance programs were in effect from 2014 to 2016; the risk adjustment
program also began in 2014 and is still in effect. It assesses charges on applicable private health insurance plans with
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 federal policy changes in the years since the enactment of the ACA;88 and
 state-level requirements.
These and other factors, such as the health of the populations enrolling in exchange plans, had
varying impacts on claims costs (the costs insurers pay for their enrollees’ health benefits), which
in turn impacted insurer participation, as well as insurers’ decisions about premium amounts and
plan designs (e.g., covered benefits, cost sharing, and provider networks).
SHOP Exchanges
Eligibility and Enrollment
markets, including in the exchanges;¹³¹

federal policy changes in the years since the enactment of the ACA;¹³² and

state-level requirements.

These and other factors, such as the health of the populations enrolling in exchange plans, had varying impacts on claims costs (the costs insurers pay for their enrollees' health benefits), which in turn impacted insurer participation, as well as insurers' decisions about premium amounts and plan designs (e.g., covered benefits, cost sharing, and provider networks).

The GAO also reports biannually on private health insurance market concentration, including in the individual exchanges. In its November 2024 and prior such reports, the GAO defines a concentrated market (in a state or otherwise) as one where "three or fewer issuers held at least 80 percent of the market share of enrollment among consumers."¹³³ The GAO finds that market concentration generally has increased in the nongroup market (the individual market overall, including the exchanges), from 2011 through 2022. Focusing on the exchanges, market concentration increased from 2015 through 2020, when all 51 individual exchange markets were concentrated, per the definition above. This number has decreased slightly since then, and as of 2022, 47 individual exchange markets were concentrated. As shown in Figure 4, other private health insurance markets were also concentrated in 2022 (i.e., the large group market in 43 states, the small group in 47 states, and the individual market overall in 35 states). Factors affecting market concentration are discussed below.

Figure 4. Private Health Insurance Market Concentration in the Individual Exchanges and Other Markets, 2022 Source: CRS illustration of data from the Government Accountability Office (GAO), Private Health Insurance: Market Concentration Generally Increased from 2011 Through 2022, November 2024, at https://www.gao.gov/products/gao-25-107194. See Table 1 in this GAO report for these 2022 as well as prior year data.

Notes: Counts include the 50 states and the District of Columbia. The individual health insurance market (nongroup market) includes the individual exchanges. And per GAO, "Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year." See GAO report for methodology, additional details, and prior year data.

Market concentration is affected by insurer entrances and exits in a given market, and the related factors discussed earlier in this section. It is also affected by market consolidation, including when one insurance company merges with or purchases another insurance company.¹³⁴ Health insurance market concentration and consolidation may have implications for insurers (e.g., in terms of their contract negotiating power with healthcare providers) and implications for consumers (e.g., in terms of plan choices and costs). However, insurer-provider interactions and health insurance premiums are also affected by numerous other factors. ¹³⁵

There are several ways to measure the health insurance options that consumers have. As discussed above in this section, there are counts of insurer participation (how many insurers are offering plans) and insurer concentration (insurers' market share of enrollment). There are also counts of the number of plans available in a market, because a given insurer might offer one or multiple plan options. Per the aforementioned CMS analysis of the 31 FFE and SBE-FP exchanges in PY2025, there are an average of 7.3 QHP issuers—and an average of 100 QHPs—available to exchange consumers per county.¹³⁶

Agency concerns about "choice overload" have contributed to recent regulatory requirements regarding "standardized plans" and limitations on non-standardized plans, discussed earlier in this report.¹³⁷

SHOP Exchanges Eligibility and Enrollment Certain small businesses are eligible to use the SHOP exchanges. For purposes of SHOP Certain small businesses are eligible to use the SHOP exchanges. For purposes of SHOP
eligibility, a small business, or eligibility, a small business, or small employer, is generally an employer with not more than 50 , is generally an employer with not more than 50
employees.employees.89 138 States also may define States also may define small employer as having not more than 100 employees–four as having not more than 100 employees–four
states do.states do.90139 As of 2017, all states have the option to allow As of 2017, all states have the option to allow large employers to use SHOP to use SHOP
exchanges, as well, but no states have done so.exchanges, as well, but no states have done so.91
140 SHOP eligibility also depends on an employer having at least at least one SHOP eligibility also depends on an employer having at least at least one common-law
employee..92141 This means, for example, that a person who is self-employed and who has no This means, for example, that a person who is self-employed and who has no
employees would not be eligible for the SHOP exchange (although they could purchase coverage employees would not be eligible for the SHOP exchange (although they could purchase coverage
in the individual exchange, if they meet the other eligibility requirements). In addition, per the in the individual exchange, if they meet the other eligibility requirements). In addition, per the
definition of common-law employee, neither the business owner nor their business partner(s) nor definition of common-law employee, neither the business owner nor their business partner(s) nor
their spouse or family members (even if involved in the business) count as an employee for their spouse or family members (even if involved in the business) count as an employee for
purposes of SHOP eligibility.purposes of SHOP eligibility.
To participate in a SHOP exchange, a small business must offer coverage to all of its To participate in a SHOP exchange, a small business must offer coverage to all of its full-time
employees, which, for purposes of SHOP eligibility, means those employees working 30 or more which, for purposes of SHOP eligibility, means those employees working 30 or more
hours per week on average.hours per week on average.93142 The business may, but is not required to, offer coverage to part-time or other employees, and/or to the spouses and dependents of any employees offered coverage.¹⁴³ Employees and their enrolling family members must meet the same eligibility requirements that apply in the individual exchanges. Enrollment Periods The business may, but is not required to, offer coverage to part-time

relatively healthier enrollees and uses collected charges to make payments to private health plans in the same state that
have relatively sicker enrollees. See “Other Federal Funding Sources” in this report regarding the charges assessed on
insurers via the risk adjustment program. The phaseouts of the other two programs are cited among “federal funding
changes” affecting insurers’ participation decisions. For descriptions of all three programs and their different
approaches, see Table 1 in CRS Report R45334, The Patient Protection and Affordable Care Act’s (ACA’s) Risk
Adjustment Program: Frequently Asked Questions.
88 See Figure 1 in the GAO report discussed in this section.
89 For purposes of SHOP eligibility, the number of employees is determined using the “full-time equivalent” (FTE)
employees calculation method. See 45 C.F.R. §155.20, “Small employer,” which references 26 U.S.C. §4980H. Also
see CRS Report R45455, The Affordable Care Act’s (ACA’s) Employer Shared Responsibility Provisions (ESRP) for
discussion of FTE calculations.
90 California, Colorado, New York, and Vermont are the only states that define small businesses as having 100 or fewer
employees for the purpose of participation in the SHOP exchanges. See CMS/CCIIO, “Market Rating Reforms,”
updated December 2021, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/
state-rating. Also see Table A-1.
91 42 U.S.C. §18032(f)(2)(B).
92 For discussion of the SHOP eligibility requirement to have at least one common-law employee, see HHS, “Patient
Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for
Employers,” March 27, 2012, 77 Federal Register 18309, page 18399.
93 For purposes of SHOP eligibility, the definition of full-time employee is at 45 C.F.R. §155.20.
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or other employees, and/or to the spouses and dependents of any employees offered coverage.94
Employees and their enrolling family members must meet the same citizenship and other
eligibility requirements that apply in the individual exchanges.
Enrollment Periods
Enrollment in a SHOP exchange is not limited to a specified OEP, except in certain Enrollment in a SHOP exchange is not limited to a specified OEP, except in certain
circumstances.circumstances.95144 Such circumstances aside, a SHOP exchange must allow employers to enroll any Such circumstances aside, a SHOP exchange must allow employers to enroll any
time during a year, and the employertime during a year, and the employer’'s plan year must consist of the 12-month period beginning s plan year must consist of the 12-month period beginning
with the employerwith the employer’'s effective date of coverage.s effective date of coverage.96145 Whereas plans sold in the individual exchanges Whereas plans sold in the individual exchanges
generally align with the calendar year, plans sold in the SHOP exchanges need not (thus, statutory generally align with the calendar year, plans sold in the SHOP exchanges need not (thus, statutory
or regulatory provisions affecting the SHOP exchanges may refer to or regulatory provisions affecting the SHOP exchanges may refer to “"plan years beginning inplan years beginning in”" a a
given year).given year).
There are SEPs for SHOP exchange coverage. Some of the SEPs for the SHOP exchanges are the There are SEPs for SHOP exchange coverage. Some of the SEPs for the SHOP exchanges are the
same as in the individual exchanges.same as in the individual exchanges.97
146 Enrollment Processes and Options
For an employee to obtain coverage through a SHOP exchange, a SHOP-eligible employer must For an employee to obtain coverage through a SHOP exchange, a SHOP-eligible employer must
select one or more plan options on the SHOP exchange for its employees to choose from.select one or more plan options on the SHOP exchange for its employees to choose from.98147 Then, Then,
employees review their employeremployees review their employer’'s plan option(s) and enroll if they choose. The process of s plan option(s) and enroll if they choose. The process of
comparing and enrolling in coverage depends partially on a statecomparing and enrolling in coverage depends partially on a state’'s SHOP exchange type:s SHOP exchange type:
 In states with FF-SHOPs (i.e., states with SHOP exchanges using the federal In states with FF-SHOPs (i.e., states with SHOP exchanges using the federal
HealthCare.gov platform), employers HealthCare.gov platform), employers and employees are able to browse and
comparedetermine their SHOP eligibility and can browse plan options on HealthCare.gov, but they need to work directly with a plan options on HealthCare.gov, but they need to work directly with a
SHOP-registered agent, broker, or insurer to purchase coverage.SHOP-registered agent, broker, or insurer to purchase coverage.99148 This is This is sometimes called SHOP called
direct enrollment, and it has been the only option in such states since plan years , and it has been the only option in such states since plan years
beginning in 2018beginning in 2018.100 Previously, employers and employees could purchase Previously, employers and employees could purchase
SHOP coverage on HealthCare.gov or via direct enrollment. HHS finalized this change in the 2019 Payment Noticecoverage on HealthCare.gov or via direct enrollment.

94 45 C.F.R. §155.710(e).
95 It is possible for SHOP exchanges to establish minimum participation rates and minimum contribution rates.
Businesses that do not comply with established rates cannot be prohibited from obtaining coverage through SHOP
exchanges; rather, health insurance plans may limit the availability of coverage for any employer that does not meet an
allowed minimum participation or contribution rate to an annual enrollment period—November 15 through December
15 of each year. See, for example, the HealthCare.gov page on SHOP eligibility and enrollment:
https://www.healthcare.gov/small-businesses/choose-and-enroll/qualify-for-shop-marketplace/.
96 45 C.F.R. §155.726(b).
97 45 C.F.R. §155.726(c). See also Section 4.4 of CMS, FFE and FF-SHOP Enrollment Manual (2022), which notes
that SHOP exchange SEPs “cross-referenc[e] most, but not all, of the qualifying events listed at 155.420(d) [which lists
SEPs for the individual exchanges].”
98 A business with locations or employees in multiple states has options for offering SHOP coverage to all its eligible
employees. See 45 C.F.R. §155.710 and HealthCare.gov, “SHOP Coverage for Multiple Locations and Businesses,” at
https://www.healthcare.gov/small-businesses/provide-shop-coverage/business-in-more-than-one-state/.
99 HealthCare.gov, “Overview of SHOP: Health insurance for small businesses,” at https://www.healthcare.gov/small-
businesses/choose-and-enroll/shop-marketplace-overview/.
100 HHS finalized this change in the 2019 Payment Notice (page 16996), citing generally low employer participation in , citing generally low employer participation in
the SHOP exchanges and decreasing insurer participation (both the SHOP exchanges and decreasing insurer participation (both further discussed discussed elsewhere in the SHOP section of this
report). HHS also confirmed in the 2019 Payment Notice that because of these reductions in federal SHOP web portal
functionality, state-based SHOP exchanges would no longer be able to use the federal IT platform. In other words,
HHS eliminated the SB-FP-SHOP option (discussed in “State-Based and Federally Facilitated Exchanges”). The two
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 below in this section).¹⁴⁹ States administering their own SB-SHOPStates administering their own SB-SHOP websitess initially were allowed to use a initially were allowed to use a
SHOP direct enrollment approach, due to early difficulties some states had in getting direct enrollment approach, due to early difficulties some states had in getting
their SHOP exchange websites online.their SHOP exchange websites online.101150 As of April 2016, HHS indicated SB- As of April 2016, HHS indicated SB-
SHOPs would need to implement online portals in time for plan years beginning SHOPs would need to implement online portals in time for plan years beginning
in 2019.in 2019.102 However, in the 2019 Payment Notice151 However, when HHS transitioned , when HHS transitioned
HealthCare.gov SHOP exchanges to direct enrollment (see previous bullet), HHS HealthCare.gov SHOP exchanges to direct enrollment (see previous bullet), HHS
also announced SB-SHOPs had the option of retaining or returning to a direct also announced SB-SHOPs had the option of retaining or returning to a direct
enrollment approach or maintaining enrollment sites if they had created them. enrollment approach or maintaining enrollment sites if they had created them.
For PY2023For PY2025, of the , of the 1516 SB-SHOP states with medical plans offered, SB-SHOP states with medical plans offered, nine11 are are
using DE approaches only.103
Besidesusing SHOP direct enrollment approaches only.¹⁵² Besides SHOP exchange website enrollment versus direct enrollment options, a significant factor exchange website enrollment versus direct enrollment options, a significant factor
affecting enrollment processes is whether any insurers are offering plans in that stateaffecting enrollment processes is whether any insurers are offering plans in that state’'s SHOP s SHOP
exchange. For exchange. For PY2023PY2025, there are no insurers offering medical plans in SHOP exchanges in , there are no insurers offering medical plans in SHOP exchanges in about
more than half of states.half of states.104153 In such states, the federal or state SHOP In such states, the federal or state SHOP webpageweb page instructs users to work directly instructs users to work directly
with an agent, broker, or insurer to obtain coverage in the small-group market off-exchange.with an agent, broker, or insurer to obtain coverage in the small-group market off-exchange.
See See Table A-1 for more information on SHOP exchange plan availability and enrollment for more information on SHOP exchange plan availability and enrollment
methods, by state.methods, by state.
Enrollment Estimates
Data Unlike individual exchange enrollment data, SHOP exchange enrollment data are not released Unlike individual exchange enrollment data, SHOP exchange enrollment data are not released
annually. However, CMS estimated that there were approximately 27,000 small employers and annually. However, CMS estimated that there were approximately 27,000 small employers and
233,000 employees using the SHOP exchanges across the country in January 2017.233,000 employees using the SHOP exchanges across the country in January 2017.105154 CMS CMS
previously estimated 10,700 active small employers and 85,000 employees in the SHOP previously estimated 10,700 active small employers and 85,000 employees in the SHOP
exchanges as of May 2015.106

states that used this option at the time, Kentucky and Nevada, were allowed to continue doing so if desired, despite the
reduced functionality of HealthCare.gov for SHOP. However, they have since transitioned their SHOPs to other types
(see Table A-1). Citation for the 2019 Payment Notice is in Table D-1.
101 For iterations of guidance on this topic issued between 2014 and 2016, see CMS, CCIIO, “Extension of State-Based
SHOP Direct Enrollment Transition,” April 18, 2016, at https://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/Downloads/1332-and-SHOP-Guidance-508-FINAL.PDF.
102 Ibid. In April 2016, CMS also outlined different options for those states to consider, including transitioning to the
federal IT platform (becoming an SB-FP-SHOP) or applying for an ACA Section 1332 waiver to obtain an exception to
the requirement to have a SHOP exchange at all. For more information about ACA Section 1332 waivers, see CRS
Report R44760, State Innovation Waivers: Frequently Asked Questions.
103 See Table A-1.
104 The number of states with no insurers offering plans in SHOP exchanges in 2023 is based on CRS analysis of the
2023 “Business Rules” public use file at CMS, “Health Insurance Exchange Public Use Files (Exchange PUFs),” at
https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf, as well as information available on
HealthCare.gov and state exchange websites. Comparable information about insurer participation in SHOP exchanges
in prior years may not be consistently available. However, a 2019 GAO report indicates that in 2015-2017, there was at
least one insurer participating in each of the 46 of 51 states for which it had such data for all three of those years. See
Table 7 in GAO, Private Health Insurance: Enrollment Remains Concentrated Among Few Issuers, Including in
Exchanges, March 21, 2019, at https://www.gao.gov/products/GAO-19-306. Hereinafter referred to as “GAO
Enrollment Report, March 2019.”
105 This estimate excludes Hawaii, as Hawaii’s SHOP exchange was no longer operational in 2017 due to the state’s
receipt of a 1332 waiver. See CMS, CCIIO, “SHOP Marketplace Enrollment as of January 2017,” May 15, 2017, at
https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/SHOP-Marketplace-Enrollment-Data.pdf.
106 This estimate excludes Vermont and Idaho; these states had not reported 2015 enrollment data to CMS. See CMS,
“Update on SHOP Marketplaces for Small Businesses,” July 2, 2015, archived at http://wayback.archive-it.org/2744/
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exchanges as of May 2015.¹⁵⁵ According to a 2019 GAO report that included 2016 SHOP exchange enrollment data for 46 According to a 2019 GAO report that included 2016 SHOP exchange enrollment data for 46
states,states,
As a proportion of the overall small-group market, SHOP exchanges in most states had
As a proportion of the overall small-group market, SHOP exchanges in most states had little enrollment—that is, typically less than 1 percent of the overall small-group market ... little enrollment—that is, typically less than 1 percent of the overall small-group market ...
The District of Columbia, Rhode Island, and Vermont were the only states where the SHOP The District of Columbia, Rhode Island, and Vermont were the only states where the SHOP
exchange was more than 3 percent of the overall small-group market. The District of
exchange was more than 3 percent of the overall small-group market. The District of Columbia and Vermont require all small-group plans to be purchased through the stateColumbia and Vermont require all small-group plans to be purchased through the state’s
's SHOP exchange.SHOP exchange.107
156 In addition, District of Columbia SHOP enrollment includes congressional Members and staff, as In addition, District of Columbia SHOP enrollment includes congressional Members and staff, as
discussed below.discussed below.
Congressional Member and Staff Enrollment via the D.C.DC SHOP Exchange
Per the ACA, Members of Congress and their Per the ACA, Members of Congress and their staff generallydesignated staff are required to obtain their health are required to obtain their health
insurance through the exchanges in order to receive a government contribution (i.e., their insurance through the exchanges in order to receive a government contribution (i.e., their
employer’employer's contribution) for their coverage.s contribution) for their coverage.108157 This includes designated staff working in a Member's home state.¹⁵⁸ As implemented, they purchase coverage through As implemented, they purchase coverage through
the District of Columbiathe District of Columbia’'s SHOP exchanges SHOP exchange. , DC Health Link. Congressional offices are not eligible for the small Congressional offices are not eligible for the small
business tax credit (discussed below), and congressional Members and staff obtaining coverage business tax credit (discussed below), and congressional Members and staff obtaining coverage
through the SHOP are not eligible for the PTC and CSRs that are available to individuals who through the SHOP are not eligible for the PTC and CSRs that are available to individuals who
enroll in coverage offered on the individual exchanges (see enroll in coverage offered on the individual exchanges (see "“Premium Tax Credits and Cost-
Sharing Reductions”).
Premiums"). Benefits, Premiums, and Cost Sharing
The information earlier in this report on The information earlier in this report on premiums and cost sharing in the individual exchanges,
including certain federal requirements that apply to certain federal requirements that apply to premiumsbenefits, premiums, and cost sharing and cost sharing (e.g.,in the individual exchanges (e.g., coverage of the EHB, minimum AV levels), AV levels),
generally applies in the SHOP exchanges, as well.generally applies in the SHOP exchanges, as well.¹⁵⁹ See CRS Report R45146, See CRS Report R45146, Federal
Requirements on Private Health Insurance Plans for other requirements applicable to the for other requirements applicable to the
nongroup and small-group markets, on and off the exchanges.nongroup and small-group markets, on and off the exchanges.
Employers who offer coverage through the SHOP exchange, like employers who offer coverage Employers who offer coverage through the SHOP exchange, like employers who offer coverage
otherwise, may choose to subsidize their employeesotherwise, may choose to subsidize their employees’' premiums. This means the employer pays premiums. This means the employer pays
for part of their employeesfor part of their employees’' premiums. premiums.
CRS is not aware of HHS or other organizationsCRS is not aware of HHS or other organizations’' reports on plan features specific to the SHOP exchanges, but certain CMS PUFs on the federal and state exchanges include data on SHOP plans.¹⁶⁰ reports on premium or cost-sharing data
specific to the SHOP exchanges.
Small Business Health Care Tax Credit
Certain small businesses are eligible for the small business health care tax credit (SBTC).Certain small businesses are eligible for the small business health care tax credit (SBTC).109161 In In
general, this credit is available only to small employers with 25 or fewer full-time-equivalent

20170118124128/https:/blog.cms.gov/2015/07/.
107 See page 24 and Appendix III of the GAO Enrollment Report, March 2019.
108 Other federal employees may obtain coverage through the Federal Employees Health Benefits Program (FEHB).
Like many other employers, the federal government contributes to the cost of its employees’ premiums. This is also
true for the Congressional Members and staff who obtain coverage through the SHOP. Certain congressional staff may
not be required to obtain their coverage through the SHOP, and may be able to otherwise obtain coverage through
FEHB. See Office of Personnel Management, “Members of Congress and Designated Staff – General,” at
https://www.opm.gov/healthcare-insurance/changes-in-health-coverage/changes-in-health-coverage-faqs/.
109 See 26 U.S.C. §45R for eligibility for the Small Business Health Care Tax Credit (SBTC) and credit amount details
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general, this credit is available only to small employers with 25 or fewer full-time-equivalent (FTE) employees that purchase coverage through SHOP exchanges and contribute at least 50% of (FTE) employees that purchase coverage through SHOP exchanges and contribute at least 50% of
premium costs for their full-time employees.premium costs for their full-time employees.110 (162 For the purpose of this tax credit, For the purpose of this tax credit, full-time
employees are those who work an average of 40 hours per week, whereas for the purpose of are those who work an average of 40 hours per week, whereas for the purpose of
SHOP eligibility, SHOP eligibility, full-time employees are those who work an average of 30 hours per week. are those who work an average of 30 hours per week.111)
163 The intent of the credit is to assist small employers with the cost of providing health insurance The intent of the credit is to assist small employers with the cost of providing health insurance
coverage to employees. The credit is available to eligible small businesses for two consecutive coverage to employees. The credit is available to eligible small businesses for two consecutive
tax years (beginning with the first year the small employer purchases coverage through a SHOP tax years (beginning with the first year the small employer purchases coverage through a SHOP
exchange).exchange).
In states with no insurers offering plans through the SHOP exchange, certain eligible employers In states with no insurers offering plans through the SHOP exchange, certain eligible employers
still may be able to receive the credit. If they received their first yearstill may be able to receive the credit. If they received their first year’'s credit by offering coverage s credit by offering coverage
through the SHOP exchange and there were no SHOP plans available the next year, they may through the SHOP exchange and there were no SHOP plans available the next year, they may
receive their second consecutive yearreceive their second consecutive year’'s credit with a plan purchased off-exchange.s credit with a plan purchased off-exchange.112
164 The maximum credit is 50% of an employerThe maximum credit is 50% of an employer’'s contribution toward premiums for for-profit s contribution toward premiums for for-profit
employers and 35% of employer contributions for nonprofit organizations. The full credit is employers and 35% of employer contributions for nonprofit organizations. The full credit is
available to employers that have 10 or fewer FTE employees who have average taxable wages of available to employers that have 10 or fewer FTE employees who have average taxable wages of
$30,700 or less (in 2023).113$33,300 or less for taxable years beginning in 2025.¹⁶⁵ In general, the credit is phased out as the number of FTE employees In general, the credit is phased out as the number of FTE employees
increases from 10 to 25 and as average employee compensation increases to a maximum of two increases from 10 to 25 and as average employee compensation increases to a maximum of two
times the limit for the full credit.times the limit for the full credit.114
Employees who enroll in a SHOP plan do not receive this tax credit166

The SBTC is different than the business expense deduction that employers can claim for the costs of the health insurance premiums they subsidize. If an employer qualifies for the SBTC, they can claim the deduction for the premiums that exceed the credit amount. If an employer doesn't qualify for the SBTC, they can claim the deduction.

Employees who enroll in a SHOP plan do not receive the SBTC, nor are they eligible for the , nor are they eligible for the
financial assistance available to certain consumers who purchase coverage on the individual financial assistance available to certain consumers who purchase coverage on the individual
exchanges (see exchanges (see "“Premium Tax Credits and Cost-Sharing Reductions”).
"). The IRS has published information on the number of SBTCs filed in tax years 2010-2016.The IRS has published information on the number of SBTCs filed in tax years 2010-2016.115167 For For
2016, the IRS indicates that 6,952 employers claimed the SBTC.2016, the IRS indicates that 6,952 employers claimed the SBTC.116
Insurer Participation
As stated above, as of PY2023, there are no insurers offering SHOP medical plans in about half
of states. Some of the factors affecting insurer participation in the individual exchanges (see
“Insurer Participation” in the Individual Exchanges section above) also may affect insurer
participation in the SHOP exchanges. For example, just as in the nongroup market, there were
new federal requirements imposed by the ACA on plans sold in the small-group market (including

described in this section.
110 See the SHOP “Eligibility and Enrollment” section of this report for discussion of full-time equivalent employees.
111 Regarding SHOP eligibility, see 26 U.S.C. §4980H, 26 CFR §54.4980H-1(a)(21), and 45 CFR §155.20. Regarding
the SBTC, see 26 U.S.C. §45R.
112 Internal Revenue Service (IRS), Small Business Health Care Tax Credit Questions and Answers: Who Gets the Tax
Credit, Question 6D, updated September 2022, at https://www.irs.gov/newsroom/small-business-health-care-tax-credit-
questions-and-answers-who-gets-the-tax-credit.
113 IRS, Rev. Proc. 2022-38, Section 3.10, at https://www.irs.gov/pub/irs-drop/rp-22-38.pdf, referring to 26 U.S.C.
§45R(d)(3)(B).
114 26 U.S.C. §45R(d)(1)(B).
115 IRS, SOI Tax Stats - Affordable Care Act (ACA) Statistics: Credit for Small Employer Health Insurance,
“Premiums,” page updated Sept. 2022, at https://www.irs.gov/statistics/soi-tax-stats-affordable-care-act-aca-statistics-
credit-for-small-employer-health-insurance-premiums.
116 Ibid. See excel file, “Small Business Health Care Tax Credits Filed in Tax Years 2010–2016,” linked on this
webpage.
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168 Provider Networks

Exchange requirements related to network adequacy and essential community providers apply in the SHOP exchanges as in the individual exchanges.¹⁶⁹

Also as for the individual exchanges, certain CMS PUFs include limited data on SHOP QHPs' provider networks—for example, plans' provider network URLs and indications of whether a plan has a nationwide network.¹⁷⁰

Insurer Participation As stated above, there are no insurers offering SHOP medical plans in more than half of states. Some of the factors affecting insurer participation in the individual exchanges also may affect insurer participation in the SHOP exchanges.¹⁷¹ For example, just as in the nongroup market, there were new federal requirements imposed by the ACA on plans sold in the small-group market (including the SHOP exchanges), and insurers in the small-group market were or are participating in risk-the SHOP exchanges), and insurers in the small-group market were or are participating in risk-
mitigation programs.mitigation programs.
There are also factors unique to the SHOP exchanges that may have affected insurer participation. There are also factors unique to the SHOP exchanges that may have affected insurer participation.
For example, in December 2016For example, in December 2016 rulemaking, effective January 2018, HHS removed a requirement that in , effective January 2018, HHS removed a requirement that in
order to participate in a federally facilitated individual exchange, an insurer with more than 20% order to participate in a federally facilitated individual exchange, an insurer with more than 20%
of the small-group market in that state also would have to participate in that SHOP exchange. In of the small-group market in that state also would have to participate in that SHOP exchange. In
the rule, HHS acknowledged the elimination of this requirement likely would reduce insurer the rule, HHS acknowledged the elimination of this requirement likely would reduce insurer
participation, and thus employer and employee participation, in affected SHOP exchanges.participation, and thus employer and employee participation, in affected SHOP exchanges.117
172 Other issues also have been discussed as affecting employer and/or insurer participation in the Other issues also have been discussed as affecting employer and/or insurer participation in the
SHOP exchanges, such as delays in setting up online enrollment capabilities when the SHOPs SHOP exchanges, such as delays in setting up online enrollment capabilities when the SHOPs
were being establishedwere being established, and the limited duration and administrative complexity of the small and the limited duration and administrative complexity of the small
business tax credit.business tax credit.118
173 Exchange Enrollment Assistance
Navigators and Other Exchange-Based Enrollment Assistance
Federal statute and regulations require exchanges to carry out certain consumer outreach and Federal statute and regulations require exchanges to carry out certain consumer outreach and
assistance functions. These functions generally include in-person and other forms of outreach and assistance functions. These functions generally include in-person and other forms of outreach and
assistance.assistance.119
174 Each exchange must have a Each exchange must have a Navigator program.program.120175 Navigators are entities whose employees Navigators are entities whose employees
and/or volunteersand/or volunteers
 conduct public outreach and education activities about the exchanges and QHPs;conduct public outreach and education activities about the exchanges and QHPs;
 provide impartial information to consumers (including small employers and their provide impartial information to consumers (including small employers and their
employees) about their insurance options;employees) about their insurance options;
 help consumers access individual and SHOP exchange coverage, exchange help consumers access individual and SHOP exchange coverage, exchange
financial assistance, and/or public program coverage (e.g., Medicaid or CHIP) if financial assistance, and/or public program coverage (e.g., Medicaid or CHIP) if
they qualify;they qualify;
 refer consumers to any applicable consumer assistance programs as needed, such refer consumers to any applicable consumer assistance programs as needed, such
as state agencies that assist consumers with questions or complaints about their as state agencies that assist consumers with questions or complaints about their
plans; andplans; and
 comply with other Navigator requirements, as specified.comply with other Navigator requirements, as specified.
States may impose additional Navigator requirements, as long as States may impose additional Navigator requirements, as long as “"such standards do not prevent such standards do not prevent
the application of the provisions of Title I of the Affordable Care Act.”121

117 2018 Payment Notice, page 94144. Citation for this rule is at Table D-1.
118 See GAO, Small Business Health Insurance Exchanges: Low Initial Enrollment Likely due to Multiple, Evolving
Factors, November 2014, at https://www.gao.gov/products/GAO-15-58; and GAO, Enrollment Remains Concentrated
among Few Issuers, including in Exchanges, March 2019, at https://www.gao.gov/assets/gao-19-306.pdf. Also see
Timothy Jost, “CMS Announces Plans To Effectively End The SHOP Exchange,” Health Affairs Blog, May 15, 2017,
at https://www.healthaffairs.org/do/10.1377/hblog20170515.060112/full/.
119 For example, see 42 U.S.C. §18031(i), 45 C.F.R. §155.205, 45 C.F.R. §155.210, and 45 C.F.R. §155.225.
120 Ibid. Specifically, for the requirement to implement Navigator programs, see 45 C.F.R. §155.210.
121 45 C.F.R. §155.210(c)(1)(iii).
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Navigators are funded by the exchanges, via grants (federal or state, depending on exchange type)
provided to qualifying organizations. Information on current and prior-year Navigator grants in
FFE states is available on the CMS website.122 Also for FFE states, additional funding was made
available for Navigator grantees in March 2021, for purposes of outreach and enrollment efforts
regarding the COVID-19 SEP (discussed earlier in this report).123
the application of the provisions of Title I of the Affordable Care Act."¹⁷⁶ Navigators are funded by the exchanges, via grants (federal or state, depending on exchange type) provided to qualifying organizations. There is no specific appropriation or statutorily required funding level for the Navigator program, and HHS funding for the Navigators in FFEs has varied over the years.¹⁷⁷ States with SBEs and SBE-FPs fund their own Navigator programs.

In August 2024, HHS announced $100 million per year in grants to 44 Navigator organizations in the 28 FFE states as of PY2025. Per this funding announcement, this is "part of a commitment of up to $500 million over five years" (August 2024-August 2029).¹⁷⁸ This is longer than prior Navigator grant periods, which have ranged from one to three years. In February 2025, CMS announced a reduction in this funding to $10 million per year, as of the 2026 grant period that starts in August 2025.¹⁷⁹ More information on current and prior year Navigator grants in FFE states is available on the CMS website.¹⁸⁰

For FFE states, certain Navigator eligibility requirements were changed in the 2019 and 2020 For FFE states, certain Navigator eligibility requirements were changed in the 2019 and 2020
Payment Notices. For example, Navigator entities were no longer required to maintain a physical Payment Notices. For example, Navigator entities were no longer required to maintain a physical
presence in their exchange service area, and it became optional rather than mandatory for presence in their exchange service area, and it became optional rather than mandatory for
Navigators to provide assistance on certain post-enrollment topics (e.g., eligibility appeals, PTC Navigators to provide assistance on certain post-enrollment topics (e.g., eligibility appeals, PTC
reconciliation, and how to use health coverage).reconciliation, and how to use health coverage).124181 In the 2022 Payment Notice In the 2022 Payment Notice “"Part 3,Part 3,”" HHS HHS
again required that FFE Navigators provide assistance on the post-enrollment topics but did not again required that FFE Navigators provide assistance on the post-enrollment topics but did not
reverse the other changes.reverse the other changes.
182 Other Navigator program changes have been made via rulemaking over time.¹⁸³ Exchanges also must have a Exchanges also must have a Certified Application Counselor (CAC) program. (CAC) program.125184 CAC staff CAC staff
and/or volunteers also provide impartial information to consumers about their insurance options and/or volunteers also provide impartial information to consumers about their insurance options
and can assist them in applying for individual and SHOP exchange coverage, exchange financial and can assist them in applying for individual and SHOP exchange coverage, exchange financial
assistance, and/or public program coverage (e.g., Medicaid or CHIP) if they qualify. They do not assistance, and/or public program coverage (e.g., Medicaid or CHIP) if they qualify. They do not
necessarily provide public outreach and education or perform many of the other functions that necessarily provide public outreach and education or perform many of the other functions that
Navigators do. CACs are not exchange-funded in FFE states and are not required to be exchange-Navigators do. CACs are not exchange-funded in FFE states and are not required to be exchange-
funded in other states.funded in other states.
Although Navigator and CAC assisters can help consumers understand their options, Although Navigator and CAC assisters can help consumers understand their options, theyassisters may may
not advise not advise themconsumers on which plan to select on which plan to select, or complete the enrollment application for consumers. Once a consumer chooses a plan, the assisters may help . Once a consumer chooses a plan, the assisters may help
them enroll in coverage.as the consumer enrolls in coverage (including educating them about the enrollment process).¹⁸⁵ Neither Navigators nor CACs may be health insurers or take Neither Navigators nor CACs may be health insurers or take
compensation for selling health policies from insurers or consumers.compensation for selling health policies from insurers or consumers.126
186 Besides facilitating the above assistance programs, exchanges must provide for the operation of a Besides facilitating the above assistance programs, exchanges must provide for the operation of a
call center and maintain a website (e.g., HealthCare.gov) that meets certain informational call center and maintain a website (e.g., HealthCare.gov) that meets certain informational
requirements.requirements.127187 Exchanges also provide consumer information and outreach via mail, radio or Exchanges also provide consumer information and outreach via mail, radio or
television ads, and/or other methods. Overall, exchangestelevision ads, and/or other methods. Overall, exchanges’' consumer outreach efforts and materials consumer outreach efforts and materials
must meet certain standards regarding accessibility for individuals with disabilities or with must meet certain standards regarding accessibility for individuals with disabilities or with
limited English proficiency.128

122 For information on FFE Navigator grants, see CMS, “In-Person Assistance in the Health Insurance Marketplaces,”
at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance. This includes the
2022 Navigator grants announced in August 2022. CRS is not aware of a compilation of information about Navigator
grants in states that administer these programs (those with SBEs and SBE-FPs).
123 CMS, “CMS Announces Additional Navigator Funding to Support Marketplace Special Enrollment Period,” March
1, 2021, at https://www.cms.gov/newsroom/press-releases/cms-announces-additional-navigator-funding-support-
marketplace-special-enrollment-period.
124 Payment Notice citations are in Table D-1.
125 For the requirement to implement certified application counselor programs, see 45 C.F.R. §155.225.
126 45 C.F.R. §155.215.
127 45 C.F.R. §155.205.
128 45 C.F.R. §155.205.
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Brokers, Agents, and Other Third-Party Assistance Entities
Pursuant to state law, exchanges also may certify insurance agents, brokers, and/or web-brokers
to help consumers obtain coverage through exchanges.129 In general, agents or brokers may be
individuals or entities that sell plans for different insurance companies, usually receiving a
commission from those companies for doing so. There are also insurance company agents who
help people enroll in that company’s plans. Different types of “web-brokers” and “direct
enrollment technology providers” can also be approved to operate non-exchange websites that
interface with exchange websites, to allow consumers to enroll in exchange plans without visiting
the exchange website.130
If certified to sell exchange plans, any of these “third party” entities must follow rules about
providing information and access to all plans that would be available to a consumer via the
exchange website.131limited English proficiency.¹⁸⁸ Brokers, Agents, and Other Third-Party Assistance Entities

Pursuant to state law, exchanges also may certify insurance agents, brokers, and/or web-brokers to help consumers obtain coverage through exchanges.¹⁸⁹ These entities are not funded by the exchanges; they are compensated by the health plans that they help sell.

According to the National Association of Insurance Commissioners (NAIC), individuals who want to "sell, solicit or negotiate insurance in the United States must be licensed as a 'producer'" in the state in which they do business.¹⁹⁰ The term producer includes insurance agents and brokers. Agents may sell plans for one insurance company or they may represent more than one company, and they may receive salary and/or commission income. Brokers "work on behalf of the customer and are not restricted to selling policies for a specific company but commissions are paid by the company with which the sale was made."¹⁹¹ Because brokers do not represent insurers, they must work through an agent or other insurance company representative to purchase a policy for a customer. In federal exchange regulations, the term "agent or broker" is defined as "a person or entity licensed by the State as an agent, broker, or insurance producer."¹⁹²

As permitted by states, and after meeting exchange requirements, agents and brokers may assist consumers in comparing and enrolling in an exchange QHP.¹⁹³ It is not apparent that any states have disallowed agents and brokers from participating in their exchange.

In all exchange types, agents and brokers may help consumers enroll via the "Marketplace pathway" as shown here. In the FFEs and SBE-FPs (and in SBEs if available), agents and brokers may also help consumers via of the other following pathways:

• Marketplace Pathway: Completing an eligibility application, comparing plans, and enrolling in a plan via HealthCare.gov or the SBE website.
• Direct Enrollment [DE] or "Classic Direct Enrollment" Pathway: Completing an eligibility application via HealthCare.gov, then redirecting to an approved DE website to compare plans and enroll in an exchange plan.
• "Enhanced Direct Enrollment" [EDE] Pathway: Completing all steps, including eligibility application, plan comparison, and enrollment, directly on the approved EDE website without needing to be redirected to HealthCare.gov (in most cases).¹⁹⁴

Agents or brokers using the DE or EDE pathways may use their own approved websites or contract with approved web-brokers, including direct enrollment technology providers that operate exchange DE and EDE websites.¹⁹⁵ In some cases, health insurance issuers and web-brokers may also offer DE or EDE to consumers without the assistance of agents or brokers.

If certified to sell exchange plans, these entities (e.g., agents, brokers, and web-brokers) must follow rules related to plan marketing, display of plan information, and enrollment assistance, among other things. This includes providing consumers "with correct information, without omission of material fact," regarding the exchanges, QHPs, and subsidies, and "refrain[ing] from marketing or conduct" that is misleading, coercive, or discriminatory, as specified.¹⁹⁶ In addition, web-broker websites must provide consumers information and access to all QHPs that would be available to them on the exchange website, and comply with rules about whether and how to promote certain QHPs over others.¹⁹⁷ Unlike the exchange websites and exchange Navigators and other assistors, Unlike the exchange websites and exchange Navigators and other assistors,
however, these entities may also assist consumers with enrolling in plans that are not available on however, these entities may also assist consumers with enrolling in plans that are not available on
the exchanges.
In states where SHOP exchanges only offer direct enrollment (i.e., consumersthe exchanges, subject to rules about displaying non-exchange plans separately from QHPs, displaying a disclaimer provided by HHS, and limiting the marketing of non-QHPs during exchange open enrollment periods.¹⁹⁸

The regulatory requirements for exchange agents, brokers, and web-brokers have previously applied primarily in the FFEs, with some extended to the SBE-FPs. The 2025 Payment Notice also applied certain of these requirements in the SBEs.¹⁹⁹

Insurers that offer QHPs are also subject to certain requirements related to marketing and plan display. Regulations also specify that a QHP issuer is responsible for its own compliance and the compliance of any "delegated or downstream entities" with all applicable federal exchange standards.²⁰⁰ The relevant definitions of delegated and downstream entities include agents and brokers.

Issuers of nongroup plans, including QHPs, are also required to disclose to enrollees any direct or indirect compensation provided to agents or brokers associated with enrolling individuals in such coverage.²⁰¹ Insurers must annually report similar information to HHS.

In SHOPs in which small businesses cannot purchase cannot purchase
SHOP plans via the exchange websiteSHOP plans via the exchange website), or in states where there are no insurers offering SHOP , or in states where there are no insurers offering SHOP
plans, the SHOP exchange websites direct plans, the SHOP exchange websites direct consumers to these third party assisters,employers to agents, brokers, or insurers who can help who can help
them enroll in SHOP plans and/or small-group plans available off-exchange.them enroll in SHOP plans and/or small-group plans available off-exchange.132
Exchange Spending and Funding
Initial Grants for Exchange Planning and Establishment
202 These options may be referenced as "SHOP direct enrollment" but such enrollment processes may be different than the DE and EDE pathways described above.

CMS Updates on Certain Unauthorized Agent and Broker Marketplace Activities

In 2024, the Centers for Medicare & Medicaid Services (CMS) released several statements regarding "reports of consumers in HealthCare.gov states whose coverage was switched by agents and brokers without their knowledge."

The CMS statements included data on these consumer complaints and updates on CMS responses. As of October 2024, CMS announced the suspension of 850 agents' and brokers' "Marketplace agreements" (approvals to offer coverage via the exchanges), for "reasonable suspicion of fraudulent or abusive conduct related to unauthorized enrollments or unauthorized plan switches." CMS also addressed these issues in the 2026 Payment Notice (finalized in January 2025), including by expanding its authority at 45 C.F.R. §155.220(k)(3) to suspend agents' and brokers' ability to conduct exchange enrollments "if HHS discovers circumstances that pose unacceptable risk" to the exchange or enrollees, as specified.

Resources:

Centers for Medicare & Medicaid Services, "CMS Update on Actions to Prevent Unauthorized Agent and Broker Marketplace Activity" October 17, 2024, https://www.cms.gov/newsroom/press-releases/cms-update-actions-prevent-unauthorized-agent-and-broker-marketplace-activity. This article also links to prior CMS updates on this issue. CMS, "HHS Notice of Benefit and Payment Parameters for 2026 Final Rule," January 13, 2025, at https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2026-final-rule. Also see the 2026 Payment Notice at https://www.federalregister.gov/d/2025-00640/p-147, cited in Table D-1. Exchange Funding Initial Grants for Exchange Planning and Establishment The ACA provided an indefinite (i.e., unspecified) appropriation for HHS grants to states to The ACA provided an indefinite (i.e., unspecified) appropriation for HHS grants to states to
support the planning and establishment of exchanges.support the planning and establishment of exchanges.133203 For each fiscal year (FY) between For each fiscal year (FY) between
FY2011 and FY2014, the HHS Secretary determined the total amount that was made available to FY2011 and FY2014, the HHS Secretary determined the total amount that was made available to
each state for exchange grants. However, none of these exchange grants could be awarded after each state for exchange grants. However, none of these exchange grants could be awarded after
January 1, 2015, and exchanges were expected to be self-sustaining beginning in 2015.January 1, 2015, and exchanges were expected to be self-sustaining beginning in 2015.134
204 Ongoing Federal Funding for Exchange Operations

Information on prior and proposed federal funding for exchange operations can be found in the annual President's budget requests. For example, the FY2025 President's budget request provided federal funding amounts for FY2023 and FY2024, as well as the proposed FY2025 amounts.

A given budget request typically provides an update on the amount that was enacted for the prior year, but temporary funding under a "continuing resolution" (CR) was in effect at the time that the FY2025 budget request was being formulated.²⁰⁵ Thus, the amount listed for FY2024 was based on an annualized estimate under that temporary funding and not the amount that was ultimately enacted for FY2024. Federal government funding for the operation of the exchanges was $2.44 billion for FY2023 (final), $2.47 billion for FY2024 (CR), and requested to be $2.34 billion for FY2025.²⁰⁶ See Appendix C, which includes these funding levels by source, as well as estimated and prior year federal funding for Ongoing Federal Spending on Exchange Operation
The federal government spent an estimated $2.09 billion on the operation of exchanges in
FY2022, projected $2.38 billion in spending for FY2023, and proposed $2.31 billion for
FY2024.135 See Table C-1, which includes these numbers as well as estimated and prior year

129 45 C.F.R. §155.220. Definitions of terms discussed in this section, and other related terms, are at 45 C.F.R. §155.20.
130 For more information, see CMS, “Direct Enrollment and Enhanced Direct Enrollment,” updated May 2022, at
https://www.cms.gov/programs-and-initiatives/health-insurance-marketplaces/direct-enrollment-and-enhanced-direct-
enrollment.
131 45 C.F.R. §155.220.
132 See “Enrollment Processes and Options” in the SHOP section of this report for more information.
133 42 U.S.C. §18031(a).
134 42 U.S.C. §18031(a)(4)(B) specifies that no grant shall be awarded under this subsection after January 1, 2015. See
CRS Report R43066, Federal Funding for Health Insurance Exchanges (last updated in October 2014) for more
information about these planning and establishment grants.
135 CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2024, March 13, 2023, at
https://www.cms.gov/files/document/cms-fy-2024-congressional-justification-estimates-appropriations-
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federal spending on the exchanges by activity (e.g., information technology, Navigator grants), as the exchanges by activity (e.g., information technology, Navigator grants), as
provided by CMS in provided by CMS in itsrecent annual budget annual budget justificationjustifications to Congress. to Congress.
In general, Much of this federal this federal spendingfunding is specific to FFEs. For example, the federal government funds is specific to FFEs. For example, the federal government funds
the Navigator program only in states with FFEs. Some of the federal the Navigator program only in states with FFEs. Some of the federal spendingfunding, particularly in , particularly in
terms of information technology and the call center, also is applicable to SBE-FPs because these terms of information technology and the call center, also is applicable to SBE-FPs because these
state-based exchanges use the federal HealthCare.gov platform. CMS performs and funds some state-based exchanges use the federal HealthCare.gov platform. CMS performs and funds some
functions for all exchanges, including SBEs, such as functions for all exchanges, including SBEs, such as “"verifying eligibility data for financial verifying eligibility data for financial
assistance through the Marketplace or other health insurance programs, including Medicaid and assistance through the Marketplace or other health insurance programs, including Medicaid and
the Childrenthe Children’'s Health Insurance Program (CHIP)s Health Insurance Program (CHIP).”136
The costs of the plans themselves are covered by enrollees’ premiums and in some cases are
" and "ensuring proper payment of financial assistance" for eligible consumers.²⁰⁷ The premiums of the plans purchased through the exchanges are covered by enrollees' premium contributions and, in some cases, are subsidized by the federal government (i.e., via PTCs). The subsidized by the federal government (i.e., via PTCs). The costs of the PTCs are financed through PTCs are financed through
a permanent appropriationa permanent appropriation through the tax code.137.²⁰⁸ These tax These tax credit costsexpenditures are beyond the scope of are beyond the scope of
this report and are not included in the funding totals discussed in this section.this report and are not included in the funding totals discussed in this section.
Funding Sources for Federal Exchange Spending
User Fees Collected from Participating Insurers
Exchanges may generate funding to sustain their operations, including by assessing fees on Exchanges may generate funding to sustain their operations, including by assessing fees on
participating health insurance plans.participating health insurance plans.138
209 To raise funds for the exchanges it administers and/or provides a web platform, HHS assesses a To raise funds for the exchanges it administers and/or provides a web platform, HHS assesses a
monthly fee on each health insurance issuer that offers plans through an FFE or SBE-FP. The fee monthly fee on each health insurance issuer that offers plans through an FFE or SBE-FP. The fee
is a percentage of the value of the monthly premiums the insurer collects on exchange plans in a is a percentage of the value of the monthly premiums the insurer collects on exchange plans in a
given state, and HHS updates the percentage each year through rulemaking. given state, and HHS updates the percentage each year through rulemaking. See Figure 3.
For example, the user fee rates in PY2025 are 1.5% of total monthly premiums for issuers in FFEs and 1.2% of total monthly premiums for issuers in SBE-FPs. See Figure 5 below. These user fee amounts are allowed to fund only federal activities or functions specific to the FFE These user fee amounts are allowed to fund only federal activities or functions specific to the FFE
and SBE-FP exchanges; the user fees cannot fund federal activities that serve all exchanges and SBE-FP exchanges; the user fees cannot fund federal activities that serve all exchanges
(including SBEs).(including SBEs).139210 The fees are lower for insurers in SBE-FP states because the federal The fees are lower for insurers in SBE-FP states because the federal
government performs fewer functions for those exchanges than for FFEs, but those insurers also government performs fewer functions for those exchanges than for FFEs, but those insurers also
may be subject to exchange participation fees levied by the states. Most of the total federal may be subject to exchange participation fees levied by the states. Most of the total federal
spending on exchange operations is funded by these user fees, as shown spending on exchange operations is funded by these user fees, as shown inin Table C-21. Other Other
funding sources, including for federal activities applicable also to SBEs, are discussed in the next funding sources, including for federal activities applicable also to SBEs, are discussed in the next
section.section.
In prior years, user fees were also assessed on insurers participating in SHOP exchanges. In prior years, user fees were also assessed on insurers participating in SHOP exchanges.
However, HHS announced in the 2019 Payment Notice that as of plan years beginning on or after However, HHS announced in the 2019 Payment Notice that as of plan years beginning on or after
January 1, 2018, the fees would no longer be assessed on insurers participating in FF-SHOPs and January 1, 2018, the fees would no longer be assessed on insurers participating in FF-SHOPs and

committees.pdf. See “Federal Marketplace Programs” table and narrative, pages 199-204, and “Health Insurance
Marketplaces Transparency Table,” pages 237-238. Hereinafter referred to as “CMS Budget Justification, FY 2024.”
136 Page 200 of the CMS Budget Justification, FY2024.
137 31 U.S.C. §1324(b).
138 42 U.S.C. §18031(d)(5)(A).
139 For further discussion, see 2020 Payment Notice (cited in Table D-1), Section E.2., page 29216. Also see discussion
of CMS activities conducted on behalf of certain versus all exchanges at CMS Budget Justification, FY2024, pages
200-201.
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SB-FP-SHOPs, due to the reduced functionality of the federal SHOP website also announced in SB-FP-SHOPs, due to the reduced functionality of the federal SHOP website also announced in
that rule.that rule.140
211

Figure 35. Federal User Fees for Insurers Participating in Specified
Types of Individual Exchanges, by Plan Year
(fee is the stated percentage of the value of monthly premiums collected by insurer on exchange plans)(fee is the stated percentage of the value of monthly premiums collected by insurer on exchange plans)

Source: CRS Source: Congressional Research Service analysis of annual analysis of annual “Payment Notice”payment notice federal rules cited in federal rules cited in Table D-1, as well as Internal Revenue well as Internal Revenue
Service, Service, “"Rev. Proc. 2013-25,Rev. Proc. 2013-25,”" May 2, 2013, May 2, 2013, at httphttps://www.irs.gov/pub/irs-drop/rp-13-25.pdf://www.irs.gov/pub/irs-drop/rp-13-25.pdf. For example, the Plan Year (PY) 2025 user fees were finalized in the 2025 Payment Notice, April 2024, starting at https://www.federalregister.gov/d/2024-07274/p-1240. Notes: FFE = federally facilitated exchange; PTC = premium tax credit; SBE = state-based.
Notes: FFE = federally facilitated exchange; SBE-FP = state-based exchange using the federal information exchange; SBE-FP = state-based exchange using the federal information
technology (IT) platform. See technology (IT) platform. See "“Types and Administration of Exchanges” for" for discussion of exchange types. discussion of exchange types.
State-based exchanges’ (SBEs’) assessment of user fees, if any, varies, as discussed below in this report.
Other Federal Funding Sources
See "Premium Tax Credits and Cost-Sharing Reductions" for information about the temporarily enhanced PTCs.SBEs' assessment of user fees, if any, varies, as discussed below in this report. The 2026 Payment Notice, finalized January 15, 2025, established two possible sets of user fee rates for PY2026: first, 2.5% for FFE issuers and 2.0% for SBE-FP issuers if the temporarily enhanced PTCs expire at the end of 2025, as provided by current law. Alternately, if the enhanced PTCs are extended through PY2026 at current or higher levels by July 31, 2025, the 2026 user fees will be 2.2% for FFE issuers and 1.8% for SBE-FP issuers. The rule did not specifically address the user fee with regard to potential extensions of the enhanced PTC that may occur after July 31, 2025. See https://www.federalregister.gov/d/2025-00640/page-4487. Other Federal Funding Sources Besides the user fees collected from participating insurers, federal funding for the exchanges Besides the user fees collected from participating insurers, federal funding for the exchanges
(including for federal activities related to all exchanges, including SBEs) largely comes from (including for federal activities related to all exchanges, including SBEs) largely comes from
discretionary appropriations for program management and program integrity. discretionary appropriations for program management and program integrity. Within these appropriations (e.g., for CMS Program Management), Congress has not required any particular level of spending on the exchanges. There is also a risk-There is also a risk-
adjustment user fee, related to the risk-mitigation program briefly mentioned earlier in this adjustment user fee, related to the risk-mitigation program briefly mentioned earlier in this
report.report.141212 There is currently no mandatory HHS appropriation for exchange activities. There is currently no mandatory HHS appropriation for exchange activities.142213 An An
overview of recent and currently proposed overview of recent and currently proposed federal funding sourcesfunding sources for exchange operations is in is in Table C-21.
State Financing of the Exchanges
States with SBEs finance their own exchange administration. States with SBE-FPs also finance States with SBEs finance their own exchange administration. States with SBE-FPs also finance
the costs associated with the exchange functions they administer (whereas the federal user fee is the costs associated with the exchange functions they administer (whereas the federal user fee is
assessed on insurers in assessed on insurers in suchFFE/SBE-FP states to finance federally run functions such as the IT platform, as states to finance federally run functions such as the IT platform, as
discussed above).

140 2019 Payment Notice (cited in Table D-1), page 17007. See “Enrollment Processes and Options” regarding the
reduced functionality of the federal SHOP website.
141 See “Insurer Participation” in the Individual Exchanges section of the report.
142 According to the “Federal Exchanges” table in the FY2020 CMS CJ, a portion of the mandatory Health Care Fraud
and Abuse Control (HCFAC) appropriation went to the exchanges in FY2018 and FY2019. However, that table in the
FY2021 CJ does not show this for FY2019, and it is also not shown in subsequent CJs. See Table C-2 for citations.
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discussed above in this section). States may finance their exchanges by collecting user fees from participating insurers, as the States may finance their exchanges by collecting user fees from participating insurers, as the
federal government does. In addition, states may use other state funding to support their federal government does. In addition, states may use other state funding to support their
exchanges. CRS is not aware of exchanges. CRS is not aware of an estimatecomprehensive estimates of total or state-level spending on of total or state-level spending on, or financing
sources for, SBE and SBE-FP exchanges.
SBE and SBE-FP exchanges, but one stakeholder group analysis includes information on these exchanges' user fees and other financing mechanisms.²¹⁴ American Rescue Plan Act Grants for Exchange Modernization
Section 2801 of the ARPA provided for new grants to be awarded to health insurance exchanges Section 2801 of the ARPA provided for new grants to be awarded to health insurance exchanges
“"for purposes of enabling such Exchange to modernize or update any system, program, or for purposes of enabling such Exchange to modernize or update any system, program, or
technology utilized by such Exchange to ensure such Exchange is compliant with all applicable technology utilized by such Exchange to ensure such Exchange is compliant with all applicable
requirements.requirements.”" The HHS Secretary was authorized to determine specified aspects of the grant The HHS Secretary was authorized to determine specified aspects of the grant
funding application process. Eligibility for these grants was limited to SBEs and SBE-FPs. The funding application process. Eligibility for these grants was limited to SBEs and SBE-FPs. The
legislation specified that FFEs were not eligible through its reference to exchanges established legislation specified that FFEs were not eligible through its reference to exchanges established
under 42 U.S.C. Section 18041(c).under 42 U.S.C. Section 18041(c).
For this grant program, $20 million was appropriated for FY2021, out of Treasury funds not For this grant program, $20 million was appropriated for FY2021, out of Treasury funds not
otherwise appropriated. The funding was to remain available until the end of FY2022. In otherwise appropriated. The funding was to remain available until the end of FY2022. In
September 2021, CMS awarded $20 million in grants to 21 SBEs and SBE-FPs that applied for September 2021, CMS awarded $20 million in grants to 21 SBEs and SBE-FPs that applied for
them.them.143
See “215 See "Premium Tax Credits and Cost-Sharing ReductionsPremium Tax Credits and Cost-Sharing Reductions”" regarding other ARPA provisions regarding other ARPA provisions
relevant to the exchanges and the plans sold in them.144

143 See CMS, 2021 State Marketplace Modernization Grant Awards, September 10, 2021, at https://www.cms.gov/
files/document/state-based-marketplace-modernization-grant-awardee-list-2021.pdf.
144 For information about other health provisions in ARPA, see CRS Report R46777, American Rescue Plan Act of
2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare Provisions.
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Appendix A. relevant to the exchanges and the plans sold in them.²¹⁶ Appendix A. Exchange Information by State
As discussed in this report, the major types of exchanges in terms of state versus federal As discussed in this report, the major types of exchanges in terms of state versus federal
administration are state-based exchanges (SBEs), federally facilitated exchanges (FFEs), and administration are state-based exchanges (SBEs), federally facilitated exchanges (FFEs), and
state-based exchanges using a federal platform (SBE-FPs). For plan year (PY) state-based exchanges using a federal platform (SBE-FPs). For plan year (PY) 20232025, there are , there are 30
28 FFEs, FFEs, 1820 SBEs, and 3 SBE-FPs. SBEs, and 3 SBE-FPs.
A few states have changed approaches one or more times (e.g., initially worked to create an SBE A few states have changed approaches one or more times (e.g., initially worked to create an SBE
but then switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of but then switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of
whether the state moved toward more or less federal involvement, but in several cases, a state whether the state moved toward more or less federal involvement, but in several cases, a state
transitioned from a fully state-based approach to an SBE-FP (i.e., transitioned toward more transitioned from a fully state-based approach to an SBE-FP (i.e., transitioned toward more
federal involvement). Recent and ongoing transitions generally are in the direction of less federal federal involvement). Recent and ongoing transitions generally are in the direction of less federal
involvement.involvement.
SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP).SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP).145217 For PY2025 For
PY2023, there are , there are 3028 FF-SHOPs and FF-SHOPs and 2022 SB-SHOPs. One state (Hawaii) is exempted from SB-SHOPs. One state (Hawaii) is exempted from
operating a SHOP exchange. However, in operating a SHOP exchange. However, in aboutmore than half of all states, no insurers are offering medical half of all states, no insurers are offering medical
plans in the SHOP exchange, meaning there is effectively no SHOP exchange there.plans in the SHOP exchange, meaning there is effectively no SHOP exchange there.
For PY2023 For PY2025, most states, most states’' individual and SHOP exchanges are administered in the same way (i.e., individual and SHOP exchanges are administered in the same way (i.e.,
both state-based or both federally facilitated). However, a few states both state-based or both federally facilitated). However, a few states (Arkansas, Hawaii, Illinois, and Oregon) have different approaches for have different approaches for
their individual and SHOP exchanges. Some resources refer to this as a their individual and SHOP exchanges. Some resources refer to this as a bifurcated approach. approach.
Table A-1 shows individual exchange types by state, with information on past changes in shows individual exchange types by state, with information on past changes in
individual exchange types and changes underway. It also shows SHOP exchange types by state individual exchange types and changes underway. It also shows SHOP exchange types by state
and provides details on SHOP plan availability and enrollment method.and provides details on SHOP plan availability and enrollment method.
Table A-1. Exchange Types and Key Details by State, Plan Year 2023
Individual Exchange Typea
SHOP Exchange Typeb
(with notes on exchange type
(with notes on plan availability
State
Exchange Website
transitions, if applicable)
and enrollment options)
2025

State

Exchange Website

Individual Exchange Type^a (with notes on exchange type transitions, if applicable) SHOP Exchange Type^b(with notes on plan availability and enrollment options)

U.S. Totals

FFE: 28

SBE: 20

SBE-FP: 3

(plans and online enrollment available in all counties, all states)

FF-SHOP (28): 6 with plans (all U.S. Totals

FFE: 30
FF-SHOP: 8 states with plans (al
SBE: 18
DE only); 22 without plans
SBE-FP: 3
SB-SHOP: 15 states with plans (9
are DE only); 5 DE only); 22 without plans without plans
(plans and online enrol ment available
in all counties, all states)

SB-SHOP (22): 16 with plans (11 are DE only); 6 without plans

No SHOP: 1

Alabama

: 1
Alabama
HealthCare.govHealthCare.gov
FFE

FFE

FF-SHOP, DE FF-SHOP, DE onlyc
Alaska
only^c

Alaska

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Arizona

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Arkansas

My Arkansas Insurance; HealthCare.gov SBE-FP as of PY17 (initially FFE)^e SB-SHOP, but no medical plans^f

California

Covered California

SBE

SB-SHOP (up to 100 employees)^g

Colorado

Connect for Health Colorado

SBE

SB-SHOP, DE only^h (up to 100 employees)^g

Connecticut

Access Health CT

SBE

SB-SHOP

Delaware

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

District of Columbia

DC Health Link

SBE

SB-SHOP

Florida

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Georgia

Georgia Access

SBE as of PY25 (initially FFE, then SBE-FP for PY24)^e SB-SHOP, DE only^h

Hawaii

HealthCare.gov

FFE as of PY17ⁱ (initially SBE, then SBE-FP for PY16)^e No SHOP exchange per waiver^j

Idaho

Your Health Idaho

HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Arizona
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Arkansas
My Arkansas Insurance;
SBE-FP as of PY17 (initially FFE)e
SB-SHOP, but no medical plansf
HealthCare.gov
California
Covered California
SBE
SB-SHOP (up to 100 employees)g
Colorado
Connect for Health
SBE
SB-SHOP, DE onlyh
Colorado
(up to 100 employees)g
Connecticut
Access Health CT
SBE
SB-SHOP

145 As of June 2018, states can no longer select the state-based using the federal IT platform (SB-FP-SHOP) approach,
except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According to CMS,
those states no longer use that model.
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Individual Exchange Typea
SHOP Exchange Typeb
(with notes on exchange type
(with notes on plan availability
State
Exchange Website
transitions, if applicable)
and enrollment options)
Delaware
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
District of
DC Health Link
SBE
SB-SHOP
Columbia
Florida
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Georgia
HealthCare.gov
FFE j
FF-SHOP, DE onlyc
Hawaii
HealthCare.gov
FFE as of PY17i (initially SBE, then
No SHOP exchange per waiverk
SBE-FP for PY16)e
Idaho
Your Health Idaho
SBE as of PY15 (initially SBE-FP)e
SB-SHOP, DE onlyh
Il inois
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Indiana
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Iowa
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Kansas
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Kentucky
kynect
SBE as of PY22 (initially SBE, then
SB-SHOP, DE onlyh
SBE-FP as of PY17)e
Louisiana
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Maine
CoverME.gov
SBE as of PY22 (initially FFE, then
SB-SHOP, DE onlyh
SBE-FP as of PY21)e
Maryland
Maryland Health Connection
SBE
SB-SHOP, DE onlyh
Massachusetts
Massachusetts Health
SBE
SB-SHOP
Connector
Michigan
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Minnesota
MNsure
SBE
SB-SHOP, but no medical plansf
Mississippi
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Missouri
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Montana
HealthCare.gov
FFEi
FF-SHOP, DE onlyc
Nebraska
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Nevada
Nevada Health Link
SBE as of PY20 (initially SBE, then
SBE as of PY15 (initially SBE-FP)^e SB-SHOP, DE only^h

Illinois

Get Covered Illinois; HealthCare.gov

SBE-FP as of PY25 (initially FFE);^e transitioning to SBE for future PY^k FF-SHOP, but no medical plans^d

Indiana

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Iowa

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Kansas

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Kentucky

kynect

SBE as of PY22 (initially SBE, then SBE-FP as of PY17)^e SB-SHOP, DE only^h

Louisiana

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Maine

CoverME.gov

SBE as of PY22 (initially FFE, then SBE-FP as of PY21)^e SB-SHOP, DE only^h

Maryland

Maryland Health Connection

SBE

SB-SHOP, DE only^h

Massachusetts

Massachusetts Health Connector

SBE

SB-SHOP

Michigan

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Minnesota

MNsure

SBE

SB-SHOP, but no medical plans^f

Mississippi

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Missouri

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Montana

HealthCare.gov

FFEⁱ FF-SHOP, DE only^c

Nebraska

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Nevada

Nevada Health Link

SBE as of PY20 (initially SBE, then SBE-FP as of PY15)^e SB-SHOP, but no medical SB-SHOP, but no medical plansf
SBE-FP as of PY15)e
New
plans^f

New Hampshire

HealthCare.govHealthCare.gov
FFEi
FFEⁱ FF-SHOP, DE only^c

New Jersey

Get Covered NJ

FF-SHOP, DE onlyc
Hampshire
New Jersey
Get Covered NJ
SBE as of PY21 (initially FFE, then SBE as of PY21 (initially FFE, then
SBE-FP as of PY20)^e SB-SHOP, DE onlyh
SBE-FP as of PY20)e
New Mexico
beWellnm
SBE as of PY22 (initially SBE-FP)e
SB-SHOP
New York
New York State of Health
SBE
SB-SHOP, DE onlyh
(up to 100 employees)g
North
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Carolina
North Dakota
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Ohio
HealthCare.gov
FFEi
FF-SHOP, DE onlyc
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link to page 38 link to page 38 link to page 38 link to page 39 link to page 39 link to page 39 link to page 39 link to page 38 link to page 39 link to page 38 link to page 38 link to page 38 link to page 39 link to page 38 link to page 39 link to page 39 link to page 39 link to page 39 link to page 38 link to page 39 link to page 39 link to page 38 link to page 38 link to page 38 link to page 6 link to page 9 link to page 26 Overview of Health Insurance Exchanges

Individual Exchange Typea
SHOP Exchange Typeb
(with notes on exchange type
(with notes on plan availability
State
Exchange Website
transitions, if applicable)
and enrollment options)
Oklahoma
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Oregon
Oregon Health Insurance
SB-SHOP, DE only^h

New Mexico

beWellnm

SBE as of PY22 (initially SBE-FP)^e SB-SHOP, but no medical plans^f

New York

New York State of Health

SBE

SB-SHOP, DE only^h (up to 100 employees)^g

North Carolina

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

North Dakota

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Ohio

HealthCare.gov

FFEⁱ FF-SHOP, DE only^c

Oklahoma

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Oregon

Oregon Health Insurance Marketplace; HealthCare.gov

SBE-FP as of PY15 (initially SBE)^e SB-SHOP, DE only^h

Pennsylvania

Pennie

SBE as of PY21 (initially FFE, then SBE-FP as of PY20)^e SBE-FP as of PY15 (initially SBE)e
SB-SHOP, DE onlyh
Marketplace; HealthCare.gov
Pennsylvania
Pennie
SBE as of PY21 (initially FFE, then
SB-SHOP, but SB-SHOP, but no medical plans^f

Rhode Island

Health Source RI

SBE

SB-SHOP

South Carolina

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

South Dakota

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Tennessee

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Texas

HealthCare.gov

FFE

FF-SHOP, but no medical plans^d

Utah

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Vermont

Vermont Health Connect

SBE

SB-SHOP, DE only^h (up to 100 employees)^g

Virginia

Virginia's Insurance Marketplace

SBE as of PY24no medical plansf
SBE-FP as of PY20)e
Rhode Island
Health Source RI
SBE
SB-SHOP
South
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Carolina
South Dakota
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Tennessee
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Texas
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Utah
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Vermont
Vermont Health Connect
SBE
SB-SHOP, DE onlyh
(up to 100 employees)g
Virginia
Cover Virginia;
SBE-FP as of PY21 (initially FFE)e
FF-SHOP, DE onlyc
HealthCare.gov
Transitioning to SBE for future PYl
Washington
Washington Healthplanfinder
SBE
SB-SHOP, but no medical plansf
West Virginia
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Wisconsin
HealthCare.gov
FFE
FF-SHOP, DE onlyc
Wyoming
HealthCare.gov
FFE
FF-SHOP, DE onlyc
Sources (initially FFE, then SBE-FP as of PY21)^e SB-SHOP, DE only^h

Washington

Washington Healthplanfinder

SBE

SB-SHOP, but no medical plans^f

West Virginia

HealthCare.gov

FFEⁱ FF-SHOP, but no medical plans^d

Wisconsin

HealthCare.gov

FFE

FF-SHOP, DE only^c

Wyoming

HealthCare.gov

FFE

FF-SHOP, DE only^c Sources: CRS analysis of data at the sources indicated in notes section below.CRS analysis of data at the sources indicated in notes section below.
Notes: FFE = federally facilitatedNotes: SHOP = Small business health options program. FFE = Federally-facilitated individual exchange; FF-SHOP exchange; FF-SHOP
= Federally-= federally facilitated SHOP exchangefacilitated SHOP exchange.; SBE = SBE = State-based individual state-based exchange; exchange; SB-SHOP = State-based SHOP
exchange. SBE-FP = State-based individual exchange using the federal information technology (IT) platform.
Counts of “states”SBE-FP = state-based exchange using the federal information technology (IT) platforms; SB-SHOP = state-based SHOP exchange; SHOP = Small Business Health Options Program. Counts of "states" include the District of Columbia. In the individual exchanges, include the District of Columbia. In the individual exchanges, “"plan yearplan year”" is generally that is generally that
calendar year, but group coverage plan years, including in the SHOP exchanges, may start at any time during a calendar year, but group coverage plan years, including in the SHOP exchanges, may start at any time during a
calendar year. See report calendar year. See report “Overview” "Overview" for discussion of exchange types; for discussion of exchange types; seesee Figure 1 for the for the 20232025 exchange exchange
types by state in map form.types by state in map form.
a. 2023 a. 2025 individual exchange types: See footnotes 1-4 at Centers for Medicare & Medicaid Services (CMS), See footnotes 1-4 at Centers for Medicare & Medicaid Services (CMS),
Center for Consumer Information and Insurance Oversight (CCIIO), Center for Consumer Information and Insurance Oversight (CCIIO), “"Health Insurance Exchange Public Health Insurance Exchange Public
Use Files (Exchange PUFs) General InformationUse Files (Exchange PUFs) General Information” (PY 2023), at https://www.cms.gov/CCIIO/Resources/Data-
Resources/marketplace-puf.
b. 2023" (PY2025, PDF), https://www.cms.gov/files/document/exchange-pufs-geninfofacts-py25.pdf; at the CMS "Exchange PUFs" page, updated December 18, 2024, https://www.cms.gov/marketplace/resources/data/public-use-files. b. 2025 SHOP exchange types: See footnotes cited in the CMS/CCIIO See footnotes cited in the CMS/CCIIO "General Information" resource at table note (a). Also see resource at table note (a). Also see
HealthCare.gov, HealthCare.gov, “Select your state,” at "Offer SHOP Insurance to Your Employees," accessed March 24, 2025, https://www.healthcare.gov/small-businesses/employers/https://www.healthcare.gov/small-businesses/employers/. At the "Pick state" list on that page, if a selected state has an SB-SHOP, users are directed to the state's exchange site. Otherwise, the selected state has an FF-SHOP. c. . States with
no medical plans available in their SHOP exchanges are indicated. In states that do have plans available in
their SHOP exchanges, there may or may not be plans available in all areas.
c. All FF-SHOPs (that offer plans) use a direct enrollment approach only, meaning HealthCare.gov meaning HealthCare.gov
does not offer online SHOP plan does not offer online SHOP plan enrol mentenrollment but instead instructs users to connect with agents or brokers but instead instructs users to connect with agents or brokers
to enrol to enroll in plans through the statein plans through the state’'s SHOP exchange. See HealthCare.gov, s SHOP exchange. See HealthCare.gov, “"How to How to offer SHOP health
insurance to your employees,” at Offer SHOP Health Insurance to Your Employees," accessed March 24, 2025, https://www.healthcare.gov/small-businesses/choose-and-https://www.healthcare.gov/small-businesses/choose-and-enrol /enrol enroll/enroll-in--in-
shop/shop/. See “Enrol ment. See "Enrollment Processes and Options” in" in the SHOP section of this report for more information. the SHOP section of this report for more information.
d. d. No insurers are currently offering SHOP medical plans in these FF-SHOP states. . (Some may be Some may be
offering SHOP dental plans, however.offering SHOP dental plans, however.) See CMS/CCIIO Exchange PUFs (PY 2023): “ See the PY2025 "Business RulesBusiness Rules" PUF at the CMS Exchange PUFs page PUF
(updated October 17, 2022), at the webpage cited in table note (a). For areas where there are no SHOP cited in table note (a). For areas where there are no SHOP
plans, HealthCare.gov suggests that small businesses contact agents, brokers, and/or insurers directly to plans, HealthCare.gov suggests that small businesses contact agents, brokers, and/or insurers directly to
learn about other coverage options. learn about other coverage options.
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link to page 25 Overview of Health Insurance Exchanges

e. See HealthCare.gov, "2025 health insurance plans and prices," accessed March 24, 2025, https://www.healthcare.gov/see-plans/#/small-business, and input a zip code from one of the states with FF-SHOPs without medical plans in the table above, such as 85001 (Maricopa County, AZ). e. While most states have maintained the same type of individual exchange they initially opted
for, some have transitioned to different exchange types. Citations for prior year exchange types: Citations for prior year exchange types:
PY2014: ASPE, ASPE, Addendum to the Health Insurance Marketplace Summary Enrollment Report, April 2014, April 2014, at
https://aspe.hhs.gov/pdf-report/addendum-health-insurance-marketplace-summary-https://aspe.hhs.gov/pdf-report/addendum-health-insurance-marketplace-summary-enrol mentenrollment-report.-report.
PY2015-2016: Footnote 3 of CMS March 2015 and March 2016 Footnote 3 of CMS March 2015 and March 2016 Effectuated Enrollment Snapshots at at
https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-enrol ment-snapshotenrollment-snapshot and and
https://www.cms.gov/newsroom/fact-sheets/march-31-2016-effectuated-https://www.cms.gov/newsroom/fact-sheets/march-31-2016-effectuated-enrol mentenrollment-snapshot, respectively.-snapshot, respectively.
PY2017-2022: CMS, “Open Enrol ment PY2017-2024: CMS, "Open Enrollment Period Public Use Files" pages at https://www.cms.gov/data-research/statistics-trends-reports/marketplace-products/2024-marketplace-open-enrollment-period-public-use-files. See PUFs and/or PUF FAQs for each year. f. Period Public Use Files” (PUFs) and/or PUF FAQs for each year, at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-
Products.
f.
No insurers are currently offering SHOP medical plans in these SB-SHOP states, per CRS review of those sites as of January 2025. . (Some may be Some may be
offering SHOP dental plans, however.offering SHOP dental plans, however.) Some state exchange websites suggest that small businesses contact Some state exchange websites suggest that small businesses contact
agents, brokers, and/or insurers directly to learn about other coverage options. See links in table.agents, brokers, and/or insurers directly to learn about other coverage options. See links in table.
g. g. For the purposes of SHOP exchange participation, states may define For the purposes of SHOP exchange participation, states may define small employers (or small businesses) as (or small businesses) as
employers that have not more than 50 or not more than 100 employees.employers that have not more than 50 or not more than 100 employees. Only four states use the threshold Only four states use the threshold
of 100; see links in table. See SHOPof 100; see links in table. See SHOP “ "Eligibility and Enrol ment” inEnrollment" in this report for more information. this report for more information.
h. h. These SB-SHOPs are using a direct enrollment approach only: They do not offer online They do not offer online
enrol mentenrollment but instead instruct users to connect with agents, brokers, insurers, or assistors – or to submit but instead instruct users to connect with agents, brokers, insurers, or assistors – or to submit
a paper application to the exchange—to a paper application to the exchange—to enrol enroll in plans through the statein plans through the state’'s SHOP exchange. See links in s SHOP exchange. See links in
table.table.
i. i.
In some FFE states, the federal government performs all exchange administration functions, but in these FFE In some FFE states, the federal government performs all exchange administration functions, but in these FFE
states, the state partners with the federal government to perform some plan management functions. See states, the state partners with the federal government to perform some plan management functions. See
footnotes cited in the footnotes cited in the General Information resource at table note (a).resource at table note (a).
j.
Georgia initially received approval through the Section 1332 state innovation waiver process to shift to its
own “Georgia Access Model,” essentially a direct enrol ment approach, beginning in PY2023. However, this
component of the waiver was later suspended for PY2023 j. Hawaii received a Section 1332 waiver exempting it from having SHOP exchange, initially for PY2017-PY2021 then extended through PY2026. This is related to the state's pre-existing program and requirements related to employment-based coverage. The 1332 process allows states to waive . The 1332 process allows states to waive
specified ACA provisions, including provisions related to the establishment of health insurance exchanges specified ACA provisions, including provisions related to the establishment of health insurance exchanges
and related activities. See CRS Report R44760, and related activities. See CRS Report R44760, State Innovation Waivers: Frequently Asked Questions, for
background on 1332 waivers and for more information about Georgia’s waiver. In February 2023, Georgia
indicated its intention to transition to an SBE approach. See State of Georgia Office of Commissioner of
Insurance and Safety Fire, Letter to CCIIO, February 14, 2023, at https://oci.georgia.gov/document/
document/georgia-sbe-blueprint-letter-cms/download.
k. Hawaii received a Section 1332 waiver exempting it from having SHOP exchange, initially for PYs 2017-2021
then extended through PY2026. This is related to the state’s pre-existing program and requirements related
to employment-based coverage. See the report cited in table note (j) for more information.
l.
Regarding Virginia’s ongoing transition to a state-based exchange, see https://scc.virginia.gov/pages/Health-
Benefit-Exchange-(6).
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link to page 10 link to page 41 link to page 41 link to page 41 Overview of Health Insurance Exchanges

Appendix B. . k. Regarding Illinois' ongoing transition to a state-based exchange, see CMS, "State-based Exchanges," updated October 8, 2024, at https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/state-marketplaces. Appendix B. Types of Plans Offered Through the Exchanges Types of Plans Offered Through the
Exchanges
In general, health insurance plans offered through exchanges must be qualified health plans In general, health insurance plans offered through exchanges must be qualified health plans
(QHPs).(QHPs).146218 See See "“Qualified Health Plans”" in this report regarding QHP certification requirements. in this report regarding QHP certification requirements.
A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be
offered outside of exchanges, as well. Besides offered outside of exchanges, as well. Besides standard QHPs, there may be other types of plans
general QHPs, certain QHP variations are also (or may be) available in a given exchange, including available in a given exchange, including standardized plans, child-only plans, catastrophic plans, consumer operated child-only plans, catastrophic plans, consumer operated
and oriented plans (CO-OPs), and and oriented plans (CO-OPs), and multi-statemultistate plans (MSPs). plans (MSPs). Technically, these are all also QHPs.
Stand-alone dental plans (SADPs) are the only non-Stand-alone dental plans (SADPs) are the only non-QHPshealth plans that are offered in the exchanges. offered in the exchanges.
Table B-1. Types of Plans Offered Through the Exchanges
PTC and
Can Be Offered
CSR
Outside

Summary
Eligible?
Exchanges?
Qualified

Summary

PTC and CSR Eligible?^a

Can Be Offered Outside Exchanges?

Qualified Health Plan (QHP)^b A plan that is offered by a state-licensed insurer that A plan that is offered by a state-licensed insurer that
Health Plan
meets specified requirements, is certified by an meets specified requirements, is certified by an
(QHP)
exchange, and covers the essential health benefits exchange, and covers the essential health benefits
Yes
Yes
(EHB) package.
QHP Variations
Child-Only
(EHB) package. Subject to applicable requirements, QHP features may vary (e.g., coverage and cost sharing for particular benefits). General QHPs may be referenced as "non-standardized," as compared to the standardized plans (also QHPs) discussed below.

Yes

Yes

QHP Variations

Standardized Plan^c

A plan that meets parameters designed by the Department of Health and Human Services, particularly regarding cost-sharing requirements (for certain categories of benefits and overall). QHP issuers in certain individual exchanges must offer standardized plans as specified in regulations.

Yes

Yes

Child-Only Health Insurance Plan^d A plan in which only individuals under the age of 21 may enrollA plan in which only individuals under the age of 21
Health Insurance
may enrol . If an insurer offers an all-ages QHP in an . If an insurer offers an all-ages QHP in an
Yes
Yes
Plan
exchange, it also must offer a child-only plan at the exchange, it also must offer a child-only plan at the
same actuarial level.same actuarial level.
Catastrophic Plan

Yes

Yes

Catastrophic Plan^e A plan that provides the EHB and coverage for at least A plan that provides the EHB and coverage for at least
No
Yes
three primary care visits; however, it does not meet three primary care visits; however, it does not meet
the minimum requirements related to coverage the minimum requirements related to coverage
generosity (i.e., actuarial value). Offered in individual generosity (i.e., actuarial value). Offered in individual
but not small business health options program (SHOP)
exchanges. Consumer eligibility requirements apply.a
Consumer
but not SHOP exchanges. Consumer eligibility requirements apply.

No

Yes

Consumer Operated and Oriented Plan (CO-OP)^f A plan sold by a nonprofit, member-run health A plan sold by a nonprofit, member-run health
Yes
Yes
Operated and
insurance company created via a Patient Protection and insurance company created via a Patient Protection and
Oriented Plan
Affordable Care Act (ACA; P.L. 111-148, as amended) Affordable Care Act (ACA; P.L. 111-148, as amended)
(CO-OP)
program.b
Multi-state Plan
program.

Yes

Yes

Multistate Plan (MSP)^g A plan sold in the exchanges under contract with the A plan sold in the exchanges under contract with the
Yes
No
(MSP)
federal Office of Personnel Management (OPMfederal Office of Personnel Management (OPM).c
Non-QHPs
Stand-alone
Coverage for dental care. May be offered either as a
dental plan
stand-alone plan or in conjunction with a QHP,).

Yes

No

Non-Health Plans

Stand-Alone Dental Plan (SADP)^h Coverage for dental care; subject to certain modified QHP requirements. May be offered either "as a stand-alone dental plan" or "in conjunction with a QHP," as long as long
Yes, in certain
(SADP)
as it covers pediatric dental benefits that meet relevant as it covers pediatric dental benefits that meet relevant
EHB requirements. Yes, in certain circumstances.circumstances.
Yes
EHB requirements.
Sources: CRS analysis of statute and regulation. QHP definition: 42 U.S.C. §18021. Child-only and
catastrophic plans: 42 U.S.C. §18022. CO-OPs: 42 U.S.C. §18021 and 42 U.S.C. §18042. MSPs: 42 U.S.C.
§18021 and 42 U.S.C. §18054. Stand-alone dental plans: 42 U.S.C. §18031(d)(2)(B)(i ), 45 C.F.R. §155.1065,
and 45 C.F.R. §155.705

Yes

Sources: CRS analysis of statute and regulation cited below. Annual payment notices are cited in Table D-1.

Notes: CSR = cost-sharing reduction; FFE = federally facilitated exchange; HHS = Department of Health and Human Services; PTC = premium tax credit; SBE = state-based exchange; SBE-FP = state-based exchange using the federal information technology (IT) platform; SHOP = Small Business Health Options Program.

a. . Premium tax credits and cost-sharing reductions: 26 U.S.C. §36B(c)(3)(A) 26 U.S.C. §36B(c)(3)(A) and, 42 42
U.S.C. §18071(f)(1).

146 42 U.S.C. §18031(d)(2)(B).
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Overview of Health Insurance Exchanges

Notes: CSR = cost-sharing reduction; PTC = premium tax credit.
a. U.S.C. §18071(f)(1). b. Qualified health plan definition: 42 U.S.C. §18021. c. Standardized plans: 45 C.F.R. §156.201, 45 C.F.R. §156.202. Insurers offering QHPs in the FFEs and SBE-FPs are required to offer a standardized plan at every product network type, at every actuarial level, and throughout every service area that they offer non-standardized QHP options. For example, if an insurer offers a non-standardized gold health maintenance organization (HMO) QHP in a given service area, such insurer must also offer a standardized gold HMO QHP throughout that service area. Insurers are also subject to limitations on offering non-standardized plan variations. In FFE and SBE-FP states, these requirements also apply in the nongroup market outside the exchanges, but these requirements do not apply in SBEs, nor in the SHOP exchanges or otherwise in the small group market. See the 2023 Payment Notice at https://www.federalregister.gov/d/2022-09438/p-1406, and see "Standardized Plans" in this report. d. Child-only plans: 42 U.S.C. §18022(f). e. Catastrophic plans: 42 U.S.C. §18022(e). Catastrophic plans are available only to individuals under the age of 30 and individuals who obtain hardship Catastrophic plans are available only to individuals under the age of 30 and individuals who obtain hardship
or affordability exemptions through the exchange. See CRS Report R44438, or affordability exemptions through the exchange. See CRS Report R44438, The Individual Mandate for
Health Insurance Coverage: In Brief..
b. The HHS Secretary f. CO-OPs: 42 U.S.C. §18021, 42 U.S.C. §18042. The Secretary of Health and Human Services (HHS) is required to use funds appropriated to the CO-OP program to finance start-up and is required to use funds appropriated to the CO-OP program to finance start-up and
solvency loans for eligible nonprofit organizations applying to become a CO-OP. The majority of products solvency loans for eligible nonprofit organizations applying to become a CO-OP. The majority of products
offered by a CO-OP must be QHPs sold in the nongroup and small-group markets, including through offered by a CO-OP must be QHPs sold in the nongroup and small-group markets, including through
exchanges. exchanges. CMSThe Centers for Medicare & Medicaid Services (CMS) initially awarded loans to 24 CO-OPs, but one initially awarded loans to 24 CO-OPs, but one of those 24 was dropped from the program was dropped from the program
prior to offering health plans. See prior to offering health plans. See archived CRS Report R44414, CRS Report R44414, Consumer Operated and Oriented Plan (CO-OP)
Program: Frequently Asked Questions. Among the remaining. Among the remaining 23 CO-OPs, it appeared that three were 23 CO-OPs, it appeared that three were stil
still offering plans as of April 2021. The other 20 offering plans as of April 2021. The other 20 CO-OPs offered health plans at one time but have shut down offered health plans at one time but have shut down
or were in various stages of shutting down. As of November or were in various stages of shutting down. As of November 20222024, the three CO-OPs are offering plans for , the three CO-OPs are offering plans for
2023 enrol ment2025 enrollment; CRS has not reconfirmed the status of the other 20 CO-OPs. See; CRS has not reconfirmed the status of the other 20 CO-OPs. See
Maine: Community Health Options: https://www.healthoptions.org/ Community Health Options: https://www.healthoptions.org/;
Idaho, Montana, and Wyoming: Mountain Health CO-OP: https://www.mountainhealth.coop/Mountain Health CO-OP: https://www.mountainhealth.coop/; and and
Wisconsin: Common Ground Healthcare Cooperative: https://www.commongroundhealthcare.orgCommon Ground Healthcare Cooperative: https://www.commongroundhealthcare.org. g. Multistate plans: 42 U.S.C. §18021, 42 U.S.C. §18054. The.
c. The ACA directs ACA directs the federal Office of Personnel Management (OPM) to contract with private ACA directs the federal Office of Personnel Management (OPM) to contract with private
insurers in each state to offer at least two QHPs under the MSP program. The term insurers in each state to offer at least two QHPs under the MSP program. The term multi-statemultistate plan is meant is meant
to indicate that this program extends across the states, not that the plans themselves are necessarily to indicate that this program extends across the states, not that the plans themselves are necessarily
interstate. There are not currently any interstate. There are not currently any multi-state plans available.


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Appendix C. Exchange Spending and Funding
Details from CMS Budget Justifications
multistate plans available. h. Stand-alone dental plans: 42 U.S.C. §18031(d)(2)(B)(ii), 45 C.F.R. §155.1065, and 45 C.F.R. §155.705. In the "Exchange Establishment" Final Rule, 2012, HHS interpreted the statutory requirement on offering SADPs "either separately or in conjunction with a qualified health plan ... to mean that the Exchange must allow stand-alone dental plans to be offered either independently from a QHP or as a subcontractor of a QHP issuer, but cannot limit participation of stand-alone dental products in the Exchange to only one of these options" (see https://www.federalregister.gov/d/2012-6125/p-1320). Per HealthCare.gov, "Dental coverage in the marketplace," FFE or SBE-FP dental plan shoppers may purchase a health plan that includes dental, or they may purchase a health plan and separate dental coverage, but they may not solely purchase an exchange SADP (see https://www.healthcare.gov/coverage/dental-coverage/, accessed March 24, 2025). CRS is not aware of statutory language requiring or prohibiting this approach. SBEs appear to take varied approaches regarding allowing the purchase of dental coverage without also purchasing health coverage. Appendix C. Exchange Funding Details from CMS Budget Justifications The Centers for Medicare & Medicaid Services (CMS) in the U.S. Department of Health and The Centers for Medicare & Medicaid Services (CMS) in the U.S. Department of Health and
Human Services (HHS) is the federal agency responsible for administering the health insurance Human Services (HHS) is the federal agency responsible for administering the health insurance
exchanges. In support of the Presidentexchanges. In support of the President’'s annual s annual proposed budgetbudget request, CMS, like other agencies, , CMS, like other agencies,
produces a performance budget, also called a budget justification. Actual spending for the produces a performance budget, also called a budget justification. Actual spending for the
proposed budget year depends on the availability of appropriations, among other factors. proposed budget year depends on the availability of appropriations, among other factors.
However, the narratives and tables in each yearHowever, the narratives and tables in each year’'s budget document are also useful in s budget document are also useful in
understanding priorunderstanding prior-year spending.
year funding. For example, per the FY2025 CMS budget justification, federal funding for the operation of the exchanges was $2.44 billion for FY2023 (final), $2.47 billion for FY2024 (continuing resolution, or CR), and requested to be $2.34 billion for FY2025. See Table C-1. The exchanges are largely funded by user fees assessed on the insurers that offer plans in federally facilitated exchanges (FFEs) and state-based exchanges using the federal platform (SBE-FPs). In addition to these user fees, funding comes from discretionary appropriations to the CMS Program Management account, risk-adjustment user fees, and appropriations to the Health Care Fraud and Abuse Control (HCFAC) account, among other sources. Within these annual appropriations, Congress has not required any particular level of spending on the exchanges. Table C-1 displays federal exchange funding by source, by year. Provisions in annual appropriations acts require CMS to provide, in its budget justification for Provisions in annual appropriations acts require CMS to provide, in its budget justification for
each fiscal year, each fiscal year, “cost information” that “"information that details the uses of all funds used by the Centers for details the uses of all funds used by the Centers for
Medicare & Medicaid Services specifically for Health Insurance Exchanges for each fiscal year Medicare & Medicaid Services specifically for Health Insurance Exchanges for each fiscal year
since the enactment of the ACA and the proposed uses for such funds [for the upcoming fiscal since the enactment of the ACA and the proposed uses for such funds [for the upcoming fiscal
year]” for the categories shown in Table C-1.147 Each budget justification also includes narrative
information about federal spending in each of the categories listed in the table.
The exchanges are largely funded by user fees assessed on the insurers who offer plans in FFE
and SBE-FP exchanges. In addition to these user fees, funding comes from discretionary
appropriations to the CMS Program Management account, risk-adjustment user fees, and
appropriations to the Health Care Fraud and Abuse Control account, among other sources. Table
C-2 displays federal exchange spending according to these funding sources.
See “Exchange Spending and Funding”year]."²¹⁹ In its annual budget justifications, CMS generally has provided a "Health Insurance Marketplaces Transparency Table" that tracks federal funding for multiple exchange activities, but such a table was not included in the FY2025 CMS budget justification. This may be because temporary funding under a CR, rather than a full-year appropriation, was in effect at the time that the FY2025 budget request was being formulated.²²⁰ However, each CMS budget justification—including for FY2025—also includes narrative information about federal funding for the same or similar activities. See Table C-2 for federal exchange funding by activity, by year. See "Exchange Funding" in this report for more information. Find current and prior in this report for more information. Find current and
prior-year CMS budget justifications at CMS, year CMS budget justifications at CMS, “"Performance and Budget,Performance and Budget,”" at at
https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudgethttps://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget.

147 See, for example, the Consolidated Appropriations Act, 2023 (), Division H, Title II, Sec. 220.
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Overview of Health Insurance Exchanges

Table C-1. CMS “Health Insurance Marketplaces Transparency Table,” Recent Years
($ in thousands)
FY2018
FY2019
FY2020
FY2021
FY2022
FY2023
FY2024
Activity
Actual
Actual
Actual
Actual
Actual
Enacted
PB
Health Plan Bid Review,
$37,910
$45,797
$45,480
$38,841
$54,255
$56,219
$53,319
Management and
Oversight
Payment and Financial
$45,141
$50,220
$39,178
$49,821
$47,780
$57,600
$57,600
Management
Eligibility and Enrol ment
$392,660
$348,488
$371,802
$350,482
$391,341
$391,627
$417,907
Consumer Information
$591,948
$579,088
$503,271
$843,729
$903,220 $1,090,299
$975,981
and Outreach
Call Center (non-add)
$525,326
$499,053
$440,000
$477,247
$535,219
$504,500
$489,500
Navigators Grants &
$12,720
$19,499
$19,689
$91,233
$133,293
$141,747
$141,200
Enrollment Assisters (non-
add)
Consumer Education and
$10,744
$11,231
$14,082
$245,749
$211,592
$382,250
$280,750
Outreach (non-add)
Information Technology
$767,413
$504,283
$549,369
$515,388
$511,706
$552,830
$561,713
Quality
$7,240
$7,334
$7,063
$6,391
$6,706
$7,777
$8,282
SHOP and Employer
$4,418
$2,117
$200
$197
$195
$195
$195
Activities
Other Marketplace
$31,196
$40,290
$63,579
$38,827
$35,400
$62,267
$63,644
Federal Payrol and Other
$70,892
$77,750
$85,833
$120,071
$134,741
$164,170
$168,924
Administrative Activities
Total
$1,948,818 $1,655,367 $1,665,775 $1,963,746 $2,085,344 $2,382,984 $2,307,565
Source: Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS),
Justification of Estimates for Appropriations Committees, Fiscal Year 2024, March 13, 2022, at https://www.cms.gov/
files/document/cms-fy-2024-congressional-justification-estimates-appropriations-committees.pdf. See “Health
Insurance Marketplaces Transparency Table,” pages 237-238, including for these data for FYs 2010-2017 and for
CMS notes on these data. Discussion of spending categories is at “Federal Marketplace Programs” table and
narrative, pages 199-204.
Notes: FY = fiscal year; CR = continuing resolution; PB = President’s Budget (proposed). Note that actual
spending for the proposed budget year depends on the availability of appropriations, among other factors.
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Table C-2. CMS Federal Exchange Funding Sources, Recent Years
($ in thousands)
FY2018
FY2019
FY2020
FY2021
FY2022
FY2023
FY2024
Treasury Accounta
Actual
Final
Final
Final
Final
Enacted
PB
Program Management
$1,944,190 $1,636,111 $1,618,091 $1,939,603 $2,066,898 $2,343,586 $2,263,744
Discretionary
Appropriation
$618,164
$263,895
$261,226
$142,455
$143,977
$147,729
$165,122
Program Operations (non-
add)
$580,886
$229,384
$226,035
$119,520
$119,685
$121,000
$137,003
Federal Administration
(non-add)
$37,278
$34,511
$35,191
$22,936
$24,292
$26,729
$28,119
Offsetting Col ections
$1,304,280 $1,351,893 $1,335,768 $1,776,028 $1,899,955 $2,163,585 $2,060,800
[FFE] User Fee (non-add)b
$1,272,168 $1,304,458 $1,310,948 $1,729,249 $1,853,605 $2,106,081 $2,001,736
Risk Adjustment User Fee
(non-add)
$32,112
$47,435
$24,820
$46,778
$46,350
$57,504
$59,064
Other
$21,746
$20,323
$21,097
$21,120
$22,966
$32,272
$37,822
Health Care Fraud and
Abuse Control
$4,629
$19,256
$47,684
$24,143
$18,446
$39,398
$43,821
Discretionary
Appropriation
$0
$19,256
$47,684
$24,143
$18,446
$39,398
$43,821
Mandatory
Appropriationc
$4,629
N/A
N/A
N/A
N/A
N/A
N/A
Total, Program Level
$1,948,818 $1,655,367 $1,665,775 $1,963,746 $2,085,344 $2,382,984 $2,307,565
FFE User Fee Amounts
as a Percentage of
65.3%
78.8%
78.7%
88.1%
88.9%
88.4%
86.7%
Program Level Funding
Sourcesd
Sources: Unless otherwise specified, compiled by CRS from Centers for Medicare & Medicaid Services (CMS)
annual budget justifications as indicated below, available at https://www.cms.gov/About-CMS/Agency-Information/
PerformanceBudget. Comparable data were not found in prior years’ budget justifications.
FY2022-2024 in this table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2024
(CMS Budget Justification FY2024), March 13, 2023. See “Federal Marketplace Programs” table, page 199.
FY2021: CMS Budget Justification FY2023, May 6, 2022. See “Federal Marketplace Programs” table, page 199.
FY2020: CMS Budget Justification FY2022, May 31, 2021. See “Federal Marketplaces” table, page 199.
FY2019: CMS Budget Justification FY2021, March 3, 2020. See “Federal Exchanges” table, page 195.
FY2018: CMS Budget Justification FY2020, March 13, 2019. See “Federal Exchanges” table, page 178.
Notes: FY = fiscal year; CR = continuing resolution; PB = President’s Budget (proposed); FFE = federally
facilitated exchange; N/A = not available. Actual spending for the proposed budget year depends on the
availability of appropriations, among other factors.
a. See source documents for description of Treasury Account categories.
b. Per communication with CMS, this row is inclusive of both federally facilitated exchange and state-based
exchange using the federal information technology platform federal user fees.
c. Health Care Fraud and Abuse Control (HCFAC) “Mandatory Appropriation” was listed in the FY2020 table
that included these FY2018 amounts but not in the FY2021 or subsequent Budget Justifications. The FY2020
table also showed $5,000 in this row for “FY2019 Enacted,” but the FY2021 table did not show any such
amounts for “FY2019 Final.” Per the FY2020 table, “HCFAC mandatory Wedge funding is subject to an
annual allocation process by the Attorney General and Secretary of Health and Human Services.”
d. Calculated by CRS.
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Appendix D. Additional Resources
HHS “Notice of Benefit and Payment Parameters” by Year
The “Notice of Benefit and Payment Parameters,” also called the “Payment Notice,” is a rule
. Table C-1. CMS Funding for the Exchanges, by Source, by Year

($ in thousands)

Treasury Account^a

FY2018 Actual

FY2019 Final

FY2020 Final

FY2021Final

FY2022 Final

FY2023 Final

FY2024 CR

FY2025 PB

Program Management

$1,944,190

$1,636,111

$1,618,091

$1,939,603

$2,066,898

$2,412,472

$2,433,889

$2,306,495

Discretionary Appropriation

$618,164

$263,895

$261,226

$142,455

$143,977

$119,243

$121,052

$125,945

Program Operations (non-add)

$580,886

$229,384

$226,035

$119,520

$119,685

$119,243

$121,052

$125,945

Federal Administration (non-add)^b

$37,278

$34,511

$35,191

$22,936

$24,292

N/A

N/A

N/A

Offsetting Collections

$1,304,280

$1,351,893

$1,335,768

$1,776,028

$1,899,955

$2,293,229

$2,266,405

$2,154,216

[FFE] User Fee (non-add)^c

$1,272,168

$1,304,458

$1,310,948

$1,729,249

$1,853,605

$2,237,915

$2,205,463

$2,087,100

Risk Adjustment User Fee (non-add)

$32,112

$47,435

$24,820

$46,778

$46,350

$55,314

$60,942

$67,116

Other^d

$21,746

$20,323

$21,097

$21,120

$22,966

$0

$46,432

$26,334

Penalty Mail

N/A

N/A

N/A

N/A

N/A

$0

$35,359

$26,334

Health Insurance Reform Implementation Fund

N/A

N/A

N/A

N/A

N/A

$0

$11,073

$0

Health Care Fraud and Abuse Control

$4,629

$19,256

$47,684

$24,143

$18,446

$28,274

$31,121

$33,705

Discretionary Appropriation

$0

$19,256

$47,684

$24,143

$18,446

$28,274

$31,121

$33,705

Mandatory Appropriation^e

$4,629

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Total, Program Level

$1,948,818

$1,655,367

$1,665,775

$1,963,746

$2,085,344

$2,440,746

$2,465,010

$2,340,200

FFE User Fee Amounts as a Percentage of Program Level Funding Sources^f

65.3%

78.8%

78.7%

88.1%

88.9%

91.7%

89.5%

89.2%

Sources: Unless otherwise specified, compiled by CRS from Centers for Medicare & Medicaid Services (CMS) annual budget justifications as indicated below, available at CMS, "Performance and Budget," updated March 28, 2025, https://www.cms.gov/about-cms/performance-budget/current. Comparable data were not found in prior years' budget justifications. FY2023-2025 in this table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2025 (CMS Budget Justification FY2025), March 15, 2024. See "Federal Marketplace Programs" table, page 201. FY2022: CMS Budget Justification, FY2024, March 31, 2023; see "Federal Marketplace Programs" table, page 199. FY2021: CMS Budget Justification, FY2023, May 6, 2022. See "Federal Marketplace Programs" table, page 199.FY2020: CMS Budget Justification, FY2022, May 31, 2021. See "Federal Marketplaces" table, page 199.FY2019: CMS Budget Justification, FY2021, March 3, 2020. See "Federal Exchanges" table, page 195.FY2018: CMS Budget Justification, FY2020, March 13, 2019. See "Federal Exchanges" table, page 178.

Notes: CR = continuing resolution; FY = fiscal year; FFE = federally facilitated exchange; N/A = not available; PB = President's budget (proposed). Actual spending for the proposed budget year depends on the availability of appropriations, among other factors.

a. See source documents for description of Treasury Account categories. b. This row is not included in the Federal Marketplace Programs table in the CMS Budget Justification, FY2025. c. Per communication with CMS, this row is inclusive of both federally facilitated exchange (FFE) and state-based exchange using the federal information technology platform (SBE-FP) federal user fees. d. The two subcategories "Penalty Mail" and "Health Insurance Reform Implementation Fund" are newly listed in the Federal Marketplace Programs table as of the CMS Budget Justification, FY2025, along with the following note: "The FY2023 Final level excludes Penalty Mail as the associated funding sources were not available for obligation. Beginning in FY2024, Penalty Mail will be obligated through other expired sources." The Federal Marketplace narrative section does not otherwise address these funding sources. e. Health Care Fraud and Abuse Control (HCFAC) "Mandatory Appropriation" was listed in the FY2020 table that included these FY2018 amounts but not in the FY2021 or subsequent budget justifications. The FY2020 table also showed $5,000 in this row for "FY2019 Enacted," but the FY2021 table did not show any such amounts for "FY2019 Final." Per the FY2020 table, "HCFAC mandatory Wedge funding is subject to an annual allocation process by the Attorney General and Secretary of Health and Human Services." f. Calculated by CRS. Table C-2. CMS Funding for the Exchanges, by Activity, by Year

($ in thousands)

Activity

FY2018 Actual^a

FY2019 Actual

FY2020 Actual

FY2021Actual

FY2022 Actual

FY2023Enacted^b FY2024 PB^c FY2025PB^d

Health Plan Bid Review, Management and Oversight

$37,910

$45,797

$45,480

$38,841

$54,255

$56,219

$53,319

$63,500

Payment and Financial Management

$45,141

$50,220

$39,178

$49,821

$47,780

$57,600

$57,600

$63,100

Eligibility and Enrollment

$392,660

$348,488

$371,802

$350,482

$391,341

$391,627

$417,907

$423,700

Consumer Information and Outreach

$591,948

$579,088

$503,271

$843,729

$903,220

$1,090,299

$975,981

$938,100

Call Center (non-add)

$525,326

$499,053

$440,000

$477,247

$535,219

$504,500

$489,500

Not specified

Navigators Grants & Enrollment Assisters (non-add)

$12,720

$19,499

$19,689

$91,233

$133,293

$141,747

$141,200

Not specified

Consumer Education and Outreach (non-add)

$10,744

$11,231

$14,082

$245,749

$211,592

$382,250

$280,750

Not specified

Information Technology

$767,413

$504,283

$549,369

$515,388

$511,706

$552,830

$561,713

$645,300

Quality

$7,240

$7,334

$7,063

$6,391

$6,706

$7,777

$8,282

$6,900

SHOP and Employer Activities

$4,418

$2,117

$200

$197

$195

$195

$195

$200

Other Marketplace

$31,196

$40,290

$63,579

$38,827

$35,400

$62,267

$63,644

$60,000^e

Federal Payroll and Other Administrative Activities

$70,892

$77,750

$85,833

$120,071

$134,741

$164,170

$168,924

$139,400

Total

$1,948,818

$1,655,367

$1,665,775

$1,963,746

$2,085,344

$2,382,984

$2,307,565

$2,340,200

Source: CRS analysis of FY2025 and FY2024 Centers for Medicare & Medicaid Services (CMS) budget justifications, particularly the Health Insurance Marketplaces Transparency Table and/or the Federal Marketplace Programs narratives, as indicated in the notes below. See table notes (b) and (c) regarding the FY2023 and FY2024 total amounts in this table, as compared to such totals in Table C-1, above, in this report.

Notes: FY = fiscal year; CR = continuing resolution; PB = President's Budget (proposed). Note that actual spending for the proposed budget year depends on the availability of appropriations, among other factors.

a. FY18-24 in the table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2024, March 31, 2023, at https://www.cms.gov/about-cms/performance-budget/prior. See "Health Insurance Marketplaces Transparency Table," pages 237-238, including for these data for FY2010-FY2017 and for CMS notes on these data. Discussion of the categories is at "Federal Marketplace Programs" narrative, pages 199-204. b. Updated FY2023 "Actual" or "Final" amounts for each activity were generally not found in the CMS Budget Justification, FY2025. The FY2023 total funding level and activity funding details in this table are from the FY2024 Transparency Table. However, the FY2025 Federal Marketplace Programs narrative did provide an updated FY2023 "final" total funding amount for the exchanges of $2.441 billion, and relevant updates on FY2023 funding by source, which is reflected in Table C-1, above. c. Updated FY2024 "Enacted" amounts for each activity in this table were generally not found in the CMS Budget Justification, FY2025. The FY2024 total funding level and activity funding details in this table are from the FY2024 Transparency Table. However, the FY2025 Federal Marketplace Programs narrative did provide an updated FY2024 "CR" total funding amount for the exchanges of $2.465 billion, and relevant updates on FY2024 funding by source, which is reflected in Table C-1, above. d. FY25 in the table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2025, March 15, 2024, at https://www.cms.gov/about-cms/performance-budget/prior. See "Federal Marketplace Programs" narrative, pages 201-205. Because the CMS Budget Justification, FY2025, did not include a "Health Insurance Marketplaces Transparency Table" as in prior years, relevant FY25 budget narrative information is provided in this table instead. e. This "Other Marketplace" amount for FY2025 includes $33.7 million for Program Integrity and $26.3 million for Planning and Performance, per the Federal Marketplace Programs narrative in the CMS Budget Justification, FY2025. In the CMS Budget Justification, FY2024, such narrative indicated $43.8 million for Program Integrity and $19.8 million for Planning and Performance, which total $63.6 million, the "Other Marketplace" amount in the FY2024 Transparency Table. Appendix D. Additional Resources

HHS "Notice of Benefit and Payment Parameters" by Year

The "Notice of Benefit and Payment Parameters," also called the "Payment Notice," is a rule published annually by the Department of Health and Human Services (HHS). It addresses the published annually by the Department of Health and Human Services (HHS). It addresses the
exchanges and certain other private health insurance topics. It includes annual updates such as exchanges and certain other private health insurance topics. It includes annual updates such as
changes to insurer user fee amounts, and policy changes such as modified eligibility requirements changes to insurer user fee amounts, and policy changes such as modified eligibility requirements
for the Navigator program. The rule is titled according to the upcoming plan year that it for the Navigator program. The rule is titled according to the upcoming plan year that it
addresses. For example, the 2021 Payment Notice was finalized in May 2020, with changes addresses. For example, the 2021 Payment Notice was finalized in May 2020, with changes
applicable to the 2021 plan year (which is generally the calendar year).applicable to the 2021 plan year (which is generally the calendar year).
Final and proposed Payment Notices can also be found by searching Final and proposed Payment Notices can also be found by searching “"Notice of Benefit and Notice of Benefit and
Payment ParametersPayment Parameters”" at www.federalregister.gov at www.federalregister.gov.
. Table D-1. HHS “"Notice of Benefit and Payment Parameters,”" Final Rule by Year
For Plan
Year

Title

Citation

Publication Date

2026

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2026; Basic Health Program

90 Federal Register 4424

January 15, 2025

2025

Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section 1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO-OP) Program; and Basic Health Program

89 Federal Register 26218

April 15, 2024

2024

Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2024

88 Federal Register 25740

April 27, 2023

2023

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2023

87 Federal Register 27208

May 6, 2022

2022, "Part 3"^a

Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond

86 Federal Register 53412

September 27, 2021

2022,

"Part 2"^a

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Manager Standards

86 Federal Register 24140

May 5, 2021

2022,

"Part 1"^a

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2022; Updates to State Innovation Waiver (Section 1332 Waiver) Implementing Regulations

86 Federal Register 6138

January 19, 2021

2021

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Publication
Year
Title
Citation
Date
2023
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 87 Federal
May 6, 2022
Payment Parameters for 2023
Register 27208
2022,
Patient Protection and Affordable Care Act; Updating Payment
86 Federal
September
“Part 3”a Parameters, Section 1332 Waiver Implementing Regulations, and
Register 53412 27, 2021
Improving Health Insurance Markets for 2022 and Beyond
2022,
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 86 Federal
May 5, 2021
“Part 2”a Payment Parameters for 2022 and Pharmacy Benefit Manager Standards Register 24140
2022,
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 86 Federal
January 19,
“Part 1”a Payment Parameters for 2022; Updates to State Innovation Waiver
Register 6138
2021
(Section 1332 Waiver) Implementing Regulations
2021
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 85 Federal
May 14, 2020
Payment Parameters for 2021; Notice Requirement for Non-Federal
Register 29164
Governmental Plans
2020
Payment Parameters for 2021; Notice Requirement for Non-Federal Governmental Plans

85 Federal Register 29164

May 14, 2020

2020

Patient Protection and Affordable Care Act; HHS Notice of Benefit andPatient Protection and Affordable Care Act; HHS Notice of Benefit and 84 Federal
April 25,
Payment Parameters for 2020
Register 17454 2019
2019
Payment Parameters for 2020

84 Federal Register 17454

April 25, 2019

2019

Patient Protection and Affordable Care Act; HHS Notice of Benefit andPatient Protection and Affordable Care Act; HHS Notice of Benefit and 83 Federal
April 17,
Payment Parameters for 2019
Register 16930 2018
2018
Payment Parameters for 2019

83 Federal Register 16930

April 17, 2018

2018

Patient Protection and Affordable Care Act; HHS Notice of Benefit andPatient Protection and Affordable Care Act; HHS Notice of Benefit and 81 Federal
December
Payment Parameters for 2018, Amendments to Special Payment Parameters for 2018, Amendments to Special Enrol ment
Register 94058 22, 2016
Periods and the Consumer Operated and Oriented Plan Program
2017
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 81 Federal
March 8,
Payment Parameters for 2017
Register 12203 2016
2016
Enrollment Periods and the Consumer Operated and Oriented Plan Program

81 Federal Register 94058

December 22, 2016

2017

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017

81 Federal Register 12203

March 8, 2016

2016

Patient Protection and Affordable Care Act; HHS Notice of Benefit andPatient Protection and Affordable Care Act; HHS Notice of Benefit and 80 Federal
February 27,
Payment Parameters for 2016
Register 10749 2015
2015
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 79 Federal
March 11,
Payment Parameters for 2015
Register 13743 2014
2014
Payment Parameters for 2016

80 Federal Register 10749

February 27, 2015

2015

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2015

79 Federal Register 13743

March 11, 2014

2014

Patient Protection and Affordable Care Act; HHS Notice of Benefit andPatient Protection and Affordable Care Act; HHS Notice of Benefit and 78 Federal
March 11,
Payment Parameters for 2014
Register 15409 2013
Payment Parameters for 2014

78 Federal Register 15409

March 11, 2013

Source: United States Federal Register at at https://www.federalregister.gov/https://www.federalregister.gov/.
Congressional Research Service

41

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Overview of Health Insurance Exchanges
.
Notes: There have been other rules and agency guidance relevant to the exchanges and private health There have been other rules and agency guidance relevant to the exchanges and private health
insurance. This table is meant to be a compilation of only this type of annual rule.insurance. This table is meant to be a compilation of only this type of annual rule.
a. a. The 2022 Payment Notice final rule, here noted as The 2022 Payment Notice final rule, here noted as “"Part 1,Part 1,”" was published by the was published by the first Trump Administration, Trump Administration,
but did not take effect before the presidential transition. The Biden Administration subsequently published but did not take effect before the presidential transition. The Biden Administration subsequently published
two more Final 2022 Payment Notices, repealing some of what had been published in Part 1, and addressing two more Final 2022 Payment Notices, repealing some of what had been published in Part 1, and addressing
some topics not included in Part 1. In this report and elsewhere, the informal references some topics not included in Part 1. In this report and elsewhere, the informal references “"Part 1,Part 1,” “" "Part 2,Part 2,”
" and and “"Part 3,Part 3,”" are used to distinguish these three final rules. are used to distinguish these three final rules.

Other Federal Resources

Selected additional resources are listed below.

Table D-2. Selected Federal Resources on the Exchanges

Resource	Summary
CMS, "Health Insurance Marketplaces"	Links to agency FAQs, letters, and other resources on the exchanges
CMS, "Qualified Health Plan Certification Information and Guidance"	Resources for health insurance issuers seeking QHP certification
CMS, "Health Insurance Exchange Public Use Files (Exchange PUFs)"	Data on QHPs (primarily in the FFEs and SBE-FPs), by year
CMS, "Health Insurance State-based Exchange Public Use Files"	Data on QHPs in the SBEs, by year
CRS Report R46638, Health Insurance Exchanges: Sources of Statistics	Compilation of HHS resources on exchange enrollment and other exchange data

Source: CRS compilation of selected resources.

Notes: CMS = Centers for Medicare & Medicaid Services; FFE = federally facilitated exchange; HHS = Department of Health and Human Services; SBE = state-based exchange; SBE-FP = state-based exchange using the federal information technology (IT) platform.

Footnotes

1.

References to "states" in this report include the District of Columbia, unless otherwise specified.

2.

In this report, the terms consumers and individuals generally are used interchangeably, often to refer to consumers purchasing coverage directly from insurers for themselves and/or their families via the individual exchanges. Similarly, small businesses and small employers may be used interchangeably, often in reference to such employers and/or their employees purchasing coverage via the SHOP exchanges.

3. For example, an estimated 20.8 million people were enrolled in health insurance through the individual exchanges as of February 2024. This figure is approximately 6.1% of the U.S. population of about 338.7 million people as of February 2024. See Table 1 regarding exchange enrollment estimates and sources. The U.S. population estimate is part of a series of monthly projections made by the U.S. Census Bureau based upon the 2020 Census, at "U.S. and World Population Clock," accessed March 24, 2025, https://www.census.gov/popclock/. 4.

The Patient Protection and Affordable Care Act (P.L. 111-148, as amended) also gave the territories the option of establishing exchanges, but none elected to do so, by the statutory deadline of October 1, 2013. See 42 U.S.C. §18043.

5.

The term individual exchange is used for purposes of this report. It is not defined in exchange-related statute or regulations.

6.

Broadly, private health insurance includes group plans (generally, employer-sponsored insurance) and nongroup plans (which consumers purchase directly from insurers). The group market is divided into small- and large-group market segments; a small group is typically defined as a group of up to 50 individuals (e.g., employees), and a large group is typically defined as one with 51 or more individuals. The nongroup market is also called the individual market.

7.

There is an option for states to coordinate in administering regional exchanges or for a single state to establish subsidiary exchanges that serve geographically distinct areas (see 45 C.F.R. §155.140), but none have done so.

8. However, health plans are not available in more than half of Small Business Health Options Program (SHOP) exchanges in 2025. See Table A-1. 9.

See Individual Exchanges "Eligibility and Enrollment", SHOP Exchanges "Enrollment Processes and Options", and "Navigators and Other Exchange-Based Enrollment Assistance" in this report.

10.

An example of a privately owned website that allows for comparison and purchase of coverage from different insurers is ehealthinsurance.com. Some types of coverage sold outside of the federal and state exchanges, potentially including some types of coverage available on private sites like this one, are not subject to some or all federal health insurance requirements. For more information, see CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.

11. See Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO), General Guidance on Federally Facilitated Exchanges, May 16, 2012, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/ffe-guidance-05-16-2012.pdf. Also see CMS, CCIIO, Guidance on State Partnership Exchange, January 3, 2013, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/partnership-guidance-01-03-2013.pdf. 12. See 2022 Payment Notice, "Part 1," https://www.federalregister.gov/d/2021-01175/p-100, regarding information in this paragraph. The Notice of Benefit and Payment Parameters, or Payment Notice, is an annually published rule that includes updates and policy changes related to the exchanges and private health insurance. Because different parts of the Final 2022 Payment Notice were published in January 2021, May 2021, and September 2021, the informal references "Part 1," Part 2," and "Part 3" are used to distinguish them in this report. See Table D-1 for Payment Notice citations. 13.

Ibid. The DE exchange would still have to "make available a website listing basic [qualified health plan] QHP information for comparison," but this website would direct consumers to "approved partner websites for consumer shopping, plan selection, and enrollment activities."

14.

2022 Payment Notice, "Part 3," starting at https://www.federalregister.gov/d/2021-20509/p-197.

15.

2025 Payment Notice, starting at https://www.federalregister.gov/d/2024-07274/p-589. As discussed in this rule, all exchanges currently do have a centralized eligibility and enrollment platform, and currently perform all eligibility determinations, but these requirements are meant to "codify existing policy and practices and help set clear expectations for existing Exchanges and States that may seek to operate State Exchanges in the future."

16.

See "Brokers, Agents, and Other Third-Party Assistance Entities" in this report.

17.

See "Enrollment Processes and Options" in the SHOP section of this report.

18.

In tallies throughout this report, the District of Columbia is counted as a state. In this report, the terms FFE, SBE, and SBE-FP refer to individual market exchanges unless otherwise specified.

19.

For some considerations regarding such transitions, see Sabrina Corlette et al., States Seek Greater Control, Cost-Savings by Converting to State-Based Marketplaces, Robert Wood Johnson Foundation, October 2019, https://www.rwjf.org/en/library/research/2019/10/states-seek-greater-control-cost-savings-by-converting-to-state-based-marketplaces.html.

20.

As of June 2018, states could no longer select a state-based SHOP using the federal IT platform (SB-FP-SHOP) approach, except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According to CMS, those states no longer use that model. See "Enrollment Processes and Options" in the SHOP section of this report for more information.

21.

See "Insurer Participation" in the SHOP section of this report for more information.

22.

Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange. Initially set to expire after PY2021, the waiver was extended through PY2026 in December 2021. For more information about the 1332 waiver process, which allows states to waive specified ACA provisions, including provisions related to the establishment of health insurance exchanges and related activities, see CRS Report R44760, State Innovation Waivers: Frequently Asked Questions.

23.

See "Qualified Health Plans" in this report.

24.

42 U.S.C. §18031(b)(1)(A).

25.

42 U.S.C. §18031(d)(4).

26. 42 U.S.C. §18031(c)(1); 42 U.S.C. §18031(e). For more information, see CMS, CCIIO, 2025 Final Letter to Issuers in the Federally Facilitated Exchanges, April 10, 2024, https://www.cms.gov/files/document/2025-letter-issuers.pdf. Hereinafter CMS, 2025 Final Letter to Issuers. Also see CMS, CCIIO, 2026 Final Letter to Issuers in the Federally-facilitated Exchanges, January 15, 2025, https://www.cms.gov/files/document/final-2026-letter-issuers.pdf. Hereinafter CMS, 2026 Final Letter to Issuers. 27.

42 U.S.C. §18031(d)(2)(B).

28.

42 U.S.C. §18021(a)(1).

29.

See "Covered Benefits" in this report for more information.

30.

42 U.S.C. §18022.

31.

45 C.F.R. §156.20.

32.

See "Cost Sharing, Actuarial Value Levels, and Maximum Out-of-Pocket Limits" in this report for more information.

33.

This is not a comprehensive comparison of requirements on QHPs and other private plans.

34.

For more information about federal requirements applicable to different types of plans, see CRS Report R45146, Federal Requirements on Private Health Insurance Plans. This report also addresses states' roles as the primary regulators of health insurance.

35.

See, for example, 42 U.S.C. §§18021, 18023, and 18031; and 45 C.F.R. §§156.200 et seq. Also see the aforementioned CMS, 2025 Final Letter to Issuers, https://www.cms.gov/files/document/2025-letter-issuers.pdf and CMS, 2026 Final Letter to Issuers, https://www.cms.gov/files/document/final-2026-letter-issuers.pdf.

36.

42 U.S.C. §18031(e)(3), 45 C.F.R. §156.220, and related data collection requirements on exchanges at 45 C.F.R. §155.1040. QHPs must make "accurate and timely disclosure" of the required information to the exchange, the HHS Secretary, the state insurance commissioner, and the public. Other reporting requirements also apply to QHPs, such as 42 U.S.C. §1320b-23, which requires QHPs or their pharmacy benefit managers to report certain prescription drug information to HHS.

37.

42 U.S.C. §300gg-15a applies the QHP reporting requirements at 42 U.S.C. §18031(e)(3) to most private health insurance plans (i.e., employer-sponsored insurance plans and all nongroup coverage), but as currently implemented, such plans are only required to report certain of the data (not, for example, data on claims denials).

38.

45 C.F.R. §156.223, as added by rulemaking finalized in 2024. See summary information and a link to the rule at CMS, "CMS Interoperability and Prior Authorization Final Rule CMS-0057-F," January 17, 2024, https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.

39. SADPs are dental insurance plans certified to be sold on the exchanges. See 42 U.S.C. §18031(d)(2)(B)(ii), 45 C.F.R. §155.1065, and 45 C.F.R. §155.705. This report does not focus on SADPs but provides some examples of SADP requirements. See the sections on "Covered Benefits" and "Cost Sharing, Actuarial Value Levels, and Maximum Out-of-Pocket Limits" as well as Table B-1. 40.

2023 Payment Notice, starting at https://www.federalregister.gov/d/2022-09438/p-1342. Federal requirements on standardized plans do not apply in FFEs or SBE-FPs where a state has its own requirements for standardized plans as of January 1, 2020 (Oregon), and there are variations of the requirements to accommodate certain states' cost-sharing laws (Delaware and Louisiana).

41.

2026 Payment Notice, starting at https://www.federalregister.gov/d/2025-00640/p-893. This discussion also references the relevant sections of the 2023-2025 Payment Notices.

42. In addition, a Commonwealth Fund analysis includes certain information regarding SBEs and standardized plans: Rachel Schwab et al., "ACA State Marketplace Models and Key Policy Decisions," updated March 14, 2025, https://www.commonwealthfund.org/publications/maps-and-interactives/aca-state-marketplace-models-and-key-policy-decisions. Hereinafter Commonwealth Fund, 2025 State Marketplace Analysis. For standardized plan information, see the spreadsheet at the "Download the data" link on this page, and the "Simplifying Plan Choice" tab of that spreadsheet. 43.

45 C.F.R. §156.201 (Standardized Plan Options) and 45 C.F.R. §156.202 (Non-standardized Plan Option Limits). Specific cost-sharing requirements for standardized plans are listed in the relevant Payment Notice's preamble (e.g., in the 2025 Payment Notice for plan year 2025, https://www.federalregister.gov/d/2024-07274/p-1472). Also see the aforementioned CMS, 2025 Final Letter to Issuers, https://www.cms.gov/files/document/2025-letter-issuers.pdf, and CMS, 2026 Final Letter to Issuers, https://www.cms.gov/files/document/final-2026-letter-issuers.pdf.

44. 45 C.F.R. §156.201. The standardized plan requirements refer to the definition of product at 45 C.F.R. §144.103: "a discrete package of health insurance coverage benefits that are offered using a particular product network type (such as health maintenance organization, preferred provider organization, exclusive provider organization, point of service, or indemnity) within a service area." A plan's "service area" is the geographic area—generally a whole county or group of counties—in which it is available to consumers. See HealthCare.gov, "Service Area," accessed March 24, 2025, https://www.healthcare.gov/glossary/service-area/. Also see 45 C.F.R. §155.1055. 45.

CMS, "HHS Notice of Benefit and Payment Parameters for 2023 Final Rule Fact Sheet," April 28, 2022, https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2023-final-rule-fact-sheet.

46.

45 C.F.R. §156.201(b) and (c).

47.

2025 Payment Notice, starting at https://www.federalregister.gov/d/2024-07274/p-1502.

48. HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), Facilitating Consumer Choice: Standardized Plans in Health Insurance Marketplaces, December 28, 2021, https://aspe.hhs.gov/reports/standardized-plans-health-insurance-marketplaces. Also see, for example, Katie Keith, "Final 2023 Payment Rule, Part 2: Standard Plans And Other Exchange Provisions," Health Affairs Forefront, April 30, 2022, https://www.healthaffairs.org/content/forefront/final-2023-payment-rule-part-2-standard-plans-and-other-exchange-provisions, and Center on Budget and Policy Priorities, "Easy Pricing Plans (Standardized Plans)," July 2024, https://www.healthreformbeyondthebasics.org/easy-pricing-plans-standardized-plans/. 49.

42 U.S.C. §18032(a) and (f) and 45 C.F.R. §155.305.

50.

State residency may be established through a variety of means, including actual or planned residence in a state, actual or planned employment in a state, and other circumstances.

51. Examples of lawfully present immigrants include lawful permanent residents, refugees, asylees, and nonimmigrants (e.g., students and temporary workers). For a full list, see CRS Report R47351, Noncitizens' Access to Health Care. For more information (including regarding Deferred Action for Childhood Arrivals (DACA) recipients), see HealthCare.gov, "Immigration status to qualify for the Marketplace," accessed March 24, 2025, https://www.healthcare.gov/immigrants/immigration-status/. 52.

42 U.S.C. §18083, 45 C.F.R. §155.405.

53.

Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as long-term services and supports, to a diverse low-income population, including children, pregnant women, adults, individuals with disabilities, and people aged 65 and older. CHIP is a means-tested program that provides health coverage to targeted low-income children and pregnant women in families that have annual income above Medicaid eligibility levels but have no health insurance. The "applicable State health subsidy programs" also include the Basic Health Program, which is operational in three states: Minnesota, New York, and Oregon.

54.

See "Exchange Enrollment Assistance" in this report for information on Navigators, agents and brokers, and approved web brokers and other technology providers.

55. 45 C.F.R. Part 155, Subpart D, including §155.302. Regarding FFE and SBE-FP states, also see Section 2.2.5 of CMS, CCIIO, Federally-facilitated Exchange (FFE) Enrollment Manual, August 19, 2024, https://www.cms.gov/files/document/ffe-enrollment-manual-2024-5cr-082024.pdf. Hereinafter CMS, FFE Enrollment Manual (2024). 56. Social Security Act §1882(d)(3)(A)(i). Medicare is a federal program that pays for covered health care services for most people aged 65 and older and for certain permanently disabled individuals under the age of 65. The prohibition on selling an individual exchange plan to someone enrolled in or entitled to Medicare does not apply to employment-based coverage, including coverage sold in the SHOP exchanges. See CMS, "Medicare and the Marketplace," updated September 10, 2024, https://www.cms.gov/marketplace/about/medicare. Also see Section 3.4.8 of CMS, FFE Enrollment Manual (2024), linked in the prior footnote. Information for consumers is at Medicare.gov, "Medicare & the Marketplace," accessed March 24, 2025, https://www.medicare.gov/basics/get-started-with-medicare/other-paths/medicare-marketplace. 57.

45 C.F.R. §155.410.

58. These annual OEP dates were updated via rulemaking, in effect as of the PY2022 OEP (in fall 2021). See the 2022 Payment Notice, "Part 3," starting at https://www.federalregister.gov/d/2021-20509/p-248. See prior year OEPs at 45 C.F.R. §155.410(b) and (e). Annual payment notices are cited in Table D-1. 59.

Consumers enrolling by December 15 of a given OEP are to have coverage beginning January 1. Consumers enrolling December 16-January 15 are to have coverage beginning February 1.

60. 45 C.F.R. §155.410(e)(4)(ii) and (iii). For PY2025 SBE OEPs, see CMS, State Exchange OE Chart PY 2025, October 14, 2024, at https://www.cms.gov/files/document/state-exchange-oe-chart-py-2025.pdf. For PY2024 and prior year SBE OEP information, see the CMS/CCIIO pages of "Marketplace Open Enrollment Period Public Use Files" (PUFs) at https://www.cms.gov/data-research/statistics-trends-reports/marketplace-products/2024-marketplace-open-enrollment-period-public-use-files. Hereinafter CMS, "Marketplace OEP PUFs." 61.

See Section 3.2.5 of the aforementioned CMS, FFE Enrollment Manual (2024), at https://www.cms.gov/files/document/ffe-enrollment-manual-2024-5cr-082024.pdf. Also see the most recent CMS guidance to nongroup market issuers on providing notices of coverage renewal or discontinuation, June 2023, at https://www.cms.gov/files/document/updated-federal-standard-notices-and-enforcement-safe-harbor-discontinuation-notices-py-2024.pdf. There, see "Instructions for Attachment 2," item 31.

62.

For more information about plan renewal options and processes, including automatic renewals of enrollees in their existing plans or in alternate plans if their existing ones will no longer be available, see Section 3.2 of the aforementioned CMS, FFE Enrollment Manual (2024) at https://www.cms.gov/files/document/ffe-enrollment-manual-2024-5cr-082024.pdf. Although this manual describes processes for HealthCare.gov states, SBEs also have processes for automatic reenrollment.

63. In addition to the examples and their regulatory citations shown here, see HealthCare.gov, "Special enrollment opportunities," accessed March 24, 2025, https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ and HealthCare.gov, "Special Enrollment Periods for complex issues," accessed March 24, 2025, https://www.healthcare.gov/sep-list/. Also see 45 C.F.R. §147.104 regarding SEPs applicable to the nongroup and group markets overall. 64.

45 C.F.R. §155.420(d)(1), (e)(1). Qualifying coverage generally means the types of minimum essential coverage (MEC) that are identified in the Internal Revenue Code (IRC) Section 5000A and its implementing regulations.

65.

While exchange plan enrollees may voluntarily terminate their coverage at any time during the plan year, this would not necessarily trigger an SEP through which someone could select a new plan.

66.

45 C.F.R. §155.420(d)(2).

67. There is no federal SEP based on pregnancy, but per CRS review (in November 2024) of the websites of the 20 SBEs for PY2025, there are pregnancy-related SEPs in at least nine SBEs: Colorado, Connecticut, Kentucky, Maine, Maryland, New Jersey, New York, Vermont, and Washington, DC. SBE websites are linked in Table A-1. In addition, see 45 C.F.R. §155.420(d)(1)(iii), which specifies that the loss of certain other pregnancy-related coverage (e.g., via Medicaid) would trigger a federal exchange SEP. 68.

45 C.F.R. §155.420(d)(3, 6).

69. 45 C.F.R. §155.420(d)(7). Note that "moving only for medical treatment or staying somewhere for vacation doesn't qualify you for a Special Enrollment Period." HealthCare.gov, "Special enrollment opportunities," accessed March 24, 2025, https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/. 70.

45 C.F.R. §155.420(d)(4, 5, 12).

71.

45 C.F.R. §155.420(d)(8-15). These include SEPs related to gaining or maintaining status as an Indian, being a victim of domestic abuse or spousal abandonment, gaining access to an Individual Coverage Health Reimbursement Account (ICHRA), the cessation of employer contributions toward COBRA continuation coverage, and more.

72.

Statutory requirements for exchange SEPs are at 42 U.S.C. §18031(c)(6), and Secretarial authority to establish standards for the exchanges is at 42 U.S.C. §18041(a). Also see 45 C.F.R. §155.420(d)(9) regarding SEPs for "exceptional circumstances." Examples of certain administrative changes made to SEPs are in the HHS final rule, "Patient Protection and Affordable Care Act; Market Stabilization," 82 Federal Register 18346, April 18, 2017, https://www.federalregister.gov/documents/2017/04/18/2017-07712/patient-protection-and-affordable-care-act-market-stabilization.

73. This SEP was initially set to end May 15, 2021, and was later extended to August 15, 2021. See CMS, "2021 Special Enrollment Period in response to the COVID-19 Emergency," January 28, 2021, https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment-period-response-covid-19-emergency, and CMS, "Extended Access Opportunity to Enroll in More Affordable Coverage Through HealthCare.gov," March 23, 2021, https://www.cms.gov/newsroom/fact-sheets/extended-access-opportunity-enroll-more-affordable-coverage-through-healthcaregov. 74.

At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA; P.L. 116-127), which included a requirement that Medicaid programs keep individuals continuously enrolled from January 1, 2020, through the end of the COVID-19 public health emergency (PHE), in exchange for enhanced federal funding. As part of the Consolidated Appropriations Act, 2023 (CAA 2023; P.L. 117-164), Congress delinked the continuous enrollment provision from the COVID-19 PHE period, ending continuous enrollment on March 31, 2023.

75.

This SEP was initially set to end on July 31, 2024, and was later extended to November 30, 2024. See CMS, Temporary Special Enrollment Period (SEP) for Consumers Losing Medicaid or Children's Health Insurance Program (CHIP) Coverage Due to Unwinding of the Medicaid Continuous Enrollment Condition Operations for Plan Year 2024, March 28, 2024, https://www.medicaid.gov/resources-for-states/downloads/extn-sep-cnsmrs-lsg-chip-cvrg-adndm-faq.pdf. This cites the initial announcement.

76.

45 C.F.R. §155.420(c)(6).

77. For example, the COVID-19 SEP, described above, was available in all FFEs and SBE-FPs. States with SBEs were "strongly encouraged" by CMS to take similar action, and all SBEs (15 in PY2021) did so. See page 19 of HHS, 2021 FINAL MARKETPLACE SPECIAL ENROLLMENT PERIOD REPORT, September 15, 2021, https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf. In addition, the aforementioned Commonwealth Fund, 2025 State Marketplace Analysis includes information on SBEs and certain special enrollment periods. Specifically, see the spreadsheet at the "Download the data" link at https://www.commonwealthfund.org/publications/maps-and-interactives/aca-state-marketplace-models-and-key-policy-decisions, and the "Reducing Enrollment Barriers" tab of that spreadsheet. 78.

For more information about SEPs, see Section 5 of the aforementioned CMS, FFE Enrollment Manual (2024), https://www.cms.gov/files/document/ffe-enrollment-manual-2024-5cr-082024.pdf.

79.

45 C.F.R. §155.420(d)(16), as added by the 2022 Payment Notice, "Part 3," starting at https://www.federalregister.gov/d/2021-20509/p-272 .

80.

2025 Payment Notice, starting at https://www.federalregister.gov/d/2024-07274/p-1087.

81.

See 45 C.F.R. §155.420(a)(3-4) for enrollment options (e.g., for enrollees and/or their dependents, and for different metal level plans) for different SEPs. Plan metal levels are explained in "Cost Sharing, Actuarial Value Levels, and Maximum Out-of-Pocket Limits" in this report.

82. Katie Keith, "Biden Administration Finalizes First Marketplace Rule, Including New Low-Income Special Enrollment Period," Health Affairs Forefront, September 20, 2021, https://www.healthaffairs.org/content/forefront/biden-administration-finalizes-first-marketplace-rule-including-new-low-income-special. The 2025 Payment Notice also addresses certain adverse selection concerns regarding this SEP, https://www.federalregister.gov/d/2024-07274/p-1096. 83.

See the aforementioned Commonwealth Fund, 2025 State Marketplace Analysis, regarding SBEs and certain SEPs including the low-income SEP. Specifically, see the spreadsheet at the "Download the data" link at https://www.commonwealthfund.org/publications/maps-and-interactives/aca-state-marketplace-models-and-key-policy-decisions, and the "Reducing Enrollment Barriers" tab of that spreadsheet.

84.

45 C.F.R. §147.104(b)(2)(i)(G), as added by the 2022 Payment Notice, "Part 3," https://www.federalregister.gov/d/2021-20509/p-899.

85. CMS, HEALTH INSURANCE MARKETPLACES 2024 OPEN ENROLLMENT REPORT, March 2024, https://www.cms.gov/files/document/health-insurance-exchanges-2024-open-enrollment-report-final.pdf. Hereinafter CMS, 2024 OEP Report. 86.

CMS, "Marketplace 2025 Open Enrollment Period Report: National Snapshot," January 17, 2025, https://www.cms.gov/newsroom/fact-sheets/marketplace-2025-open-enrollment-period-report-national-snapshot-2.

87.

CMS, Effectuated Enrollment: Early 2024 Snapshot and Full Year 2023 Average, July 2024, https://www.cms.gov/files/document/early-2024-and-full-year-2023-effectuated-enrollment-report.pdf.

88. However, a number of government and stakeholder resources provide analysis and data on enrollment trends, including the federal reports linked in the "Additional Exchange Statistics" section of CRS Report R46638, Health Insurance Exchanges: Sources of Statistics. Also see, for example, Terry Burke et al., "9 Trends Driving Historic ACA Enrollment Growth," Oliver Wyman, January 2024, https://www.oliverwyman.com/our-expertise/perspectives/health/2024/jan/9-trends-driving-historic-aca-enrollment-growth.html; and Cynthia Cox and Jared Ortaliza, "Where ACA Marketplace Enrollment is Growing the Fastest, and Why," KFF, May 16, 2024, https://www.kff.org/policy-watch/where-aca-marketplace-enrollment-is-growing-the-fastest-and-why/. 89.

See "Qualified Health Plans" in this report.

90.

The 10 categories of EHB are ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. For more information on EHB requirements and state specification of their EHB, see the CRS report in the following footnote, and see CMS, CCIIO, "Information on Essential Health Benefits (EHB) Benchmark Plans," updated January 14, 2025, https://www.cms.gov/cciio/resources/data-resources/ehb.

91.

These and other federal requirements on private health insurance plans, applicable to the nongroup market and otherwise, are discussed in CRS Report R45146, Federal Requirements on Private Health Insurance Plans.

92. Regarding the pediatric dental exception for QHPs and requirements on SADPs, see 42 U.S.C. §18022(b)(4)(F), 42 U.S.C. §18031(d)(2)(B)(ii), and 45 C.F.R. §155.1065(d). See Appendix Table B-1 for more information on SADPs. 93.

42 U.S.C. §18023(a) and (c). For more information, including on states requiring or prohibiting abortion coverage, see "Does Federal Law Require Private Health Insurance Coverage of Abortions or Abortion Counseling?" in CRS Report R46785, Federal Support for Reproductive Health Services: Frequently Asked Questions.

94.

Ibid. See "Can Federal Funds Be Used to Pay for Abortion in Private Health Insurance Plans?"

95. Public Use Files (PUFs) that primarily include data on plans in the FFEs and SBE-FPs, by year, are available at CMS, CCIIO, "Health Insurance Exchange Public Use Files (Exchange PUFs)," updated December 18, 2024, https://www.cms.gov/marketplace/resources/data/public-use-files. See, for example, the PY2025 "Benefits and Cost Sharing PUF" at that page. A separate webpage includes similar exchange PUFs for plans in each SBE by year: CMS, CCIIO, "Health Insurance State-based Exchange Public Use Files," updated September 10, 2024, https://www.cms.gov/marketplace/resources/data/state-based-public-use-files. Hereinafter CMS, "Exchange PUFs" and CMS, "SBE PUFs," respectively. Note that these are different than the Marketplace OEP PUFs cited elsewhere in this report, which primarily provide data on OEP enrollment. 96.

See CRS Report R47507, Private Health Insurance: A Primer for further background on private health insurance premiums.

97.

See CRS Report R45146, Federal Requirements on Private Health Insurance Plans for more information about this and other federal requirements related to setting premiums.

98.

See "Exchange Administration" in this report.

99. Jared Ortaliza et al., "How Much and Why ACA Marketplace Premiums Are Going Up in 2025," Peterson-KFF Health System Tracker, August 2, 2024, https://www.healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2025/. 100. American Academy of Actuaries, Drivers of 2025 Health Insurance Premium Changes, August 2024, https://www.actuary.org/sites/default/files/2024-08/health-brief-2025-premium-changes.pdf. 101.

In general, beginning with each plan year, an enrollee pays 100% of the costs of their covered benefits until they meet a threshold amount called a deductible. Exceptions apply. After that, the enrollee pays coinsurance (a percentage amount) or co-payments (a flat amount) for covered benefits, and the plan pays the rest. If an enrollee's spending meets an annual OOP limit, the plan will generally pay 100% of covered costs for the remainder of the plan year.

102. Grandfathered plans are nongroup or group plans in which at least one individual was enrolled as of enactment of the ACA (March 23, 2010) and which continue to meet certain criteria. Plans that maintain their grandfathered status are exempt from some, but not all, federal requirements. There are no grandfathered plans sold through the exchanges, but they may be available off the exchanges. For more information, see CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements, as well as HealthCare.gov, "Grandfathered health insurance plans," accessed March 24, 2025, https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/. 103.

42 U.S.C. §18022(d).

104.

45 C.F.R. §156.20.

105.

Regulations allow plans to fall within a specified AV range and still comply with one of the four levels; see 45 C.F.R. §156.140(c)(2).

106.

45 C.F.R. §156.200(c)(1).

107. See Table 5 in the aforementioned CMS, 2024 OEP Report, https://www.cms.gov/files/document/health-insurance-exchanges-2024-open-enrollment-report-final.pdf. For more data, including state-level estimates, see the aforementioned CMS, "Marketplace OEP PUFs," https://www.cms.gov/data-research/statistics-trends-reports/marketplace-products/2024-marketplace-open-enrollment-period-public-use-files. See "Enrollment " in this report for more information on effectuated and pre-effectuated enrollment. 108. 45 C.F.R. §156.130(a). The annual out-of-pocket limit is generally only required to apply to the plan's covered EHB that are furnished by an in-network provider, unless otherwise addressed in federal or state law. See CRS Report R45146, Federal Requirements on Private Health Insurance Plans for more information, including about self-only and other-than-self-only coverage, as shown in Figure 2 of this report. 109.

For example, per the aforementioned CMS, 2025 Final Letter to Issuers, SADPs are subject to a 2025 OOP limit specific to their EHB pediatric dental coverage: $425 for one covered child and $850 for two or more children. See https://www.cms.gov/files/document/2025-letter-issuers.pdf. Also see "Qualified Health Plans" in this report regarding SADPs, and "Covered Benefits" in the Individual Exchanges section of this report regarding EHB requirements and SADPs.

110.

For more information about these forms of consumer financial assistance, including applicable eligibility criteria and illustrative examples, see CRS Report R44425, Health Insurance Premium Tax Credit and Cost-Sharing Reductions.

111.

The ACA requires the HHS Secretary to provide full reimbursements to insurers that provide these cost-sharing subsidies to their enrollees. However, the ACA did not appropriate funds for such payments. In October 2017, the Trump Administration halted these payments, effective immediately, until Congress appropriates funds. Insurers still must provide the subsidies to eligible consumers, but insurers are not reimbursed. See HHS, Payments to Issuers for Cost-Sharing Reductions, October 12, 2017, https://www.hhs.gov/sites/default/files/csr-payment-memo.pdf.

112.

Consumers may choose to receive the premium tax credit on a monthly basis, in advance of filing taxes, to coincide with the payment of insurance premiums (technically, advance payments go directly to insurers). Advance payments automatically reduce monthly premiums by the credit amount. This option is called the advance premium tax credit, or APTC. Consumers may instead claim the full credit amount of the PTC when filing their taxes, even if they have little or no federal income tax liability.

113. In the HHS reports cited in Table 3, certain of these data are also available at the state level. In such reports, and in other HHS reports (e.g., on pre-effectuated enrollment) some data are also available on demographics and/or metal levels of plans. For more information, see CRS Report R46638, Health Insurance Exchanges: Sources of Statistics. 114. For example, regarding premiums and cost sharing on plans offered in FFEs and SBE-FPs in PY2025, see CMS, CCIIO, Plan Year 2025 Qualified Health Plan Choice and Premiums in HealthCare.gov Marketplaces, October 2024, https://www.cms.gov/marketplace/resources/data/qualified-health-plan-choice-premiums-healthcaregov-states. Hereinafter "CMS, QHP Choice, PY2025. Also see KFF, "Average Marketplace Premiums by Metal Tier, 2018-2025," accessed March 24, 2025, https://www.kff.org/affordable-care-act/state-indicator/average-marketplace-premiums-by-metal-tier/; and KFF, "Deductibles in ACA Marketplace Plans, 2014-2024," December 22, 2023, https://www.kff.org/private-insurance/issue-brief/deductibles-in-aca-marketplace-plans/. 115.

However, some federal requirements (e.g., mental health parity) may have implications for plans' provider networks. Other federal requirements (e.g., continuity of care) are related to plan interactions and consumer interactions with providers. See CRS Report R45146, Federal Requirements on Private Health Insurance Plans.

116.

QHP network adequacy requirements are at 42 U.S.C. §18031(c)(1)(B) and 45 C.F.R. §156.230.

117.

45 C.F.R. §156.230(a)(1)(ii). Prior regulations on network adequacy requirements applied only to QHPs that used provider networks. As of PY2024, all QHPs are required to use provider networks and to comply with network adequacy requirements. See the 2024 Payment Notice, starting at https://www.federalregister.gov/d/2023-08368/p-1358.

118.

45 C.F.R. §156.230(a)(2)(i)(A).

119.

See the CMS 2023 Final Letter to Issuers in the Federally-facilitated Exchanges, April 2022, https://www.cms.gov/cciio/resources/regulations-and-guidance/downloads/final-2023-letter-to-issuers.pdf. The aforementioned CMS, 2025 Final Letter to Issuers and 2026 Final Letter to Issuers generally refer to the CMS, 2023 Final Letter to Issuers regarding network adequacy requirements. See https://www.cms.gov/files/document/2025-letter-issuers.pdf and https://www.cms.gov/files/document/final-2026-letter-issuers.pdf.

120.

45 C.F.R. §156.230(a)(2)(i)(B). Also see CMS, 2025 Final Letter to Issuers, linked in the prior footnote.

121.

45 C.F.R. §156.235(a)(1). Also see 42 U.S.C. §18031(c)(1)(C).

122.

45 C.F.R. §156.230(b).

123. See the aforementioned CMS, "Exchange PUFs" page (primarily on plans in the FFEs and SBE-FPs), https://www.cms.gov/marketplace/resources/data/public-use-files. For example, the PY2025 "Plan Attributes" PUF indicates whether plans have a national network, and the "Network" PUF on such plans includes links to plans' network details. Also see similar files on plans in the SBEs in the aforementioned CMS, "SBE PUFs" page, https://www.cms.gov/marketplace/resources/data/state-based-public-use-files. 124. Matthew Rae et al., "How Narrow or Broad Are ACA Marketplace Physician Networks?," KFF, August 26, 2024, https://www.kff.org/private-insurance/report/how-narrow-or-broad-are-aca-marketplace-physician-networks/. Also see Terry Burke et al., "Understanding Why Narrow Networks Dominate the ACA Exchange," Oliver Wyman, March 2024, https://www.oliverwyman.com/our-expertise/perspectives/health/2024/march/understanding-why-narrow-networks-dominate-the-aca-exchange.html. 125.

See, for example, Erica Teichert, "Last 'Bare' County in the U.S. Scores ACA Exchange Coverage," Modern Healthcare, August 24, 2017, https://www.modernhealthcare.com/article/20170824/NEWS/170829941/last-bare-county-in-the-u-s-scores-aca-exchange-coverage.

126. As stated in Figure 3, values may not add to 100% due to rounding. 127.

See the aforementioned CMS, QHP Choice, PY2025, https://www.cms.gov/marketplace/resources/data/qualified-health-plan-choice-premiums-healthcaregov-states. See Figure 1 in that resource, as well as Figure 2 in that resource for changes in issuer participation at the county level.

128. Government Accountability Office (GAO), Health Insurance Exchanges: Claims Costs and Federal and State Policies Drove Issuer Participation, Premiums, and Plan Design, January 2019, https://www.gao.gov/products/gao-19-215. Hereinafter GAO, Issuer Participation report, January 2019." 129.

Several provisions of the ACA, such as guaranteed issue of health insurance, generally have increased higher-risk individuals' ability to purchase insurance and restricted insurers' ability to deny or limit coverage to such individuals. The ACA created some new requirements and expanded some existing requirements, including by applying requirements on the nongroup market that previously existed in one or more segments of the group market.

130.

See "Premium Tax Credits and Cost-Sharing Reductions" in this report for background on these topics. One of the factors cited in the aforementioned GAO, Issuer Participation report, January 2019, as affecting insurers' participation was "federal funding changes," including the ending of federal payments for cost-sharing reduction subsidies in October 2017. See https://www.gao.gov/products/GAO-19-215.

131.

Of the three ACA risk-mitigation programs—risk corridors, reinsurance, and risk adjustment—one was designed to be permanent. The risk corridors and reinsurance programs were in effect from 2014 to 2016; the risk adjustment program also began in 2014 and is still in effect. It assesses charges on applicable private health insurance plans with relatively healthier enrollees and uses collected charges to make payments to private health plans in the same state that have relatively sicker enrollees. See "Other Federal Funding Sources" in this report regarding the charges assessed on insurers via the risk adjustment program. The phaseouts of the other two programs are cited among "federal funding changes" affecting insurers' participation decisions. For descriptions of all three programs and their different approaches, see Table 1 in CRS Report R45334, The Patient Protection and Affordable Care Act's (ACA's) Risk Adjustment Program: Frequently Asked Questions.

132.

See Figure 1 in the aforementioned GAO, Issuer Participation report, January 2019, https://www.gao.gov/products/GAO-19-215.

133.

GAO, Private Health Insurance: Market Concentration Generally Increased from 2011 through 2022, November 2024, https://www.gao.gov/products/gao-25-107194.

134.

Insurance company merges and acquisitions are an example of horizontal market consolidation. Insurers can also engage in vertical integration (e.g., mergers and acquisitions between insurers and other types of entities such as healthcare providers or pharmacy companies). This expands their operations outside of strictly insurance functions, but can still affect their activities as an insurer.

135.

For example, insurer-provider interactions are also affected by providers' market power, which can be affected by provider concentration and consolidation dynamics. Full discussion of these issues is beyond the scope of this report. Regarding other factors affecting premiums, see "Premiums" in the Individual Exchanges section in this report.

136.

See the aforementioned CMS, QHP Choice, PY2025, https://www.cms.gov/marketplace/resources/data/qualified-health-plan-choice-premiums-healthcaregov-states. See Table 1 in that report, as well as the appendix file linked within that report, which includes issuer and plan availability data by HealthCare.gov state, and for selected counties, by year. According to the report methodology, the counts exclude catastrophic, child-only, SADP, and SHOP plans. Certain metrics in the report (e.g., average premiums) are weighted by enrollee plan selections (and PY2025 data are weighted by PY2025 plan selections because this report was published before PY2025 enrollment began), but it is not clear if state and county averages of insurer participation and plan availability are similarly weighted.

137.

See "Standardized Plans" in this report for an overview of these plans. Regarding "choice overload," see footnote 48 for a December 2021 ASPE report and an April 2022 Health Affairs article.

138.

For purposes of SHOP eligibility, the number of employees is determined using the "full-time equivalent" (FTE) employees calculation method. See 45 C.F.R. §155.20, "Small employer," which references 26 U.S.C. §4980H. Also see CRS Report R45455, The Affordable Care Act's (ACA's) Employer Shared Responsibility Provisions (ESRP) for discussion of FTE calculations.

139. California, Colorado, New York, and Vermont are the only states that define small businesses as having 100 or fewer employees for the purpose of participation in the SHOP exchanges. See CMS/CCIIO, "Market Rating Reforms," updated September 10, 2024, https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating. Also see Table A-1. 140.

42 U.S.C. §18032(f)(2)(B).

141. For discussion of the SHOP eligibility requirement to have at least one common-law employee, see HHS, "Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers," March 27, 2012, 77 Federal Register 18310, https://www.federalregister.gov/d/2012-6125/p-1139. Hereinafter HHS, "Exchange Establishment" Final Rule, 2012. 142.

For purposes of SHOP eligibility, the definition of full-time employee is at 45 C.F.R. §155.20.

143.

45 C.F.R. §155.710(e).

144. It is possible for SHOP exchanges to establish minimum participation rates and minimum contribution rates. Businesses that do not comply with established rates cannot be prohibited from obtaining coverage through SHOP exchanges; rather, health insurance plans may limit the availability of coverage for any employer that does not meet an allowed minimum participation or contribution rate to an annual enrollment period—November 15 through December 15 of each year. See, for example, HealthCare.gov, "Find out if your small business qualifies for SHOP," accessed March 24, 2025, https://www.healthcare.gov/small-businesses/choose-and-enroll/qualify-for-shop-marketplace/. 145.

45 C.F.R. §155.726(b).

146.

45 C.F.R. §155.726(c).

147. A business with locations or employees in multiple states has options for offering SHOP coverage to all its eligible employees. See 45 C.F.R. §155.710 and HealthCare.gov, "SHOP coverage for multiple locations & businesses," accessed March 24, 2025, https://www.healthcare.gov/small-businesses/provide-shop-coverage/business-in-more-than-one-state/. 148. HealthCare.gov, "Overview of SHOP: Health insurance for small businesses," accessed March 6, 2025, https://www.healthcare.gov/small-businesses/choose-and-enroll/shop-marketplace-overview/. 149. 2019 Payment Notice, starting at https://www.federalregister.gov/d/2018-07355/p-654. In that rule, HHS also confirmed that because of these reductions in federal SHOP web portal functionality, state-based SHOP exchanges would no longer be able to use the federal IT platform. In other words, HHS eliminated the SB-FP-SHOP option (discussed in "State-Based and Federally Facilitated Exchanges" in this report). The two states that used this option at the time, Kentucky and Nevada, were allowed to continue doing so if desired, despite the reduced functionality of HealthCare.gov for SHOP. See https://www.federalregister.gov/d/2018-07355/p-442. They have since transitioned to SB-SHOPs (see Table A-1). 150.

For iterations of guidance on this topic issued between 2014 and 2016, see CMS, CCIIO, "Extension of State-Based SHOP Direct Enrollment Transition," April 18, 2016, https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/1332-and-SHOP-Guidance-508-FINAL.PDF.

151.

Ibid. In April 2016, CMS also outlined different options for those states to consider, including transitioning to the federal IT platform (becoming an SB-FP-SHOP) or applying for an ACA Section 1332 waiver to obtain an exception to the requirement to have a SHOP exchange at all. For more information about ACA Section 1332 waivers, see CRS Report R44760, State Innovation Waivers: Frequently Asked Questions.

152. See Table A-1. 153. The number of states with no insurers offering plans in SHOP exchanges in 2025 is based on CRS analysis of the 2025 "Business Rules" public use file at the aforementioned CMS, "Exchange PUFs" page, https://www.cms.gov/marketplace/resources/data/public-use-files, as well as information available on HealthCare.gov and state exchange websites at Table A-1. Comparable information about insurer participation in SHOP exchanges in prior years may not be consistently available. However, a 2019 GAO report indicates that in 2015-2017, there was at least one insurer participating in 46 of 51 states for which it had such data for all three of those years. See Table 7 in GAO, Private Health Insurance: Enrollment Remains Concentrated Among Few Issuers, Including in Exchanges, March 21, 2019, https://www.gao.gov/products/gao-19-306. Hereinafter GAO, Issuer Concentration report, March 2019. 154.

This estimate excludes Hawaii, as Hawaii's SHOP exchange was no longer operational in 2017 due to the state's receipt of a 1332 waiver. See CMS, CCIIO, "SHOP Marketplace Enrollment as of January 2017," May 15, 2017, archived at https://web.archive.org/web/20170517142657/https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/SHOP-Marketplace-Enrollment-Data.pdf.

155. This estimate excludes Vermont and Idaho; these states had not reported 2015 enrollment data to CMS. See CMS, "Update on SHOP Marketplaces for Small Businesses," July 2, 2015, archived at http://wayback.archive-it.org/2744/20170118124128/https:/blog.cms.gov/2015/07/. 156.

See page 24 and Appendix III of GAO, Issuer Concentration report, March 2019, https://www.gao.gov/products/gao-19-306.

157.

Other federal employees may obtain coverage through the Federal Employees Health Benefits Program (FEHB). Like many other employers, the federal government contributes to the cost of its employees' premiums. This is also true for the congressional Members and staff who obtain coverage through the SHOP. Certain congressional staff may not be required to obtain their coverage through the SHOP, and may be able to otherwise obtain coverage through FEHB. See Office of Personnel Management, "Members of Congress/Staff," accessed March 24, 2025, https://www.opm.gov/healthcare-insurance/changes-in-health-coverage/eligibility-enrollment/#url=Members-of-CongressStaff.

158. See the OPM list of frequently asked questions regarding health coverage for Members of Congress and staff, including the question, "If I do not live in Washington, DC, am I still eligible to sign up for coverage in the DC Health Link?," accessed March 24, 2025, https://www.opm.gov/healthcare-insurance/insurance-faqs/. 159.

For example, the aforementioned CMS, 2025 Final Letter to Issuers describes various requirements for QHP certification in the HealthCare.gov exchanges, and notes that unless otherwise specified, its references to QHP requirements in the FFEs also include QHPs in the FF-SHOPs. See https://www.cms.gov/files/document/2025-letter-issuers.pdf. One difference between the individual and SHOP exchanges is that QHP issuers in the SHOP exchanges are not subject to standardized plan requirements, as discussed earlier in this report.

160.

See the aforementioned CMS, "Exchange PUFs" page (primarily on plans in the FFEs and SBE-FPs), https://www.cms.gov/marketplace/resources/data/public-use-files. For example, the PY2025 "Plan Attributes" PUF includes SHOP plans, and that file can be linked to the PY2025 "Benefits and Cost Sharing" PUF for more information. Also see similar files on plans in the SBEs in the aforementioned CMS, "SBE PUFs" page, https://www.cms.gov/marketplace/resources/data/state-based-public-use-files.

161.

See 26 U.S.C. §45R for eligibility for the Small Business Health Care Tax Credit (SBTC) and credit amount details described in this section.

162.

See the SHOP "Eligibility and Enrollment" section of this report for discussion of full-time equivalent employees.

163.

Regarding SHOP eligibility, see 26 U.S.C. §4980H, 26 C.F.R. §54.4980H-1(a)(21), and 45 C.F.R. §155.20. Also see the SHOP "Eligibility and Enrollment" section of this report. Regarding the SBTC, see 26 U.S.C. §45R.

164.

Internal Revenue Service (IRS), Small Business Health Care Tax Credit Questions and Answers: Who Gets the Tax Credit, Question 6D, updated September 13, 2024, https://www.irs.gov/newsroom/small-business-health-care-tax-credit-questions-and-answers-who-gets-the-tax-credit.

165.

Section 2.10 of IRS, Rev. Proc. 2024-40, October 22, 2024, https://www.irs.gov/pub/irs-drop/rp-24-40.pdf, referring to 26 U.S.C. §45R(d)(3)(B).

166.

26 U.S.C. §45R(d)(1)(B).

167.

IRS, SOI Tax Stats - Affordable Care Act (ACA) Statistics: Credit for small employer health insurance premiums, updated November 8, 2024, https://www.irs.gov/statistics/soi-tax-stats-affordable-care-act-aca-statistics-credit-for-small-employer-health-insurance-premiums. See excel file, "Small Business Health Care Tax Credits Filed in Tax Years 2010–2016," linked on this web page.

168.

Ibid. CRS is not aware of more recent data than this.

169.

See "Provider Networks" in the Individual Exchanges section of this report.

170.

See the aforementioned CMS, "Exchange PUFs" page (primarily on plans in the FFEs and SBE-FPs), https://www.cms.gov/marketplace/resources/data/public-use-files. For example, the PY2025 "Plan Attributes" PUF indicates whether plans have a national network, and the "Network" PUF on such plans includes links to plans' network details. These files include SHOP plans. Also see similar files on plans in the SBEs in the aforementioned CMS, "SBE PUFs" page, https://www.cms.gov/marketplace/resources/data/state-based-public-use-files.

171.

See "Insurer Participation" in the Individual Exchanges section of this report.

172.

2018 Payment Notice, starting at https://www.federalregister.gov/d/2016-30433/p-884.

173.

See GAO, Small Business Health Insurance Exchanges: Low Initial Enrollment Likely due to Multiple, Evolving Factors, November 2014, https://www.gao.gov/products/gao-15-58; and GAO, Issuer Concentration report, March 2019. Also see Timothy Jost, "CMS Announces Plans To Effectively End The SHOP Exchange," Health Affairs Blog, May 15, 2017, https://www.healthaffairs.org/content/forefront/cms-announces-plans-effectively-end-shop-exchange.

174.

For example, see 42 U.S.C. §18031(i), 45 C.F.R. §155.205, 45 C.F.R. §155.210, and 45 C.F.R. §155.225.

175.

Ibid. Specifically, for the requirement to implement Navigator programs, see 45 C.F.R. §155.210.

176.

45 C.F.R. §155.210(c)(1)(iii).

177. See "Ongoing Federal Funding for Exchange Operations" and Table C-2 in this report for more information. 178.

CMS, "Biden-Harris Administration Awards $100 Million to Navigators Who Will Help Millions of Americans—Especially in Underserved Communities—Sign Up for Health Coverage," August 26, 2024, https://www.cms.gov/newsroom/press-releases/biden-harris-administration-awards-100-million-navigators-who-will-help-millions-americans.

179.

CMS, "CMS Announcement on Federal Navigator Program Funding," February 14, 2025, https://www.cms.gov/newsroom/press-releases/cms-announcement-federal-navigator-program-funding.

180. CMS, "In-Person Assistance in the Health Insurance Marketplaces," updated February 18, 2025, "Navigators" section, https://www.cms.gov/marketplace/in-person-assisters/programs-procedures/in-person-assistance#Navigators. CRS is not aware of a compilation of information about Navigator grants in states that fund and administer these programs (those with SBEs and SBE-FPs). 181. 2019 Payment Notice starting at https://www.federalregister.gov/d/2018-07355/p-473; 2020 Payment Notice starting at https://www.federalregister.gov/d/2019-08017/p-550. Payment Notice citations are in Table D-1. 182.

2022 Payment Notice, Part 3, starting at https://www.federalregister.gov/d/2021-20509/p-156.

183.

For example, in the 2024 Payment Notice, HHS removed a prohibition on Navigators going door-to-door to conduct consumer outreach and enrollment assistance. See https://www.federalregister.gov/d/2023-08368/p-590. No Navigator program changes were made in the 2025 or 2026 Payment Notices.

184.

For the requirement to implement certified application counselor programs, see 45 C.F.R. §155.225.

185.

Per a CMS training document for Navigators, assisters must not "log into the consumer's online Marketplace account, fill out the Marketplace application, or select a plan for the consumer." See page 29 of CMS, "Course 1 – Training Overview," linked at CMS, "Navigator and Certified Application Counselor Training Courses," updated February 19, 2025, https://www.cms.gov/marketplace/technical-assistance-resources/training-materials/certified-application-counselor-training-courses.

186.

42 U.S.C. §18031(i)(4). Also see 45 C.F.R. §155.215.

187.

45 C.F.R. §155.205.

188.

See, for example, 45 C.F.R. §155.205.

189.

45 C.F.R. §155.220.

190.

National Association of Insurance Commissioners (NAIC), "Producer Licensing," updated February 10, 2025, https://content.naic.org/insurance-topics/producer-licensing.

191.

NAIC, "Glossary of Insurance Terms," accessed March 24, 2025, https://content.naic.org/consumer_glossary. The NAIC states that its glossary represents a "common or general use of the term," as "based on various insurance references."

192.

45 C.F.R. §155.20.

193.

See, for example, 45 C.F.R. §155.220(a) and (d).

194.

For more information, see CMS, "Direct Enrollment and Enhanced Direct Enrollment," updated March 10, 2025, https://www.cms.gov/programs-and-initiatives/health-insurance-marketplaces/direct-enrollment-and-enhanced-direct-enrollment. Although CMS offers the DE and EDE "pathways" for FFE and SBE-FP states only, SBEs may also choose to offer their own DE and EDE options, which would interface with their exchange websites rather than HealthCare.gov. The 2025 Payment Notice, which clarifies that exchanges must operate a centralized eligibility and enrollment platform, emphasizes that this does not preclude the use of DE and EDE options, including for state exchanges. See https://www.federalregister.gov/d/2024-07274/p-616.

195.

Ibid. At 45 C.F.R. §155.20, "web-broker" is defined as "an individual agent or broker, group of agents or brokers, or business entity registered with an Exchange under §155.220(d)(1) that develops and hosts a non-Exchange website that interfaces with an Exchange to assist consumers with direct enrollment in QHPs offered through the Exchange as described in §155.220(c)(3) or §155.221. The term also includes an agent or broker direct enrollment technology provider." Several types of direct enrollment entities are also defined at 45 C.F.R. §155.20.

196.

See this and other "standards of conduct" at 45 C.F.R. §155.220(j)(2).

197.

45 C.F.R. §155.220(c)(3).

198.

45 C.F.R. §155.221(b).

199. See 45 C.F.R. §155.220(n) and §155.221(j). 200.

45 C.F.R. §156.340 and definitions at 45 C.F.R. §156.20.

201.

42 U.S.C. §300gg-46.

202.

See "Enrollment Processes and Options" in the SHOP section of this report for more information.

203.

42 U.S.C. §18031(a).

204.

42 U.S.C. §18031(a)(4)(B) specifies that no grant shall be awarded under this subsection after January 1, 2015. See CRS Report R43066, Federal Funding for Health Insurance Exchanges (last updated in October 2014) for more information about these planning and establishment grants.

205.

For further information, see pp. 5-6 of CRS Report R48060, Department of Health and Human Services: FY2025 Budget Request.

206. CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2025, March 15, 2024, https://www.cms.gov/about-cms/performance-budget/prior. See "Federal Marketplace Programs" table and narrative, pages 200-205. Hereinafter CMS Budget Justification, FY2025." 207.

Page 202 of the aforementioned CMS Budget Justification, FY2025, https://www.cms.gov/about-cms/performance-budget/prior.

208.

31 U.S.C. §1324(b). The permanent appropriation provides indefinite budget authority for PTC/APTC disbursements.

209.

42 U.S.C. §18031(d)(5)(A). Also see 45 C.F.R. §156.50.

210. For further discussion, see the 2025 Payment Notice (cited in Table D-1), starting at https://www.federalregister.gov/d/2024-07274/p-1240. Also see discussion of CMS activities conducted on behalf of certain exchanges versus all exchanges at CMS Budget Justification, FY2025, page 202, https://www.cms.gov/about-cms/performance-budget/prior. 211.

2019 Payment Notice, https://www.federalregister.gov/d/2018-07355/p-769. Regarding the reduced functionality of the federal SHOP website, see "Enrollment Processes and Options" in the SHOP Exchanges section of this report.

212.

See "Insurer Participation" in the Individual Exchanges section of the report.

213. According to the "Federal Exchanges" table in the FY2020 CMS budget justification, a portion of the mandatory Health Care Fraud and Abuse Control (HCFAC) appropriation went to the exchanges in FY2018 and FY2019. However, that table in the FY2021 budget justification does not show this for FY2019, and it is also not shown in subsequent budget justifications. See Table C-1 for citations. 214.

See the aforementioned Commonwealth Fund, 2025 State Marketplace Analysis: Select the spreadsheet at the "Download the data" link at https://www.commonwealthfund.org/publications/maps-and-interactives/aca-state-marketplace-models-and-key-policy-decisions and see the "Marketplace Governance" tab of that spreadsheet.

215.

See CMS, 2021 State Marketplace Modernization Grant Awards, September 10, 2021, https://www.cms.gov/files/document/state-based-marketplace-modernization-grant-awardee-list-2021.pdf.

216.

For information about other health provisions in ARPA, see CRS Report R46777, American Rescue Plan Act of 2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare Provisions.

217.

As of June 2018, states can no longer select the state-based using the federal IT platform (SB-FP-SHOP) approach, except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According to CMS, those states no longer use that model.

218.

42 U.S.C. §18031(d)(2)(B).

219. See, for example, the Further Consolidated Appropriations Act, 2024 (CAA 2024; P.L. 118-47), Division D, Title II, §220. See also the Consolidated Appropriations Act, 2023 (CAA 2023; P.L. 117-328), Division H, Title II, §220. 220.

The CMS Budget Justification, FY2025, was released on March 15, 2024. The CAA 2024, which included the requirement for an FY2025 Marketplace Transparency Table, was enacted on March 23, 2024. For further information, see pp. 5-6 of CRS Report R48060, Department of Health and Human Services: FY2025 Budget Request.

Other Federal Resources
Selected resources are available at the following links.
 Center for Consumer Information and Insurance Oversight (CCIIO) FAQs,
letters, and other resources related to the exchanges (also see pages linked to
the left side of the webpage): https://www.cms.gov/CCIIO/Programs-and-
Initiatives/Health-Insurance-Marketplaces
 CRS compilation of HHS resources on exchange enrollment and other
exchange data: CRS Report R46638, Health Insurance Exchanges: Sources for
Statistics


Author Information

Vanessa C. Forsberg

Analyst in Health Care Financing



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Congressional Research Service
R44065 · VERSION 20 · UPDATED
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