On the pending expiration of the ACA's ARPA subsidy enhancements

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ARPA subsidy boosts going, going...

I’d like here to highlight some factors that will affect how much ACA marketplace enrollment is likely to shrink if Republicans decline to extend the increases to ACA marketplace premium subsidies and eligibility first enacted by the American Rescue Plan Act (ARPA) in March 2021, and later extended through 2025 by the Inflation Reduction Act. I’ll assume no other major changes to the ACA (perhaps a dubious assumption).

The ARPA subsidy boosts made benchmark silver plan coverage free for enrollees with income up to 150% of the Federal Poverty Level (FPL), removed the ACA’s notorious income cap on subsidy eligibility (400% FPL), reduced the percentage of income required for a benchmark silver plan at all income levels between 150-400% FPL, and capped benchmark silver premiums at 8.5% of income for those with income above 400% FPL.

Since the Open Enrollment Period (OEP) for 2021, the last OEP before the ARPA subsidies took effect, ACA marketplace enrollment increased by 79% (9.4 million) through OEP 2024 (see Table 1 below). That enrollment growth was overwhelmingly concentrated at the 100-150% FPL income bracket, where silver coverage with strong Cost Sharing Reduction (CSR) is available for $0 premium, and in the ten states that have refused to date to enact the ACA Medicaid expansion. In those “nonexpansion” states, eligibility for marketplace subsidies begins at 100% FPL, whereas in the expansion states it begins at 138% FPL, the Medicaid eligibility threshold for almost all lawfully present adults.

The Urban Institute estimates that in 2025, the total number of people with subsidized marketplace enrollment (92% of total enrollment) will be 7.2 million higher than it would be without without the ARPA subsidy boosts. One might assume a similar drop in enrollment in years following 2025 if the ARPA enhancements expire. Urban further estimates, “In 2025…household net premiums will be lower by 50 to 100 percent for the lowest income groups under a policy of enhanced PTCs compared with a policy of original PTCs. Net premiums will be lower by about one-quarter for people with higher incomes who receive subsidized Marketplace coverage.” Reverse that for the effects of ARPA expiration.

Without venturing an overall estimate, I want to highlight the concentration of marketplace enrollment (and post-ARPA enrollment growth) at low incomes and the extent to which zero-premium coverage will still be available to low-income enrollees (albeit with lower actuarial value). I assume that Urban’s estimates of premium impact are for benchmark silver premiums, not premiums for plans actually selected, which will change if the ARPA enhancements expire.

Consider the following as to the makeup of current marketplace enrollment:

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• From OEP 2021 to OEP 2024, enrollment nationwide increased by 79%, from 12.0 million to 21.4 million.

• 59% of that growth was in the 100-150% FPL income bracket, where benchmark silver coverage was rendered free by ARPA (see Table 1 below).

• In 2024, 73% of enrollment in the 100-150% FPL income bracket was in the 10 nonexpansion states (78% if you count North Carolina, which enacted a Medicaid expansion on 12/1/23*). In 2024, 6.9 million enrollees in nonexpansion states (excluding NC) had income in the 100-150% FPL range.

• In OEP 2021, enrollment was flat nationwide except for in the nonexpansion states, where it increased 10%. Since OEP 2020, enrollment growth in nonexpansion states has accounted for 74% of enrollment growth nationwide.

• Before ARPA passed, the ACA’s income cap on subsidy eligibility was politically fraught, as the ACA’s guaranteed issue and Essential Health Benefits requirements raised premiums, and, after steep premium hikes in 2017 and 2018 ,several million subsidy-ineligible people were priced out of the market. Removing the income cap on subsidies went a long way toward fulfilling the ACA’s promise of “affordable care.” For all that, in 2024, enrollment of those who reported income higher than 400% FPL (i.e., expected premium subsidies) was 1.5 million, about 7% of total on-exchange enrollment. Another 856,000 enrollees did not report income and so paid full price (Table 1).

Keeping in mind the heavy concentration of ACA enrollment at low incomes, various factors will preserve some availability of zero-premium coverage for most enrollees with income up to 150% FPL, and often well beyond, or foster enrollment in other ways. These include:

Silver loading, Part I. In October 2017, Trump cut off federal reimbursement of insurers for providing the Cost Sharing Reduction (CSR) subsidies mandated by the ACA to low-income enrollees in silver plan. (His basis: while the ACA mandated this reimbursement, it left funding those reimbursements up to Congress, and Republican Congresses declined to do so. The Obama administration had found reimbursement funds in couch cushions.) CSR increases the value of a silver plan to a roughly platinum level for enrollees with income up to 200% FPL. The move had been anticipated, and most state regulators responded by allowing or encouraging insurers to price CSR directly into silver plans, since CSR is available only with silver plans. Since ACA income-adjusted premium subsidies are set to a silver benchmark, this “silver loading” led to sharp reductions in net-of-subsidy premiums for bronze and gold plans (and less often, for the one silver plan priced below the benchmark in each market). As a result, the Kaiser Family Foundation (KFF) calculated that beginning in 2018, most enrollees with income up to 150% FPL, and a good number with higher incomes, had access to $0 premium bronze plans.

Silver loading, Part II. As direct CSR reimbursement had been contested from the start, prior to Trump’s cutoff, analysts at CMS, the Urban Institute, and CBO had anticipated the effects of pricing CSR into silver premiums. All three analyses anticipated that gold plans would be priced below silver plans, because most silver plan enrollees have incomes qualifying for strong CSR, and silver plan enrollees on average therefore obtain higher actuarial value than gold plan enrollees. It mostly didn’t shake out that way, as insurers have strong incentives to underprice silver plans. In about fifteen states, however, varying by year, gold plans are available at premiums below benchmark silver, sometimes by regulatory or statutory requirement, and sometimes by insurer choice (usually of a dominant insurer). Most notably — and astonishingly — Texas enacted a law requiring marketplace insurers to price gold plans far below silver. (That makes sense, since 75% of enrollees in Texas have income below 200% FPL, and the average actuarial value of a silver plan in the state is over 90%, compared to 80% for gold plans.) Accordingly, Texas’s 2.2 million enrollees with income under 150% FPL will have access to $0 premium gold plans if the ARPA subsidy boosts expire, barring other changes.

Zero-deductible bronze plans. While median bronze plan deductibles were $7,200 for a single enrollee in 2023, bronze plans with $0 medical deductibles have become an increasingly common marketplace option. At low incomes, the premium is often $0 as well. These plans have their coverage traps, like a $3,000 drug deductible (usually not applicable to generics) or a $1,500 first-day hospital inpatient copay, but they can be attractive to healthy enrollees, or those willing to trade risk and out-of-pocket cost for a more expansive provider network and doctor visits not subject to the deductible.

Agent/broker commitment. The first Trump administration cut ACA marketplace advertising and nonprofit enrollment assistance, but they did cater to and encourage participation from agents and brokers — implementing a “help on demand” feature on HealthCare.gov, and encouraging development of commercial “enhanced direct enrollment” (EDE) platforms that streamline brokers’ work and organize their client files. Thanks in part to that support, along with the ARPA subsidy boosts and insurers’ re-commitment to the marketplace, broker registration with HealthCare.gov increased from 49,000 in 2018 to 83,000 in 2024. In OEP 2024, 78% of active enrollments in HealthCare.gov states (which includes all the nonexpansion states) were broker-assisted. This growing broker engagement has been something of a mixed bag, as the widespread availability of free coverage, coupled with inadequately controlled broker access to client data in EDE platforms, has led to a major outbreak of broker fraud and encouraged entry into the market of high-volume, high-speed call centers that likely provide poor service short of outright fraud. Broker participation will probably also be pared back as offerings become less affordable (assuming ARPA subsidy expiration) — e.g., if insurers also pull back and/or reduce broker commissions. But pre-ARPA, one of the marketplace’s chief limitations was the general public’s ignorance of what was on offer. Several years of broker outreach have probably increased awareness and the likelihood of being approached among those who may need coverage.

Year-round enrollment at low incomes. In early 2022, CMS implemented a rule enabling people with income under 150% FPL to enroll year-round, via permanent availability of a monthly “Special Enrollment Period.” The model here was Medicaid; the presumption is that circumstances change often for low-income people. As a result, the gap between marketplace enrollment totals as of the end of OEP and annual “average monthly enrollment” (AME) has narrowed considerably, and AME has grown even more dramatically than end-of-OEP totals (AME was 99% of OEP enrollment in 2023 and may have actually exceeded it in 2024, when the Medicaid unwinding sent a stream of newly uninsured people into the marketplace). This too has been something of a mixed bag, as the monthly SEP has facilitated broker fraud in the form of unauthorized plan-switching of enrollees. Year-round first-time enrollment could be maintained without providing a monthly SEP. More likely, the Trump administration will rescind the rule. (Originally, the rule was contingent on $0 premium silver coverage remaining available at incomes up to 150% FPL, but that condition was later withdrawn.)

A preview of low-income options in a post-ARPA marketplace

Pre-ARPA, enrollees with income up to 138% FPL paid 2% of income for a benchmark silver plan. We can preview what options may look like in this lowest income bracket by looking at what’s available to someone paying 2% of income for benchmark silver in the 2025 marketplace — that is, a single enrollee with an income of $30,000. That’s a shade under 200% FPL, and at that income, benchmark silver is currently $49/month.

Let’s look at what’s available for a single 40 year-old at this income in Houston and Miami. (You can replicate these results or look at other markets most easily via HealthSherpa’s plan shopper.) In Florida and Texas combined, as of the end of OEP 2024, 4.1 million enrollees had income in the 100-138% FPL range — about 60% of the 6.9 million enrollees in that income range nationwide.

In Houston in 2025 (zip code 77005), a single 40 year-old earning $30,000 would pay (as noted above) $49/month (1.94% of income) for the benchmark silver plan, which has a $500 deductible and a $3,000 out-of-pocket (OOP) maximum. That’s what enrollees with income up to 138% FPL will pay for benchmark silver if the ARPA subsidy boosts expire and there are no further changes. That premium could be prohibitive at a lower income (100% FPL in this year’s marketplace is slightly over $15,000/year). But in 2025, this same Houstonian also has access to two gold plans for $0 premium, as well as to a bronze plan with a $0 deductible for $15/month (and to the one silver plan below benchmark for $38/month). Both of the $0 premium gold plans are from Blue Cross, a desired brand in Texas, whereas the lowest-cost silver BCBS plan available to this person is $61/month.

Switch the scene to Miami (zip code 33134), and the 40-year old with the $30k income, paying 1.94% of income for the benchmark silver plan, does not have cheap gold available, nor any premium difference between the benchmark and lowest-cost silver (both $49/month). But this Miamian does have access to two $0 deductible bronze plans for $5 or $6/month — not to mention a ridiculous eleven zero-premium bronze plans with high deductibles.

The zero-deductible bronze plans both have OOP maxes of $9,200, whereas the two cheapest silver plans for enrollees with income under 150% FPL in Miami this year have OOP maxes of $1,800 and $2,000 respectively. Forgoing CSR vastly expands financial risk. Nonetheless, in two of the largest ACA markets for people with income that would put them in Medicaid in expansion states, no-premium or ultra low-premium options would be available if they had to pay 2% of income.

Zero premium, but more risk

Expiration of the ARPA subsidy enhancements will exacerbate a negative long-term trend in marketplace coverage: reduced silver plan selection by enrollees with income low enough to qualify for strong CSR, which raises the actuarial value of a silver plan to 94% (at income up to 150% FPL) or 87% (at income from 150-200% FPL). That compares to 60-65% AV for enhanced bronze (the commonest bronze type now) or 80% for gold. Perhaps most damagingly, those who forgo strong CSR give up an OOP max that’s capped at $3,000, and averaged just $1,388 in 2024 at incomes up to 150% FPL), in favor of bronze and gold OOP maxes that usually top $7,000 and are often set at the maximum allowable $9,200.

At incomes up to 150% FPL, silver plan selection has dropped from 89% in 2017 to 76% in 2024 (see Table 2 below). At 150-200% FPL, silver selection has plummeted from 83% in 2017 to 57% in 2024. Competition among marketplace insurers to offer lowest-cost coverage has narrowed provider networks over time, and some enrollees may be forgoing CSR to access a lower level of coverage from an insurer with a more robust network. I look at such tradeoffs in specific markets here.

ARPA subsidy expiration will be a major blow to coverage availability for those who lack access to other affordable options. It will probably be combined with other blows: it may be coupled with a major Trump 2.0 effort to stand up and promote an alternative market of medically underwritten, lightly regulated plans, and/or, most damagingly, with major assaults on Medicaid eligibility and funding. “This won’t be the worst harm you suffer” is pretty cold comfort when staring down the barrel of an ignorant, cruel, corrupt government in formation. But the ACA marketplace proved resilient during the Trump 1.0 regime, and it may prove resilient once again.

Table 1: ACA Marketplace Enrollment Growth by Income, 2021-2024

Table 2: Silver Plan Selection at Incomes up to 200% FPL

CMS’s marketplace enrollment Public Use Files are available here.

Photo by cottonbro studio

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If the ACA is not repealed

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Trump said during the campaign that he would not work to repeal the Affordable Care Act. Of course, Trump’s promises are not worth the breath polluted by his utterance of them, and Republicans in Congress, flush with the Republican trifecta, are talking about block-granting Medicaid. that would probably go hand in glove with phasing out the ACA Medicaid expansion — the ACA’s most important and effective program, responsible for most of the drop in the uninsured rate achieved by the ACA.

But let’s undertake the dubious exercise of taking Trump at his word. Repealing and replacing (or, in the case of the Medicaid expansion, declining to replace) the ACA’s core programs may fail, as it did in 2017. Congress may take some hacks at the law, as they did in 2017 (remember the individual mandate? or the tax on insurers?) without changing the core subsidy structure of the ACA marketplace (minus the subsidy enhancements enacted in the American Rescue Plan, which expire in 2026) or entirely eliminating the Medicaid expansion. And the Trump administration may do much to reshape the marketplace administratively — as Trump 1.0 did, but much more. As I noted earlier this fall, JD Vance sketched out how Trump might, um, “build on” (that is, partially dismantle) the ACA marketplace.

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Let’s look at the various means by which the Trump administration and Republican Congress might reshape the ACA’s core programs (Medicaid expansion and Marketplace) short of wholesale repeal.

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Medicaid work requirements. Billed as a way to help “able-bodied” (read: unworthy, largely nonwhite) Medicaid enrollees discover the joys and dignity of wage labor, this Republican favorite is actually a means pushing eligible people off the rolls, as brief experiments in Trump 1.0 demonstrated. As the Kaiser Family Foundation never tires of documenting, a large majority of Medicaid expansion enrollees do work, and almost all the rest are otherwise constructively engaged, e.g., in school or caring for loved ones, or disabled. During Trump 1.0, CMS administrator Seema Verma enthusiastically promoted work requirements, inviting states to file waivers enacting them. While thirteen states had waivers approved, only Arkansas implemented them, with reporting requirements so onerous and so incompetently administered that the D.C. Circuit Court shut the program down after some 18,000 had been gratuitously disenrolled, holding that the waivers were unlawful because CMS failed to consider the impact on coverage, as required for Medicaid waivers. The pandemic then interrupted other states’ waiver plans, and the Biden administration removed approvals. Various court challenges were paused or dismissed as moot. Get ready for Round 2.

Medicaid de-expansion. The path on this front is laid out by the Trumpist Paragon Institute, headed by Brian Blase, who was on Trump’s NEC. The Paragon proposal, like the 2017 ACA repeal bills, would end the federal government’s 90% match rate (FMAP) for Medicaid enrollees rendered eligible by ACA criteria (eligibility for legally present adults (except recent immigrants) with income up to 138% of the Federal Poverty Level, reducing the FMAP to each state’s FMAP for other Medicaid programs, which ranges from 50% in the wealthiest (a.k.a. blue) states to 77% in Mississippi. The proposal would allow states to drop the eligibility threshold to 100% FPL, which would then be the starting point for marketplace subsidy eligibility, as it is now in the ten remaining states that have refused to implement the ACA expansion (Paragon notes gleefully that those states, which include Texas and Florida, will never enact the expansion under this proposal). In an extra swipe at wealthy (blue) states, Paragon would drop the minimum FMAP from 50% to 40%. This proposal nominally does not end the expansion, and allows states to avoid a “coverage gap” on the current Wisconsin model (Medicaid to 100% FPL, marketplace from 100% FPL). As the federal government pays 100% of marketplace premium subsidies, the shift of enrollees in the 100-138% FPL range offset a bit of the cost to states of the reduced match rate. But most states would probably find maintaining expansion at the reduced FMAP unsustainable — especially if the Republican Congress also imposes block grant funding or per capita caps on federal Medicaid spending, which would slow-strangle Medicaid over the course of a decade or two.

Undercutting the ACA marketplace. With Republicans in control of Congress, the enhanced premium subsidies enacted through 2022 by the American Rescue Plan Act and extended through 2025 by the Inflation Reduction Act are almost certainly dead. (Had Democrats won the House, they might have leveraged the expiration of Trump’s income tax cuts to preserve the ARPA subsidy boosts.) Those subsidy increases were doubtless the main cause of a 78% enrollment increase nationally from 2021-2024 and a 123% increase in the nonexpansion states, where the enhanced subsidies rendered benchmark silver coverage free for enrollees with income in the 100-150% FPL range. That means that the pre-ARPA income cap on subsidy eligibility, 400% FPL ($60,240 annually for a single person in 2024), will snap back into place, rendering ACA-compliant coverage unaffordable for several million people.

From there, a supercharged version of Trump 1.0’s parallel, ACA-noncompliant market will go to work to reduce the ACA marketplace to a sort of high risk pool. Vance sketched out how this might work, as I noted a few weeks ago. If more wholesale repeal/redesign does not happen, Trump 2.0 might

rebuild Trump 1.0’s alternative market of medically underwritten, ACA-noncompliant plans (so-called Short-Term Limited Duration, or STLD, plans*), and 2) prompting states to implement measures like the waiver concepts put forward by Trump’s former CMS administrator, Seema Verma. These “concepts” included 1) replacing ACA premium subsidies with a lump-sum health savings account that could be used to pay premiums for any plan; 2) inviting states to restructure the federal premium subsidy as they wished; 3) allowing states to grant premium subsidies for ACA-noncompliant plans; and 4) creating state high risk pools. Options 1 and 3 could effectively convert the ACA-compliant marketplace as we know it into a high risk pool of sorts, and in combination with option 4, could create the multiple stratified risk pools that Vance described in followup comments.

Verma’s waiver concepts plainly violated the ACA statute, as alternative state schemes outlined in an ACA Section 1332 “innovation waiver” proposal has to provide coverage at least as comprehensive as that stipulated in the ACA; provide coverage and cost sharing protections that are at least as affordable; and cover a comparable number of residents. Amending the waiver provision to allow Verma-esque concepts would be low-hanging fruit for a Republican Congress, and in fact was under negotiation after Republican repeal attempts failed in 2017.

Georgia made a brief attempt to take Verma up on her waiver concepts, filing a waiver proposal in late 2020 that would have eliminated a state-sponsored exchange, relying on commercial Enhanced Direct Enrollment (EDE) platforms commissioned by the federal government, and, in one early iteration, allow plans that did not include all Essential Health Benefits to be paid for with federal subsidies. That provision was cut from the submitted waiver, as it violates the ACA statute too plainly even for Trump 1.0’s administrators. But this may be the ACA’s future, if it has any future: some semblance of the ACA subsidy that can be used for ACA noncompliant plans — including, perhaps, medically underwritten plans. As those plans would be cheaper for healthy people, ACA-compliant marketplace enrollment might be reduced to those who would a) pay very little for comprehensive coverage because of low income and a favorable shakeout of price spreads, and/or b) those who know they need comprehensive coverage or who could not get a viable offer when subjected to medical underwriting.

The big enchilada, now as ever, is the ACA Medicaid expansion — and behind that, sustained federal funding for Medicaid programs generally. Perhaps Republicans will divide the baby, and cut the ACA expansion’s enhanced FMAP, say to 80% instead of 90% — and/or cut it disproportionately for states with higher per capita income. Under the best scenarios, the uninsured rate will rise substantially, and the individual market for health insurance will degrade considerably. Just one set of the many pillars of our society likely to come crashing down in coming months and years.

Update: It’s worth noting that when the Trump administration created an ACA-noncompliant market by extending the allowable limit of so-called Short-term, limited duration (STLD) plans to a full year, renewable twice, many states imposed or preserved strict limits of their own. (The STDL plans are medically underwritten, don’t have to cover the ACA’s ten Essential Health Benefits, and are not subject to medical loss ratio limits, e.g., the requirement to spend at least 80% of premiums on patients’ medical expenses.) As of this year, 14 states have either banned STDL plans outright or effectively regulated them out of existence, and others had either imposed other duration limits (often six months) or new coverage rules. If the ACA is not substantially repealed, state markets will doubtless diverge further in how they regulate and reshape coverage.

Update 2, 11/16/24: Charles Gaba, by means of Georgetown’s Edwin Park, runs down the more extreme scenario, Republicans enacting their proposals to destroy Medicaid

* Borrowing my last quick rundown of the Trump admin’s STLD program:

The Trump administration’s major initiative to “build on” the ACA marketplace after repeal failed was to stand up (by administrative rule in 2018) a parallel market of medically underwritten, lightly regulated plans by extending the allowable duration of already-existing so-called “short-term, limited duration plans” (STLD) to up to one year, renewable twice. The Obama administration had limited STLD duration to three months, though not until 2016. In combination with the Republican Congress’s zeroing out of the tax penalty for failing to obtain ACA-compliant insurance, the STLD market was an alternative for people who were priced out of the regulated ACA marketplace — as several million people were before the Biden administration removed the income cap on subsidy eligibility via the American Rescue Plan Act (ARPA) in March 2021. (The ARPA subsidy enhancements were temporary, and extended by the Inflation Reduction Act only through 2025.)

STLD plans can refuse access to people with pre-existing conditions or exclude coverage for the condition. They do not have to cover the ACA’s Essential Health Benefits and generally offer very limited prescription drug coverage, if any, and no substance abuse coverage. They are not subject to the ACA requirement to spend at least 80% of premiums on members’ medical bills (and on a few allowed other expenses) and have been reported to spend as little as 45% of premiums on claims. They do not have to offer a provider network and can pay providers what they deem appropriate, exposing enrollees to balance billing. They do not have to provide an annual out-of-pocket cost cap on covered benefits, though some do. They are much like the plans offered in the pre-ACA individual market.

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Just prior to launch, Georgia Access culls the EDE crop

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Georgia Access has culled the EDE crop

ACA marketplace participants and observers will recall that this past August CMS suspended BenefitAlign and Inshura, Enhanced Direct Enrollment (EDE) entities owned by Speridian Global Holdings, which also owns the health insurance brokerage TrueCoverage (Inshura is simply TrueCoverage’s rebranded version of BenefitAlign).

Speridian, TrueCoverage, BenefitAlign, and Inshura are principle defendants in a putative class action lawsuit alleging a massive fraud scheme in which insurance agents used BenefitAlign to switch the plan selections of hundreds of thousands of marketplace enrollees without their knowledge or consent.*

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In a September letter explaining the suspension, CMS states that it has reason to believe the BenefitAlign is hosting CMS data, including personally identifiable information (PII) at Speridian data centers located overseas, in violation of CMS regulations. The suspension letter also cites the lawsuit’s allegations:

Further, the Speridian Companies, BenefitAlign and True Coverage dba Inshura, are defendants in a pending lawsuit, filed by private parties in 2024, alleging that they engaged in a variety of illegal practices, including violations of the RICO Act, misuse of consumer PII, and insurance fraud that they allegedly carried out by misusing BenefitAlign’s access to the Marketplace. Plaintiffs in the lawsuit likewise claim that BenefitAlign allows access to the Exchange from abroad and houses CMS data overseas.

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Rather incredibly, CMS notes that Speridian Companies (TrueCoverage and BenefitAlign) have been terminated or suspended four times since 2018.**

BenefitAlign has been a major player in broker-assisted ACA enrollment. In a suit filed on Sept. 6 seeking to force CMS to end Benefitalign’s suspension, Benefitalign [sic - the suit does not capitalize the “a”] and TrueCoverage aver that in OEP 2024, “Benefitalign’s Enhanced Direct Enrollment platform accounted for at least 1.2 million ACA applications, making it the second largest channel for ACA enrollments” (p. 4). (Note that the count is of “applications,” not “enrollments.”) By comparison, HealthSherpa, the dominant EDE in the federal exchange, says it executed 6.6 million enrollments in 2024 — slightly more than half of the 12.7 million “active” enrollments registered in HealthCare.gov states. (“Active enrollments” excludes passive auto re-enrollments, which constitute 22% of total enrollment on HealthCare.gov and which are not credited to any EDE.)

Enter now Georgia Access, the newest-minted state-based exchange (SBD), launching today. GA is the first SBE (there are now 20) to enable EDE, which will make it easier for agents serving the Georgia marketplace to transition to the state exchange. In states using the federal marketplace, some 80% of agent-assisted enrollment is via EDE — and in 2024, 78% of active enrollments were agent-assisted.

Georgia is ideologically committed to EDE. In 2020, it filed a waiver proposal that would have eliminated any government-run exchange for the state (along with, in one early iteration, allowing premium subsidies to be credited to ACA-noncompliant plans, which would have created a market something like what JD Vance has sketched out). The Trump administration approved that waiver, but the Biden administration suspended most of it (except for a reinsurance program). Georgia came back with a more conventional EDE proposal, which CMS conditionally approved this past August. While establishing a conventional state-based exchange, the Georgia initiative remains largely focused on EDEs. The state has approved virtually all of the EDE platforms — and until this week, the list included BenefitAlign and Inshura.

This apparent inclusion of the suspended EDEs was an ongoing mystery that I’ve been tracking. Some weeks ago, a spox at Georgia’s Office of the Commissioner of Insurance and Safety Fire, Ethan Stiles, told me, “BenefitAlign’s license has been suspended, not terminated. We are monitoring the situation and do not foresee changing tack. BenefitAlign met all of our standards.” At the same time, Stiles said, “We will work with CMS. I have no reason to think GA would use products not of the highest quality. “

Two subsequent voicemails to the Department went unanswered. Could Georgia, a champion of free enterprise in health insurance, be dismissing CMS’s security concerns about a major player in the ACA marketplace that’s also a suspected engine of large-scale fraud? Fortunately, no.

Yesterday, I caught up with Bryce Rawson at the Office of the Commissioner, who told me that Georgia Access had waited until BenefitAlign’s 45-day curative period under the CMS suspension was complete. As BenefitAlign/Inshura was unable to to allay CMS’s concerns, Georgia Access has “frozen” both EDEs. The Atlanta Journal-Constitution learned this a day ahead of me and reported yesterday:

King’s office told the AJC on Thursday that two of the web brokers that the state originally approved, Benefitalign and Inshura, will be blocked from Georgia’s website barring further developments. Those two are also banned by the federal site and have been sued for allegedly unethical practices. They deny wrongdoing.

Interestingly, though, CMS had previously told me that an SBE could deploy an EDE not approved by CMS. A spokesperson wrote: “states that utilize a direct enrollment technology do so under their own rules, though some follow federal rules. Please reach out to Georgia directly regarding its enhanced direct enrollment partners.”

That seemed a surprising response to my query (sent when BenefitAlign and Inshura were still on Georgia Access’s approved EDE list) as to whether GA could in fact deploy the two suspended EDEs. As I pointed out in my query, CMS’s August letter of conditional approval authorizing Georgia Access to deploy for OEP 2025 states, in a chart itemizing “notable requirements Georgia Access must maintain or continue to meet, to keep conditional approval:

FFE certification as an EDE is a core requirement for application as a GAEDE partner, so organizations failing to pass FFE review for compliance are not considered for certification with GA.

I have asked CMS to clarify how Georgia might go its own way on EDE approval, given that strict requirement — which, as it turns out, is specific to CMS’s dealings with Georgia Access.

For SBEs generally, while CMS’s 2025 Notice of Benefit and Payment Parameters (NBPP) for the ACA marketplace took pains to specify that web-brokers commissioned by state-based exchanges must conform to an array of CMS standards for display of information and consumer protection, and also specifies that the state exchange must be solely responsible for eligibility determinations (with EDEs interfacing with the state’s “centralized eligibility and enrollment platform”), the NBPP did not delegate to CMS the certification of web-brokers and other EDEs (e.g., single-insurer EDEs). That is, while the rule took pains to spell out that states cannot replace a state exchange with an array of EDEs, it also affirmed SBEs’ right to contract with rule-compliant EDEs as it sees fit.

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* The fraud alleged in the suit — and similar fraud documented by CMS — was enabled by the ability of agents registered with the federal exchange, HealthCare.gov, to access and make changes to enrollee accounts via the commercial EDE platforms, needing only the enrollee’s name, date of birth, and state of enrollment. In July, CMS shut down that ability; agents purporting to newly represent enrollees with an existing current account must now either engage the new client in a three-way call with the marketplace, or use a newly launched rather elaborate workaround on an EDE platform, in which the application must be finalized by the enrollee herself (after identity proofing).

** Re Speridian’s four terminations/suspensions,, here is CMS’s summary:

The Speridian Companies have a history of noncompliance with CMS regulations and agreements dating back to 2018. On April 19, 2018, TrueCoverage had its 2018 CMS agreements terminated, which ended their ability to transact information with the Marketplace, due to the severe nature of its suspected and, in some cases, admitted violations of CMS regulations.5 After the termination, the Speridian Companies were not registered with the Exchanges or permitted to assist with or facilitate enrollment of qualified individuals through the Exchange, including direct enrollment. The Speridian Companies admitted that their agents and brokers submitted false Social Security Numbers in connection with Marketplace eligibility applications, and CMS had reasonable suspicions of other fraud, improper enrollments, and misconduct by the Speridian Companies. The Speridian Companies regained their connection to CMS in 2019 after CMS, satisfied with the good-faith evidence provided, entered into Exchange agreements in Plan Year 2019

Photo by Markus Spiske

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