If you’ve been following healthcare news recently, one thing is clear: there is no shortage of ideas about how to “fix” the system.
Over the past year, policymakers, regulators, and lawmakers have increasingly focused on rising healthcare costs, insurance complexity, and barriers to care. Congressional hearings have brought insurers before lawmakers to answer questions about affordability, prior authorization, and access to treatment. At the same time, proposals ranging from drug pricing reforms to insurance market changes are being introduced at both the federal and state levels.
Against this backdrop, the Centers for Medicare & Medicaid Services (CMS) has proposed a policy change that could significantly reshape the Affordable Care Act (ACA) marketplace.
Like many recent proposals, it is being framed as a way to expand consumer choice and lower costs.
But as with many policy changes, the details matter.
What Is CMS Proposing?
CMS has proposed allowing a new type of health plan to be sold on ACA marketplaces beginning in 2027: plans that do not rely on traditional provider networks.
These “non-network” plans would differ from most current marketplace coverage. Today, ACA plans typically contract with a defined group of doctors, hospitals, and specialty providers. These networks help establish negotiated rates and give patients a clearer understanding of where they can receive care. Under the proposal, plans could meet access standards without maintaining those formal provider contracts.
Supporters of the policy argue that allowing non-network plans could expand consumer choice, reduce administrative costs associated with maintaining provider networks, and increase competition, which they say would lead to lower premiums for consumers.
Why Are Some Stakeholders Raising Concerns?
Health insurers and provider organizations, groups that do not always align, have raised concerns in a joint letter to CMS about how these plans could function in practice.
In that letter, they highlight several key issues:
- Verifying access to care may be difficult.
Without formal provider contracts, it may be challenging to ensure that patients can actually access doctors, hospitals, and specialists when they need care. - Consumer confusion could increase.
Patients shopping on the marketplace may not easily distinguish between traditional plans and non-network options, particularly if differences in access are not clearly communicated. - Lower-cost plans may attract healthier enrollees.
Some stakeholders warn that these plans could draw healthier individuals, potentially leaving sicker patients concentrated in traditional plans and affecting overall market stability.
These concerns are emerging at a time when ACA enrollment has already declined following the expiration of enhanced subsidies, adding another layer of uncertainty to the marketplace.
Infusion Access Foundation Weighs In
The Infusion Access Foundation recently submitted comments to CMS outlining concerns about how this proposal could affect patients who rely on specialty medications and provider-administered therapies.
For patients with chronic, complex, or rare conditions, access to care often depends on established relationships with specialists, availability of infusion centers or trained providers, and coordination across multiple sites of care. Plans that do not maintain meaningful provider networks could make it more difficult for patients to identify where and how they can receive treatment.
The comments also highlight several specific concerns:
- Risk of “coverage without meaningful access.”
Patients may enroll in a plan believing it provides comprehensive coverage, only to find that accessing care requires going out-of-network or paying significantly higher costs. - Challenges for infusion and injection patients.
Many therapies are administered in clinical settings such as infusion centers, hospital outpatient departments, or physician offices. Without defined networks, patients may struggle to find providers able to deliver these treatments under their plan. - Potential disruption to continuity of care.
Patients managing serious conditions often rely on consistent relationships with experienced providers. Changes that weaken network expectations could make maintaining those relationships more difficult. - Increased risk of confusion.
The proposal could create situations similar to “ghost networks,” where coverage appears robust on paper but is difficult to navigate in practice.
The Foundation emphasized that while affordability and choice are important goals, marketplace coverage should ensure patients can realistically access the care their plan promises to cover.
A Proposal in a Broader Moment of Change
Recent congressional hearings have underscored widespread frustration with the current system. Lawmakers from both parties have raised concerns about high out-of-pocket costs, delays and denials of care, the role of intermediaries like pharmacy benefit managers, and the growing complexity of navigating insurance.
At the same time, policymakers are actively exploring a wide range of solutions: from simplifying plan designs to restructuring parts of Medicare and private insurance markets. In that context, proposals like this one reflect a broader trend: efforts to expand options and reduce costs, sometimes by rethinking long-standing structures like provider networks. But as new ideas are introduced, questions about how they will work in practice, and who they will work for, remain central.
What Patients May Want to Watch For
For patients who rely on consistent access to providers and treatment, especially those receiving infusion or injectable therapies, this proposal raises several practical considerations:
- How will access to providers be defined?
If a plan does not have a traditional network, how will patients know where they can receive care? - What will costs look like in practice?
Lower premiums may not always translate to lower overall costs if care is accessed outside of established arrangements. - Will it be easy to compare plans?
Understanding the differences between plan types may become more complex when shopping for coverage. - How could this affect continuity of care?
Patients who rely on specific providers or treatment sites may want to consider how plan structure could impact those relationships. - What happens if your health needs change?
A plan that works when you are healthy may function differently if you need specialized or ongoing care.
In Conclusion
CMS’s proposal to allow non-network plans in the ACA marketplace is part of a broader attempt to address affordability and expand consumer choice. However, stakeholders across the healthcare system, including patient advocacy organizations, have raised serious concerns about how these plans would function and what they could mean for access to care.
For patients and caregivers, the key takeaway is not to assume that all insurance plans work the same way. If finalized, these types of plans could appear alongside traditional options on the marketplace. But a lower premium does not always mean better coverage. As is already the case today, it will remain important to look closely at whether your doctors, medications, and treatment sites are actually accessible under a plan before enrolling.