Trump’s Addition of Non-Network Health Coverage Lacks Specifics

The Trump administration’s move to expand the types of health plans on the Obamacare exchanges to those that don’t include built-in doctor networks clears the way for alternative insurance companies to enter the market, even as several operational questions remain unanswered.

The Centers for Medicare & Medicaid Services last month finalized a rule opening the exchanges in 2028 to non-network plans. The plans instead offer a fixed rate for medical care, and enrollees can theoretically see any doctor as long as they’ll pay any difference between the doctor’s charge and the plan’s payment.

The move underscores the Trump administration’s goal to undo restrictions under the Affordable Care Act in order to lower costs. But the addition of the non-network model raises questions about how it will work under the ACA’s statutory constraints, and critics fear the plans could confuse consumers and expose them to balance bills.

“We spent a good amount of time trying to figure out what this administration just put forward,” said Ellen Montz, managing director at Manatt Health, who oversaw the exchanges at CMS during the Biden administration. “But we couldn’t get there and I don’t believe they did either.”

Health insurance premiums increased 20% for the roughly 23 million enrollees on the exchanges in 2026, with people trading silver-level plans for lower-premium, higher-deductible bronze plans. CMS said in the rule that non-network plans could help lower costs, nodding to efforts on price transparency as an engine to power competition among providers.

The rule tweaked CMS’s proposal by requiring plans to outline strategies to help patients receive real-time price changes and navigate incidents like hospital stays, which involve multiple doctors. The rule also delays approval of the plans on Healthcare.gov until 2028, although states can certify plans for 2027.

The safeguards fall short, said Sabrina Corlette, co-director of the Georgetown University Center on Health Insurance Reforms. It doesn’t seem as if CMS will check plans’ self-reporting around the rule’s requirements, she said, and protections from balance bills don’t exist.

“How is a person supposed to be sophisticated or prescient enough to know in advance how many providers might provide these services to them as they undergo an episode of care?” she said.

CMS didn’t say how many doctors must accept the plan’s payment in order to meet its definition that patients must have a “sufficient choice of providers,” she added.

“It could be 1%,” she said. “It could be half a percent.”

CMS said it skipped setting a minimum provider threshold in order “to learn more about this novel plan type.” It will require non-network plans to report data on how many providers accept their rates.

Potential Takers

One non-network insurer that has tried to join the exchanges is Sidecar Health, which reimburses doctors a preset amount based on commercial averages. The insurer—whose current and past advisers include former Trump officials such as Marty Makary, Brian Blase, and David Shulkin—was approved by Ohio to join its marketplace in 2021, but was rejected by CMS under the Biden administration.

Sidecar is now eyeing a 2028 marketplace debut, but is awaiting details on key questions it hopes will be answered in future regulatory guidance.

“There are things other than the network rule that make it hard to do business on the exchanges,” said Kevin Knight, president of national strategic accounts for the company. “And I think that we would like to see further improvements made to just the structure of the exchanges generally.”

One of those improvements revolves around “risk adjustment,” or payment modifications CMS makes to account for the distribution of sicker enrollees across insurers. Sidecar asked the agency to revisit the methodology in comments on the rule, saying it doesn’t have the same incentives to maximize billing codes like traditional insurers.

Sidecar is different from “reference-based pricing” plans, which frequently base their physician payments on Medicare rates, Knight said.

“The intent is not to come up with a cheap reimbursement and hope that we can pressure providers to accept that as payment in full,” he said. “It is to say, in effect, let’s make sure that you have access to at least half the providers where you live without paying anything, and in fact, in most cases, the option to earn money.”

Consumers keep extra money for choosing lower-cost doctors, he added, and are protected from emergency bills under the No Surprises Act.

Reference-based Pricing Plans

It’s not clear whether other companies offering reference-based pricing plans—which currently focus on the self-funded employer market, such as Sidecar—can or will join the exchanges. The companies are seeing increased uptake as they invest in customer service in an attempt to shake the bad reputation associated with earlier reference-based pricing plans.

Imagine360 CEO Jeff Bak said the company’s participation will boil down to future regulations by CMS and states that choose to allow non-network plans.

“We may not have a lot of options at the end of the day based on the requirements imposed by different states,” he said.

The fundamental differences between non-network and traditional plans make it hard for consumers to compare them, Montz said. The inclusion of non-network plans undermines the exchanges’ aim to simplify and standardize health insurance in a market where consumers are extremely price-sensitive, she said.

“It very much concerns me that a consumer could pick this plan and not know they’re getting themselves into negotiating their own healthcare,” she said.

Corlette doubts states will be interested in letting non-network plans into the market. The rule is so vague on what qualifies as a non-network plan that it could include fixed indemnity plans too, she said. Indemnity plans offer flat rates for specific medical services, and some of them are “absolute bottom feeders,” she said.

“At the end of the day, there’s no contractual agreement between the plan and the provider and the patient,” Corlette said.