Summary

Creates a federal reinsurance program to lower premiums for certain off‑Exchange individual market plans and allows insurers that opt out of the ACA single risk pool to treat their opted plans as a single internal pool. It also changes age‑rating rules for those opt‑out plans, requires plans to allow certain out‑of‑network payments to count toward deductibles and out‑of‑pocket maximums, and forces providers to disclose when a patient’s cost‑sharing would exceed the provider’s self‑pay charge, with a private right of action for violations. Many provisions take effect for plan years or calendar years starting January 1, 2026; the reinsurance program is funded by annual appropriations for 2026–2030.

Key Points

• Creates an HHS reinsurance program to subsidize high claims for certain off‑Exchange individual market enrollees, funded for 2026–2030 with an annual cap of $6 billion.
• Allows insurers that opt out of the ACA single risk pool to pool their opted individual plans internally but removes those plans’ qualified‑health‑plan status for certain purposes.
• Removes a statutory age‑rating restriction for opt‑out plans while keeping a 3:1 adult age‑rating cap for certified qualified health plans.
• Requires plans to let enrollees apply certain low out‑of‑network charges toward deductibles and out‑of‑pocket limits when those charges meet specified benchmarks.
• Requires providers and facilities to disclose whether a patient’s cost‑sharing would exceed the provider’s self‑pay charge; gives patients a private right to sue for violations.
• Secretary must set initial reinsurance parameters (attachment point, payment rate, cap) within 120 days so the program can operate in 2026.
• Funding mechanism ties appropriations to member‑months ($50 per member‑month), with unused funds carried forward.
• New rules are effective largely for plan years or services beginning January 1, 2026, increasing near‑term implementation demands on agencies, insurers, and providers.

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