Leo Dulay

Federal marketplace rules now allow non-network plans to qualify for Exchanges, starting PY 2027 in state-run markets and PY 2028 on federal platforms.
These plans still must cover essential health benefits, respect cost-sharing limits, follow balance-billing protections, and demonstrate provider access without traditional contracted networks.
Lower-cost silver options could shift benchmark pricing, affecting premium tax credits for subsidized consumers while employers may reassess individual coverage reimbursement arrangements.
Providers should review benefit-amount payments, balance-billing limits, and reference-pricing strategies as reimbursement disputes may grow under non-network Exchange products in affected markets.
After a June 3, 2026 lawsuit, the rule remains set for July 20, 2026; stakeholders should plan for possible stays or changes.

US Exchanges Add Non-Network Plan Options

By Mid-Q2 2026, D-SNP membership reached 6.5M, representing ~20% of Medicare Advantage enrollment and highlighting growing use of coordinated coverage options nationwide today.
D-SNPs operate in every state except Alaska, New Hampshire, and Vermont, while >9 in 10 dual eligibles have a county option available.
Federal rules require population-based care models, Medicaid coordination, screening for transportation, housing, and food needs, plus advisory committees representing enrollees and served communities.
States can shape contracts by setting enrollment rules, care coordination details, cost-sharing responsibilities, transparency expectations, and added access protections for dual eligibles.
As enrollment continues growing, advocates can monitor provider access, transitions, appeals, supplemental benefits, and equity outcomes to support coordinated care for dual eligibles.