Cost sharing has always been foundational to plan design. But heading into the 2027 filing cycle, it’s carrying more weight—and more risk—than usual.
In today’s episode of Regulatory Joe, ClearFile President Joe Boyle is breaking down what’s changing, where plans tend to get stuck, and how to approach cost sharing strategically in a year defined by tight timelines and incomplete guidance.
Why Cost Sharing Is More Complex Than Ever for ACA Health Plans
Cost sharing—deductibles, copays, and coinsurance—is the direct input to actuarial value and metal tier positioning. That’s not new. What is new is the environment surrounding those decisions.
With enhanced subsidies ending, affordability gaps will be more visible, especially for members above 400% of the federal poverty level and for lower-income populations that rely more heavily on care. At the same time, key federal guidance that typically informs plan design is arriving later than usual.
The result is a compressed decision window. Plans still need to model scenarios, finalize designs, and submit filings—often before all parameters are fully defined.
Waiting for perfect clarity isn’t realistic this year. And deferring cost-sharing decisions only increases downstream risk.
Foundational Inputs for ACA Cost Sharing Decisions
Historically, CMS has kept actuarial value ranges within plus or minus five percent. That means metal tiers themselves are unlikely to change dramatically, though flexibility within those tiers may increase. That flexibility is where many plans will look to adjust copays, deductibles, and service-level cost sharing.
Joe’s guidance is to ground decisions in what’s already approved and defensible:
- Last year’s final, state-approved plan designs
- CMS federal EHB benchmark plans
- Available competitive cost-sharing data
This approach doesn’t eliminate uncertainty, but it gives plans a stable baseline to work from while guidance continues to emerge.
Where Cost Sharing Breaks Down in QHP Filings
Cost-sharing issues rarely come from the initial plan design. They surface later, when changes start stacking up and controls aren’t in place.
As guidance evolves, cost-sharing values are adjusted across benefit grids, actuarial models, and plan and benefits templates. Too often, those updates happen in parallel across teams, with no formal change governance. Values are revised, but prior versions aren’t preserved. Dependencies across templates aren’t consistently rechecked.
By the time final submissions are assembled, teams may no longer be confident which cost-sharing values were tied to which version of the design — or whether those values still align across all required templates.
In a year with shifting assumptions and limited time for correction, unmanaged cost-sharing changes become a direct filing risk — not just a design issue.
Regulatory Joe’s Recommendations on Cost Sharing for ACA Health Plans
- Start cost-sharing discussions now, anchoring designs to last year’s final, state-approved plans and federal EHB benchmarks rather than waiting for new guidance.
- Model multiple cost-sharing scenarios in parallel, recognizing that guidance will continue to evolve and decisions will need to be made before everything is finalized.
- Start competitive cost-sharing intelligence early, using a tiered approach: CMS public use files for baseline signals, state-published filings where available, and FOIA requests to fill in the gaps where data isn’t public.
- Establish clear change governance, including version control and documented decision trails, so cost-sharing updates remain traceable as assumptions shift.
- Set a hard internal cutoff date for cost-sharing changes to allow time for cross-validation across all plan and benefits templates before submission.
Be sure to watch the full episode to hear all of Regulatory Joe’s insights on cost sharing.
