Health plans that aren’t built around provider networks will be allowed on the ACA individual marketplace beginning in 2028, marking a structural change to a system that has operated exclusively on network-based models since the ACA launched more than a decade ago.
For Sidecar Health, an insurer that sells employer-sponsored plans without provider networks, the change opens up a market it has long wanted to enter. The company administers benefits for hundreds of employer clients, ranging from companies with 51 to 60,000 covered lives across 25 industries in 48 states.
“The individual population and individual people and families — they’re a critical piece of our mission,” Sidecar CEO Patrick Quigley told Becker’s. “Today we only serve employers. What this does is open the door for us to serve even more people, and an audience that is frankly often left behind.”
Sidecar’s model sets fixed benefit amounts based on average local prices rather than contracting with providers. Its members pay at the point of care using a company-issued Visa card and keep half the savings when a provider charges less than the benefit amount. The company says that in 2025, fewer than 1% of claims were clinically denied.
The policy change from CMS, finalized May 15, arrives on the doorstep of an ACA market in turmoil. Overall enrollment is declining and premiums have risen sharply following the expiration of enhanced premium tax credits at the end of 2025. The remaining risk pool has grown older and sicker, driving bronze plan membership from 30% to 40% of total enrollment. Multiple major insurers have pulled back from or exited the market entirely in recent months. That environment, Mr. Quigley contends, is one that the Sidecar model is designed to perform in.
“One of our first plans was actually an off-exchange ACA plan, so we’re very familiar with how to price ACA populations,” he said. “If the exchange population in a particular area is riskier, that whole population is going to have a higher cost to serve, but relative to all other options in that market, we are still going to reduce medical costs by 20%.”
To qualify under the new CMS pathway, non-network plans must demonstrate that a sufficient range of providers accepts the plan’s benefit amount as full payment, including essential community providers and mental health and substance use disorder specialists.
In an internal analysis, Sidecar found that ACA plans in markets it studied covered as few as 15% of local providers, with typical exchange plans covering around 30%. The company says it prices benefit amounts such that 50% of local providers fall at or below the reimbursable amount.
“If you think about access, we will walk into these markets with more access to doctors than any ACA plan currently on the exchanges,” Mr. Quigley said.
Sidecar currently sells to employers based in Ohio, Georgia, Florida and Texas, and Mr. Quigley said those states are the likely starting point for any exchange applications, though no formal decisions have been made.
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