A Practical Action Plan for ACA Issuers Preparing for an Uncertain Market
The individual Affordable Care Act (ACA) market is entering one of its most challenging periods since the early years of the legislation.
Declining enrollment, higher morbidity, issuer exits, elevated rate increases, and continued regulatory uncertainty are making participation and profitability more difficult to predict. For health plans competing in the individual ACA market, waiting until the 2028 pricing cycle to begin planning may leave too little time to identify risks, evaluate opportunities, and make informed strategic decisions.
The planning window starts now.
Download 2028 ACA Market Readiness: A Q4 Action Plan for a practical framework to help your organization translate emerging market signals into stronger 2028 strategy.
DOWNLOAD NOWWhat Should ACA Issuers Do In Q4 2026?
This white paper outlines five areas of work that can help issuers prepare for 2028:
1. Evaluate 2026 Performance
Conduct a comprehensive review of 2026 experience, including member-level profitability, actual-to-expected results for key pricing assumptions, network and unit-cost performance, pharmacy trends, and administrative expenses.
These analyses can help identify the drivers of profitability and loss, refine future pricing assumptions, and inform decisions about products, service areas, and market participation.
2. Prioritize Risk Adjustment Operations
Risk adjustment activities should begin early enough to address documentation gaps, improve data integrity, support hierarchal condition category (HCC) recapture, incorporate risk adjustment data validation (RADV) learnings, and reduce the risk of unintended miscoding.
Stronger risk adjustment operations can improve financial performance while giving issuers more reliable profitability information for 2028 pricing and strategy.
3. Prepare for 2027 Open Enrollment
Open enrollment provides important information for the 2028 planning cycle.
Issuers should prepare brokers and distribution partners, monitor enrollment and plan-selection patterns, evaluate the potential impact of auto-enrollment and market exits, and develop member retention strategies where appropriate.
A stayer, leaver, and joiner analysis can help issuers assess how enrollment changes may affect population morbidity and future assumptions.
4. Analyze the 2027 Competitive Landscape
Review competitor pricing, product positioning, service-area decisions, metal-level strategies, market exits, and new market entrants by geography.
This analysis can help determine whether the market is underpriced or overpriced and whether potential 2028 strategies—including service-area expansion, product changes, or market exits—are likely to succeed.
5. Scenario-Test the 2028 Regulatory Environment
Regulatory uncertainty is expected to continue into the 2028 pricing cycle.
Issuers should monitor federal and state developments, pending litigation, the 2028 Notice of Benefit and Payment Parameters, pre-enrollment verification requirements, cost-sharing reduction policy, and cost-sharing reduction (CSR) reporting expectations.
Scenario testing can help organizations prepare for the most likely regulatory environment while developing contingency plans for alternative outcomes.
Key Questions for Your 2028 ACA Strategy
Preparing for 2028 requires issuers to evaluate current performance. Draw on insights in this white paper to assess whether your organization can answer the following questions:
- What makes 2028 a unique plan year?
- How will your organization define success in 2028?
- Are you actively monitoring 2026 experience and addressing unfavorable trends?
- What did the 2026 and 2027 competitive landscapes reveal about potential opportunities?
- Are your risk adjustment operations designed to maximize accurate risk scores?
- How could regulatory changes affect enrollment, morbidity, pricing, and market participation?
- Should you optimize your current service area, expand into new geographies, or reduce your offerings?
What You Will Learn from This Report
Inside the report, you will find guidance on how to:
- Translate 2026 experience into 2028 pricing and product decisions
- Identify profitability drivers at the member level
- Improve risk adjustment readiness and operational accountability
- Use 2027 open enrollment to inform future strategy
- Evaluate competitor pricing and market exits
- Assess potential service-area expansion opportunities
- Model enrollment and morbidity impacts from policy changes
- Build contingency plans for uncertain regulatory outcomes
Who Should Read This Report?
This report is designed for leaders and decision-makers at:
- Individual ACA health plans
- National and regional insurers
- Provider-sponsored health plans
- Actuarial and pricing teams
- Risk adjustment leaders
- Product and network strategy teams
- Market and regulatory strategy teams
- Executive teams evaluating ACA participation
