HMA Weekly Roundup

CSR Funding, Budget Debates, and the Future of Marketplace Affordability

In May 2025, the US House of Representatives passed a budget bill that includes funding for cost-sharing reduction (CSR) payments, marking a potential end to the “silver loading” practice that has shaped pricing in the Affordable Care Act (ACA) Marketplace pricing since 2017. The US Senate is now considering this legislation as part of a broader budget reconciliation package that includes major Medicaid reforms, such as new work requirements and changes to eligibility and financing rules.

This evolving policy landscape has significant implications for states, payers, providers, and consumers. Wakely, an HMA Company, recently published Implications of Ending Silver-Loading on the Individual Market, which outlines how reinstating CSR payments could reshape ACA marketplace plan pricing, enrollment patterns, and federal subsidy flows. It also highlights the operational and financial risks stakeholders must prepare for in 2026.

Broad Loading and Silver Loading

Because CSR loading increases premium costs on silver plans that determine subsidies, they also increase federal payments for premium tax credit (PTC) subsidies. Guidance from the US Department of Health and Human Services on silver plan pricing has evolved over time. Three types of CSR loading are occurring in ACA markets, specifically:

• Broad loading: Increasing premiums for all metal level qualified health plans (QHPs) in the individual market to collect enough revenue to offset the CSR costs of the silver plan variants enrollees
• Two means of silver loading:
  • Increasing premiums for only silver QHPs in the individual market to collect enough revenue to offset the CSR costs of the silver plan variant enrollees
  • Raising premiums, functionally, for only on-exchange silver QHPs

As discussed in the Wakely paper, the impact of silver loading is that the federal government is likely paying out more in additional PTC subsidies than would be paid if CSR payments were fully funded. On Friday, May 2, 2025, the Centers for Medicare & Medicaid Services (CMS) released guidance related to silver loading and CSR payments for 2026 rate filings. This action was urgently needed, especially for states with May filing deadlines.

What’s at Stake

If Congress does appropriate funding for CSR payments, some issuers will be reimbursed for the difference in cost sharing between standard and CSR-enhanced silver plans. Issuers that cover nonemergency pregnancy termination services, would be ineligible for CSR payments; however, as the Wakely paper indicates, these payments would not cover the additional utilization driven by richer benefits. For example, it is anticipated that a member in a 94 percent actuarial value CSR plan will use more services (i.e., four primary care visits versus three in a standard plan), but reimbursement would only reflect the cost-sharing difference—not the increased volume of care.

States like Georgia and New Mexico, which mandate silver loading, could see significant shifts in premium relativities and enrollment behavior. Wakely’s modeling suggests that changes in CSR policy—especially if paired with the expiration of enhanced premium subsidies at the end of 2025—could lead to higher net premiums, reduced enrollment, and a deterioration in risk pool morbidity.

What to Watch

The Senate’s deliberations will determine whether CSR funding is restored and could have significant implications on whether enhanced premium subsidies are extended beyond 2025. These decisions will directly affect the following:

• 2026 rate filings and benefit designs
• Marketplace affordability and enrollment stability
• State reinsurance funding and 1332 waiver dynamics
• Consumer costs and plan switching behavior

Wakely’s analysis also cautions that if CSR funding is restored without accounting for induced utilization, issuers may still need to price for higher service use—potentially leading to premium volatility. In addition, if broad loading is mandated instead of silver loading, it could raise premiums across all metal tiers and reduce the value of premium tax credits for many enrollees.

Key Considerations for Stakeholders

• States should assess how CSR policy changes affect reinsurance programs, waiver funding, and Medicaid redeterminations.
• Payers must prepare for multiple pricing scenarios and evaluate how changes in subsidy structures influence enrollment and risk adjustment, 1332 reinsurance programs, and overall market risk.
• Providers should anticipate shifts in patient mix and utilization (i.e., more uncompensated care with more uninsured patients).
• Advocates need to monitor how policy changes affect access and affordability for low-income and underserved populations.

These developments also create more opportunities for movement between Medicaid, Marketplace, and uninsured populations, underscoring renewed opportunity for integrated eligibility systems and coordinated outreach.

Connect with Us

Health Management Associates (HMA), experts are actively advising stakeholders on how to navigate these complex changes. Whether you’re a state policymaker, health plan executive, provider leader, or advocate, we can help you assess the impact and plan strategically.

These issues will also be explored in depth at the HMA Conference in October 2025. To discuss how these developments will affect your organization, contact our featured expert, Michael Cohen.

2025 HMA Conference Plenary Sessions Will Bring Medicaid Issues into Focus: View the Agenda Today

Health Management Associates (HMA) is excited to announce that the agenda for the Plenary Sessions that will take place during the 2025 HMA Conference is now available. These sessions will reflect the most urgent and complex issues facing healthcare leaders and their partners across the nation.

This year’s conference, Adapting for Success in a Changing Healthcare Landscape, is designed for a diverse and engaged audience: state and federal agencies, payers, health systems, providers including behavioral health clinicians, philanthropy and investors, and other key stakeholders. Whether you’re shaping Medicaid policy, managing delivery systems, or financing innovation, you will find content tailored to your work and your mission.

Medicaid at the Center of the Conversation

With 2025 shaping up to be a pivotal year for Medicaid, the conference agenda puts these issues front and center. Plenary Sessions will explore:

• The future of Medicaid financing and eligibility, including the implications of federal budget negotiations, work requirement initiatives, and program integrity actions
• Medicaid’s role in behavioral health transformation, with a focus on integration, access, and sustainability
• The intersection of Medicaid and philanthropy and private capital, examining how investment is shaping innovation—and what it means for health outcomes and accountability
• Strategies for fostering cross-sector collaborations, with the goal of creating sustainable healthcare systems that deliver sustainable outcomes across communities

These sessions are designed to offer both strategic insight and practical guidance, drawing on the expertise of national leaders and HMA consultants who are collaborating with states and stakeholders every day.

More to Come

In the coming weeks, HMA will unveil more details about smaller group sessions, which will offer deeper dives into topics such as:

• Key changes in the Medicare Advantage program, including Medicare STARs, expansion of audits, and risk-adjustment policies
• Operational approaches to discharging patients with behavioral health needs
• The evolving quality landscape
• Innovation in digital health tools
• Strengthening states’ behavioral health crisis systems

During these sessions, strategy meets implementation, with guidance from the HMA experts and partners who are doing the work on the ground. Attendees will leave with ideas they can implement.

Early Bird Registration Ends July 31

The HMA Conference is designed to be more than a meeting—it’s a gathering of leaders who are shaping the future of publicly funded healthcare. With major policy decisions on the horizon—including the fate of funding for Affordable Care Act Marketplace cost-sharing reductions and premium subsidies, Medicaid demonstrations, and behavioral health investments—this program will help leaders prepare for what happens next.

Explore the Plenary Sessions and secure your spot today!