Marketplace Pulse: If You Build it, Will They Come?—Off-Exchange Offerings Explode in 2026

The Marketplace Pulse series provides expert insights on timely policy topics related to the health insurance marketplaces. The series, authored by RWJF Senior Policy Adviser Katherine Hempstead, analyzes changes in the individual market; shifting carrier trends; nationwide insurance data; and more to help states, researchers, and policymakers better understand the pulse of the marketplace.

Two high level trends informed expectations around 2026 insurer participation in the marketplace. In anticipation of the expiration of the Affordable Care Act (ACA)’s enhanced premium tax credits (ePTCs) and associated changes in enrollment and risk, there was an expectation of reduced enthusiasm for offering plans in the marketplace in 2026. At the same time, growing interest in the Individual Coverage Health Reimbursement Arrangement (ICHRA) mechanism was predicted to boost offerings off-exchange, a primary focus of ICHRA marketing.  

Between 2025 and 2026, the number of offerings* on the marketplace declined 7%, from about 12,600 to 11,700. This reflected the exits of Aetna and a number of smaller plans, along with partial withdrawals from some remaining insurers. On the other hand, the number of off-exchange offerings increased by more than one-third, from about 6,600 to nearly 9,000. This expansion mostly reflects large national insurers that are already participating in the marketplace expanding into off-exchange coverage. In 2026, off-exchange offerings accounted for more than 40% of all offerings, something that hasn't been true since 2017. If this pattern were to persist, off-exchange offerings would slightly exceed those on the marketplace as soon as next year.

State Patterns

Most states saw minimal change in the marketplace. However, a handful of largely Midwestern and Southern states saw notable declines in offerings. These include Illinois, Kansas, Kentucky, Missouri, Mississippi, North Carolina, and Wisconsin—reflecting the withdrawal of Aetna, some exits by regional plans, and reductions in footprint among existing carriers. In Kansas, for example, Aetna departed and UnitedHealth Group withdrew from about two-thirds of the counties in which they participated in 2025. In Wisconsin, several plans exited, while others downsized their participation, reducing total offers from 324 to 230. A very small number of states saw an appreciable increase in on-exchange offerings. In Oklahoma, for instance, three insurers increased their footprint, so the number of total offerings increased from 225 to 285.

In terms of the off-exchange, many states gained considerably, including a handful of states that had little or no off-exchange availability in 2025, like Alabama, Iowa, Idaho, Nebraska, and Wyoming. Other states saw large increases, including Georgia, which went from 349 to 737 off-exchange offerings, as Caresource and Elevance entered that market while UnitedHealth Group increased their footprint. The only states that saw reductions in off-exchange offerings were a handful with state-administered marketplaces, including California, Connecticut, and Washington.

Individual Insurers

Most of the activity involved national insurers, for whom marketplace participation changed relatively little, while off-exchange participation increased considerably. UnitedHealth Group had the most dramatic surge in off-exchange presence, with the number of offerings more than quadrupling alongside entry into 20 new states. Elevance, Oscar, and Caresource roughly doubled their off-exchange offerings. Centene's overall number of off-exchange offerings declined, but this largely reflects some recalibration, as it entered some new states and replaced some of its existing off-exchange plans with new ones.  There was little change in off-exchange activity among Blues plans, although Florida's Guidewell entered their off-exchange market. Provider-sponsored and regional plans largely maintained their positions.

ICHRA Alert

The growth in off-exchange offerings is a clear signal of insurer enthusiasm for ICHRAs, which allow employers to contribute toward employee premiums in the individual market. The question of whether ICHRA enrollment should primarily take place on the marketplace or off-exchange is not completely settled. Currently, there is often a tax advantage for employees if they purchase their plan off-exchange. Additionally, from a marketing standpoint, many insurers would like to create plan choices for ICHRA enrollees off-exchange that are more similar to employee plans. Some insurers have created a new line of products which they market as being explicitly for ICHRAs. Others may be configuring plans that are similar to their small group plans, so that they are able to compete if employers want to migrate enrollees to ICHRAs.

Unfortunately, relatively little is known about ICHRA enrollment, which is currently estimated to be in the roughly 400,000 to 800,000 range. It is commonly believed that about 80% of ICHRA enrollees are in off-exchange plans, but there is not much detail about the breakdown. The broader population of off-exchange enrollees was estimated to be about 3 million in 2025, so it clearly comprises a considerably larger group than those enrolled via an ICHRA. The off-exchange market also includes enrollees who are ineligible for tax credits, either because their income exceeds 400% FPL, or because of their immigration status. Some off exchange enrollees are likely eligible for a tax credit but choose not to apply for one. There also may be some who are enrolled on the off-exchange because there is a plan available there that is not on the marketplace, perhaps with a specific provider network. Off-exchange and marketplace enrollees are both part of the single ACA risk pool.

Future Growth

Off-exchange plan offerings have increased dramatically and could soon exceed those in the marketplace if current trends continue. Right now, enrollment in the marketplace greatly exceeds that in the off-exchange, but there are trends at work that could cause that to change. One is the potential for rapid growth in ICHRA, which currently is largely marketed in the off-exchange. Additionally, due to the expiration of the ePTCs and changes in subsidy eligibility for people with certain immigration statuses, there is a growing share of potential individual market enrollees that are not eligible for a tax credit. If use of the ICHRA mechanism grows in the way that many anticipate, perhaps with increasing participation by larger employers, and the ePTCs are not restored, it not difficult to imagine that off-exchange enrollment could rival or exceed marketplace enrollment at some point in the future.

Yet there are reasons why this may not happen. There are a number of policy changes that could steer people back to the marketplace. For example, the much-discussed codification of ICHRA could reduce or eliminate the off-exchange tax advantage, although there will likely not be consensus about that proposed change. Restoring the ePTCs or other policies that increase the generosity of premium tax credits could direct more interest to the marketplace. Some have proposed that ICHRA should permit employees to combine PTCs with employer contributions, a move that would clearly favor marketplace growth. If ICHRA fails to scale appreciably and the individual market as a whole is not flourishing, it becomes a little harder to imagine off-exchange enrollment exceeding that in the marketplace, since the population of individual enrollees above 400% FPL or otherwise unable or unwilling to get a PTC is somewhat limited. In a scenario where the individual market is struggling and plans become increasingly expensive, that population will be even more constrained. 

There are many possible futures, but for now insurers are signaling that they feel relatively bullish about the off-exchange. It remains to be seen whether or not this growth in offerings will be met with increased enrollment, and what that might mean for the individual market as a whole.   

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*Footnote: Participation here is measured at the insurer level. An offering is defined as whether an insurer is participating in a particular market segment in a particular county, and is not based on how many plans that insurer might offer.

Tables and Figures