The exchange managers and plan issuers will need artificial intelligence systems, other forms of automation, and the most flexible possible support programs to cope with the uncertainty, Softheon said.

What it means: Employers that want to use individual coverage health reimbursement arrangements, or ICHRAs, to provide cash that workers can use to buy their own individual health coverage in 2026 don't yet know what 2026 individual coverage will look like.

The Affordable Care Exchange backdrop: Congress created the ACA public exchange system in an effort to help consumers shop for private health coverage on an apples-to-apples basis and use federal premium tax credit subsidies to pay for the coverage.

The theory was that making it easy and affordable for people to buy coverage would increase the number of relatively young, healthy people paying for coverage and make the individual commercial health insurance market more stable.

The Centers for Medicare and Medicaid Services' HealthCare.gov provides exchange services for people in 31 states.

Nineteen states and the District of Columbia have their own, locally based ACA exchange programs.

Some of the exchanges sell Small Business Health Options Program coverage, or group coverage, as well as individual coverage.

Health insurers and managed care companies can also sell individual coverage outside of the exchange system in states that allow that, but the exchange system now dominates individual market coverage distribution in most states and serves about 20 million of the 24 million people with individual or family coverage.

The uncertainty also affects the managers of the 20 state-based exchanges, including Covered California and Connecticut's Access Health CT.

The new uncertainty: Provisions in the One Big Beautiful Act tax and budget bill could change the ACA premium tax credit rules in complicated ways.

The version of the act approved by the House would replace the ICHRA with a somewhat more flexible "custom health option and individual care expense" arrangement, or CHOICE arrangement.

Related: 14 HSA and HRA sweeteners in the House 'One Big Beautiful' tax bill

A set of proposed ACA exchange market integrity regulations could change enrollment rules and require exchanges to their open enrollment period, or time when people can buy coverage without showing they have what the government classifies as a good reason to be shopping for coverage, Dec. 15.

The proposed regulations could also impose new requirements on consumers trying to buy coverage outside of the open enrollment period through "special enrollment period" rules.

The administration of President Donald Trump seems to want some version of the current ACA exchange system to survive, at least in 2026, and it has protected core ACA exchange operations from the kinds of deep cuts it has imposed on other divisions of the U.S. Department of Health and Human Services — the department that includes the Centers for Medicare and Medicaid Services.

Republicans in Congress want to complete work on the tax and budget bill, which would answer the toughest questions, by the end of this month.

But there are no guarantees Congress will meet the Republicans' bill passage deadline. Even if Congress approves the commercial health insurance parts of the package that were in the package approved by the House as is this week, exchanges and insurers will be getting the rules for 2026 coverage very late.

The uncertainty also hangs over the actuaries trying to design and price the health insurance to be sold through the exchange system.

Normally, the actuaries would be completing final rate filings this month.

This year, insurers may have to get permission to change their "final" rates or withdraw from the individual market if the 2026 market rules turn out to be much different than they had expected.

Medicare blahs: Health insurers have been quick to leave the ACA exchange plan system and the individual health insurance market in recent years when they were unhappy with the results.

Some insurers could be even quicker to "reduce the size of their ACA market footprints" in 2026 if uncertainty about the 2026 gameboard continues.

Now, insurers are facing pressure from higher-than-expected Medicare plan and Medicaid plan claim costs and a squeeze on federal Medicare subsidy payments.

Some insurers may be having problems with their Medicare plans partly because of uncertainty about 2025 Medicare Advantage plan marketing rules that lingered until a court ruling resolved it in July 2024. Memories of the fight over 2025 Medicare plan rules that may further reduce insurers' willingness to put up with uncertainty about 2026 coverage rules.putting

Executives from CVS Health, for example, have already said that they expect to withdraw from markets where Aetna has been an independent ACA exchange plan provider.

Softheon's perspective: For Softheon, the uncertainty is frustrating, because it, the ACA public exchange managers and many employers have been enthusiastic about the ICHRA concept.

Softheon is offering insurers a Cloud-based ICHRA administration service that can help employers with everything from uploading employee rosters to providing employer coverage contributions.

Exchanges like Connecticut's Access Health CT have sent Softheon detailed requests for proposals for ICHRA platforms and other small business coverage administration systems.

Softheon is trying to respond to the lack of clarity by positioning its systems as an answer to the lack of clarity.

The right technology can help insurers "meet tight deadlines while creating better experiences that keep members satisfied and enrolled," the company said.