TL;DR
- As employers face a projected 9.5% rise in health care costs for 2027, more are turning to ICHRAs to cap their spending.
- 89% of employers say they would be more likely to adopt an ICHRA if they could count on group-plan network quality and choice.
- Of the 298 Marketplace reporting units CMS rated for 2026, only 7% earned five stars under the Quality Rating System (QRS), and just 36% reached four stars on Medical Care, the category that measures clinical performance.
- But the QRS does not apply to plans sold off-Exchange, which is where ICHRA employees get steered: Centene sells its ICHRA plans off-exchange in 13 states, and UnitedHealthcare routes ICHRA shoppers there.
- Only 65% of eligible Marketplace shoppers enrolled in a plan rated three stars or better in PY2025.
- To win this membership and unlock employer adoption, health plans must provide validated proof of network quality.
Part 1 traced where ICHRA adoption is growing, what makes employers adopt these new benefit options, and why employees are embracing ICHRAs.
Here in Part 2, we will explore how carriers are rebuilding distribution around employees who now have control over which plans they pick.
Insurers are rebuilding distribution around the individual buyer
Group insurance is a business-to-business-to-consumer (B2B2C) model, with carriers winning over employers or brokers. Employees received a short menu of generic health plans, generally only changing when they switched employers or during open enrollment periods.
ICHRA pushes carriers toward something closer to retail, where the employer still finances the coverage, but the individual decides which insurer and eligible benefits they are interested in purchasing.
While there are hurdles, including concerns of increased market rates driven by individual purchasing, regulatory vulnerability for a benefit created by rule rather than statute, and choice paralysis for employees, skyrocketing healthcare costs are increasingly driving employers towards ICHRA plans.
Employees absorbed part of that already, with out-of-pocket costs up 10.2% in a single year, even while costs for employers increased 9.5%. For employers, every renewal at that slope sends another benefits team looking for a number it can actually budget, and a defined contribution through an ICHRA is the most direct answer on the shelf.
Every major carrier is selling ICHRA off-exchange
Centene built an organization around it
Centene has sent the clearest structural signal. In January 2025 it created a dedicated president role over its ICHRA business, Ambetter Health Solutions, and named Alan Silver to it. Chief Executive Sarah London said at the time that the company believes ICHRA is the future of healthcare coverage for individuals and families. Ambetter Health Solutions now markets ACA-compliant, ICHRA-compatible individual plans in 13 states, sold off-exchange, on a pitch of predictable costs for the employer and personalized plan selection for the employee.
For a carrier already operating at scale in the ACA individual market, ICHRA is less a new insurance product than a new source of funded membership flowing into infrastructure the company already runs.
Oscar is selling access rather than price
Oscar has come at the same opportunity from its consumer-oriented individual-market roots. For 2026 it partnered with Hy-Vee Health on a greater Des Moines product available to employees through employer-funded individual coverage, pairing the insurance with $0 primary care, urgent care, and telehealth at Hy-Vee Health Exemplar Care clinics, direct access to MercyOne specialists, pharmacy pricing, and dedicated care guides. The companies claim employer savings of 20% to 30% and employee savings of $500 to $1,000 a year, and they intend to bring the model to additional markets.
Oscar is the tell. Its differentiator is not the premium but a named set of providers and a defined care experience, which is a quality claim concrete enough for an employee to evaluate. Chief Executive Mark Bertolini has been explicit about the size of the prize, arguing that ICHRA adoption among employers under 1,000 employees would expand the company’s targetable market from roughly 21 million lives to 96 million.
Imcumbents like UnitedHealthcare treat ICHRAs as off-exchange plans
UnitedHealthcare takes a less aggressive public posture, but its consumer shopping guidance already treats an employer ICHRA or QSEHRA offer as a reason someone is shopping the individual market, and routes those shoppers to off-exchange plans on the logic that an affordable ICHRA offer generally cancels premium tax credit eligibility. ICHRA has entered mainstream individual-market distribution whether or not a carrier is building a business unit around it.
Oliver Wyman frames the strategic question for carriers as a choice rather than an option: disrupt their own profitable group business to retain those members as individual customers, or defend the value of group coverage with employer decision-makers. Its analysts note that if a carrier is not presenting ICHRA to its group clients, someone else will, and cite Centene’s estimate that as much as 45% of the employer group market could eventually be disrupted through ICHRA growth.
The quality signal stops at the Exchange door
CMS rates Marketplace plans from one to five stars under the Quality Rating System, combining Medical Care, Member Experience, and Plan Administration, and weighting Medical Care most heavily. For plan year 2026 it rated 298 reporting units: 86% reached three stars, 48% reached four, and 7% reached five.
Medical Care is where plans separate. Only 36% reached four stars there, against 77% on Plan Administration and 99% on Member Experience. Service is table stakes; clinical performance is the category with real headroom.
None of those ratings exist off-exchange. CMS excludes off-Exchange plans from the QRS entirely, so the fastest-growing segment of the individual market carries the least public quality data, and no carrier selling into it can point at a CMS star to make its case.
What carriers have to be able to prove
EBRI reported that 89% of employers are looking at network quality as the primary lever for choosing an ICHRA plan.
Employers will move their budget to whichever carrier can convince them their workers still get good care, which means answering the employee’s questions with evidence.
| What the employee is asking | What the carrier has to be able to show |
|---|---|
| Is my doctor in this network? | A directory validated against claims, not self-attestation |
| Will I actually get good care? | Medical Care performance at the measure level, not one composite star |
| Can I get an appointment? | Access and enrollee-experience results for this network, in this market |
| Does this fit my situation? | Performance on the conditions this household has, not the average member |
On-exchange, CMS supplies part of this. Off-exchange, the carrier owns all of it: generate the measurement, validate it well enough that a benefits consultant will accept it, and render it plainly enough that an employee can use it mid-enrollment.
The carriers that win ICHRA membership will not be the ones with the lowest premium. They will be the ones that answer a network-quality question with validated data rather than reassurance.
Sources
- Aon, “U.S. Employer Health Care Costs Continue Multi-Year Climb, Projected to Rise 9.5% in 2027” (August 20, 2026): the 9.5% status-quo projection for 2027, the 8.8% increase into 2026, $17,562 average plan cost per employee, the 10.2% rise in employee out-of-pocket costs, and the 1,100-employer dataset. aon.com
- CMS, “Health Insurance Exchanges Quality Rating System (QRS) for Plan Year 2026: Results-at-a-Glance”: the 353 eligible and 331 scoring-eligible reporting units, the 298 rated, the 86% / 48% / 7% overall distribution, the Medical Care, Member Experience, and Plan Administration category results, the exchange-type split, the >99% access and 65% PY2025 enrollment figures, and the footnote excluding off-Exchange QHPs from QRS requirements. cms.gov
- CMS, Health Insurance Marketplace Quality Initiatives: QRS scope, the relative-performance scoring method, the three rating categories and the greater weight given to Medical Care, and the QRS public use files. cms.gov
- EBRI and Morgan Health, “2026 EBRI-Morgan Health Employer ICHRA Survey” (July 2026): the 89% network-quality result and the affordability, out-of-pocket, and plan availability concerns. ebri.org
- HealthCare.gov and Norris, healthinsurance.org (2026): the premium tax credit interaction with an affordable ICHRA offer, and the rule permitting pre-tax salary reduction toward off-exchange individual coverage but not on-exchange coverage. healthcare.gov
- UnitedHealthcare, off-exchange ACA Marketplace shopping guidance: ICHRA and QSEHRA participants generally do not qualify for subsidies and are directed to off-exchange plans. uhc.com
- Oliver Wyman, Burke, Vichare, and Mar, “Emerging Health Reimbursement Accounts May Disrupt Insurers” (January 2024): the disrupt-or-defend framing for carriers and the Centene estimate that up to 45% of the employer group market could be disrupted through ICHRA growth. oliverwyman.com
- Healthcare Dive, Brady, “ICHRAs, a growth opportunity for insurers, face uphill battle” (April 8, 2026): the fall in fully insured large group enrollment from 46 million in 2013 to 38 million in 2023, and the adoption hurdles. healthcaredive.com
- Oscar Health, “Hy-Vee Health and Oscar Serve Up a New Era of Employer Healthcare” (August 14, 2025): the greater Des Moines ICHRA product and its $0 primary care, urgent care, and specialist access. hioscar.com
- Centene, Ambetter Health Solutions: ICHRA-compatible off-exchange individual plans in 13 states, marketed on predictable employer costs and personalized employee plan selection. centene.com