This Note is organized into three parts. Part II provides a brief overview of ACOs under the MSSP. It transitions into a discussion of commercial ACOs, including one operating in Kentucky. It concludes with an overview of ACO criticism. Part III discusses states’ authority under the McCarran-Ferguson Act and the Employee Retirement Income Security Act (ERISA) savings clause to regulate insurance. It further discusses how a provider organization assumes insurance risk. It concludes that a commercial ACO assumes such risk in a shared savings arrangement. Part IV discusses Kentucky’s Insurance Code and whether it adequately regulates commercial ACOs. Part IV concludes by proposing that Kentucky’s legislature should enable the Department of Insurance to regulate commercial ACOs to ensure accountability.