The PPACA includes a provision authorizing the creation of what are called "Consumer Operated and Oriented Plans" (CO-OPs), which are meant to offer consumer-friendly, affordable health insurance options to individuals and small businesses. CO-OPs will be funded by federal loans in hopes that with more players in the healthcare marketplace, the additional competition will lead to a more efficient and less costly healthinsurance market. CO-OPs must make decisions now about building their organizations, designing their plans, enlisting providers, and how their marketing strategies. These financial and operational decisions must be made as soon as possible to ensure that CO-OPs file and receive state approval to be in place in January 2014. This article discusses the current operational challenges and opportunities for new CO-OPs.