Here we go. Here are the changes that are going to stick.
The intro to the final rule says that "A number of the policies that CMS is finalizing are temporary measures to immediately tamp down on improper enrollments and the improper flow of federal funds" and "are designed to stabilize the risk pool, lower premiums, and reduce improper enrollments with a goal of improving healthcare affordability and access while maintaining fiscal responsibility."
The fact sheet on this from CMS can be found here: 2025 Marketplace Integrity and Affordability Final Rule | CMS
I'm just doing a super quick rundown here without a lot of background but more information can be found in my blog post re: the proposed changes to the ACA and in this tracker from KFF. The KFF tracker has links to the details on proposed changes to Medicare, Medicaid, and HSAs as well.
OFFICIAL CHANGES TO THE ACA FROM THE 2025 MARKETPLACE INTEGRITY AND AFFORDABILITY FINAL RULE
Satisfaction of Debt for Past-due Premiums
CMS is finalizing the repeal of the rule that prohibits issuers from denying health insurance coverage based on unpaid past due premiums.
"This change will permit an issuer, to the extent permitted by applicable State law, to require payment of both the initial and past-due premium amounts in order to effectuate new coverage."
(effectuate: for coverage to go into effect after enrollment)
Eliminating Gross Premium Percentage-Based and Fixed-Dollar Premium Payment Thresholds
CMS is finalizing elimination of the fixed-dollar and gross percentage-based premium payment thresholds, allowing issuers to only adopt the net percentage-based threshold.
This means that issuers will no longer have the option to allow consumers to maintain coverage based on paying a fixed dollar amount or a percentage of the gross premium. Instead, issuers will only be able to use a net premium percentage-based threshold, requiring consumers to pay a percentage (specifically, at least 95%) of their net premium to avoid triggering a grace period.
This provision, along with several other program integrity measures, is being implemented on a temporary basis through PY 2026.
Standardizing the Annual OEP for Individual Market Coverage
CMS is finalizing changes to the annual OEP beginning with the OEP for plan year 2027.
This adjustment will apply to both on and off-Marketplace individual market coverage.
- The final rule allows all Exchanges flexibility to set their own OEPs within set parameters for timing and duration.
- Each OEP must start no later than November 1 and end no later than December 31, and the OEP may not exceed 9 calendar weeks.
- Finally, all enrollments pursuant to Open Enrollment Period must begin on January 1.
For Exchanges on the Federal platform, the OEP will run from November 1 through December 15 preceding the coverage year, beginning with the OEP for plan year 2027.
Ensuring Subsidies for Eligible Individuals Affirming Previous Interpretation of "Lawfully Present" Definition
CMS is finalizing amendments to the definition of “lawfully present” to exclude DACA recipients, returning to the interpretation adopted in the 2012 Interim Final Rule (77 FR 52614).
This change will make DACA recipients ineligible
- To enroll in a Qualified Health Plan (QHP) through the Marketplace
- For premium tax credits, APTC, and cost-sharing reductions (CSRs)
- For Basic Health Programs (BHPs) in states that elect to operate a BHP
reversing the 2024 DACA Rule.
Verifying Consumer Income Eligibility for Insurance Affordability Programs
Failure to File and Reconcile
CMS is finalizing the reinstatement of its 2015 policy requiring Exchanges to determine an individual ineligible for APTC if they (or their tax filer) failed to file their federal income taxes and reconcile APTC for one year instead of for two consecutive tax years as implemented in the 2024 Notice of Benefit and Payment Parameters (the 2024 Payment Notice).
Under this change, a Marketplace must determine a tax filer ineligible for APTC if
(1) CMS notifies the Marketplace that the tax filer or someone in their household received APTC for a prior year for which tax data would be utilized for verification of income, and
(2) the tax filer or someone in their household did not comply with the requirement to file a federal income tax return and reconcile APTC for that year.
60-Day Extension to Resolve Income Inconsistency
CMS is finalizing the removal of the automatic 60-day extension of the statutorily-required 90-day period for resolving income inconsistencies introduced in the 2024 Payment Notice.
This change will ensure enrollees verify their incomes on a timely basis within the 90-day window prescribed in statute and reduce the opportunity for enrollees with unverified incomes to receive APTC premiums through the full length of the verification period.
Income Verification When Data Sources Indicate Household Income Less than 100% of the FPL
CMS is finalizing the requirement that Marketplaces generate annual income inconsistencies in certain circumstances when a tax filer’s attested projected annual household income would qualify the taxpayer as an applicable taxpayer according to 26 CFR 1.36B-2(b), while the income data returned by the Internal Revenue Service reports that the tax filer’s income is less than 100% of the FPL.
CMS is finalizing the requirement through plan year 2026 only.
Income Verification When Tax Data is Unavailable
CMS is finalizing the removal of the requirement that Exchanges accept an applicant’s or enrollee’s self-attestation of projected annual household income when the Exchange attempts to verify the attested projected annual household income with the IRS, but the IRS confirms there is no such tax return data available.
Under this change, Exchanges will be required to verify income with other trusted data sources (if available) and to require applicants to submit documentary evidence or otherwise resolve the income inconsistency.
Consistent with the approach mentioned above, CMS is finalizing the requirement through plan year 2026 only.
Reducing Improper Enrollments through Annual Eligibility Redeterminations and SEPs
Requiring $5 Premium Responsibility
CMS is finalizing modifications to the annual eligibility redetermination process by requiring Marketplaces on the Federal platform to ensure that consumers who are automatically re-enrolled with no premium responsibility following application of APTC and without affirming or updating their eligibility information, are automatically re-enrolled with a $5 monthly premium beginning in plan year 2026.
Once consumers confirm or update their information, the $5 monthly bill will be eliminated if they continue to be eligible for a $0 premium after application of APTC. As with all enrollees, they may receive a refund or reduction on the taxes they owe (or may owe) when they file and reconcile their APTC on their federal income tax return.
CMS is not finalizing this requirement for State Marketplaces.
This policy will sunset at the end of the 2026 plan year.
Re-enrollment Hierarchy Standards
CMS is finalizing the repeal of a regulation that allows Marketplaces to automatically re-enroll CSR-eligible bronze QHP enrollees in a silver QHP if the silver QHP is in the same product, has the same provider network, and has a lower or equivalent net premium as the bronze plan into which the enrollee would otherwise have been re-enrolled.
State Marketplaces may continue seeking approval from the Secretary to design and conduct their own annual eligibility redetermination process.
Monthly SEP for APTC-Eligible Individuals with Household Incomes at or Below 150% of FPL
CMS is finalizing the repeal of the monthly SEP for individuals with projected household incomes at or below 150% of the FPL, due to concerns over increased unauthorized enrollments and adverse selection risk, as the SEP has been exploited to enroll consumers or change their plans without their knowledge.
This policy is effective 60 days after the enactment of the final rule.
As noted above, in response to some commenters’ concerns, this provision will be effective only for the 2026 plan year.
HHS also clarifies that a change in income is not an Exceptional Circumstance within the meaning of 45 CFR 155.420(d)(9). Thus, Marketplaces may not offer income-based SEPs under this authority.
All Marketplaces Conducting Eligibility Verification for SEPs
CMS is finalizing a requirement that Marketplaces conduct pre-enrollment verification for SEP eligibility beginning plan year 2026 for Marketplaces on the Federal platform, but is not finalizing this requirement for State Marketplaces at this time.
The final rule provides that this requirement will sunset for Marketplaces on the Federal platform at the end of the 2026 plan year.
Marketplaces Conducting Eligibility Verification for 75% of New Enrollments through SEPs
CMS is finalizing a rule mandating pre-enrollment eligibility verification for at least 75% of new enrollments through SEPs beginning plan year 2026 for Marketplaces on the Federal platform, with the policy to sunset at the end of the 2026 plan year.
HHS is not finalizing this requirement for State Marketplaces at this time to address issues concerning operational feasibility and increased burdens and costs.
Aligning EHB with Benefits Covered by Typical Employer Sponsored Plans
Prohibiting Coverage of Specified Sex-trait Modification Procedures as an EHB
CMS is finalizing that, effective beginning in plan year 2026, issuers subject to EHB requirements (that is, non-grandfathered individual and small group market plans) may not cover specified sex-trait modification procedures, as an EHB.
In the final rule, CMS is also adding a definition of the term “specified sex-trait modification procedure” in response to comments and specifying that certain services would not qualify as a “specified sex-trait modification procedure” under this definition.
This policy will not prohibit issuers of coverage subject to EHB requirements from voluntarily covering specified sex-trait modification procedures, nor will it prohibit states from requiring coverage of such services, subject to the rules related to state-mandated benefits at 45 CFR § 155.170.
This policy will align EHB with the benefits covered by typical employer-sponsored plans, as required by the applicable statute.
Improving Cost-Sharing, Premium Adjustments, and Plan Options
Premium Adjustment Percentage (PAPI) Methodology
CMS is finalizing updates to the methodology for calculating the premium adjustment percentage to establish a premium growth measure that captures premium changes in both the individual and employer-sponsored insurance markets for the 2026 plan year and beyond.
CMS is also finalizing the plan year 2026 maximum annual limitation on cost sharing, reduced maximum annual limitations on cost sharing, and required contribution percentage using the finalized premium adjustment percentage methodology.
This policy will ensure these annual adjustments to ACA parameters align more closely with the changes in premium trends in the markets they aim to track.
De Minimis Thresholds
CMS is finalizing widening the de minimis ranges to +2/-4 percentage points for all individual and small group market plans subject to the AV requirements under the EHB package, other than for expanded bronze plans, for which CMS is finalizing a de minimis range of +5/-4 percentage points.
CMS is also finalizing removing from the conditions of QHP certification the de minimis range of +2/0 percentage points for individual market silver QHPs and specifying a de minimis range of +1/-1 percentage points for income-based silver CSR plan variations.
Establishing Evidentiary Standard for Termination of Agent, Broker, and Web-Broker Marketplace Agreements for Cause
CMS is finalizing the adoption of a “preponderance of the evidence” standard of proof with respect to issues of fact for HHS to assess whether an agent, broker, or web-broker’s Marketplace Agreement should be terminated due to noncompliance with applicable HHS rules and the terms of their Marketplace Agreements.
This change will improve transparency in the process for holding agents, brokers, and web-brokers accountable for compliance with applicable law, regulatory requirements, and their Marketplace Agreements and protect consumers from the impacts of potential noncompliance, including improper enrollments.
THE END, FOR BETTER OR WORSE
The only "good news" feeling I got from this AT ALL is that several of these changes are only intended to last through the end of plan year 2026 (but I don't know if I trust them on this). I will certainly feel these changes personally when I re-enroll so I have to start thinking about how I'm going to prove my income before I can continue my coverage when I have a variable income and don't have any way of knowing ahead of time how much it will be. Whatever. My blood is boiling so I'm going to take a quick break and hurry up and get this post live before the world crumbles.
If there are formatting errors in here, I'll catch them later. I was more concerned with shouting this from the rooftops so we can get some discussion going. As always, feel free to contact me any time with questions or for guidance on how to find more information.
Keep watching my blog for more on this and other developments. My next planned post is the third in the series on Alternative Health Plans: Scam or Bargain? Mark my words - there are going to be so many shady "opportunities" going around when people are desperate. Follow my series and learn what to watch out for. The next installment is about Health Sharing Ministries: Pros and Cons.
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