The new rule is expected to reduce Marketplace premiums by up to 5% thanks to a multi-pronged strategy that focuses on minimizing unauthorized enrollments and reinforcing compliance at entry level. Many of these updates are temporary, applying through the 2026 plan year, and are designed to stabilize the risk pool during a period of transition as enhanced subsidies from the COVID-19 era begin t phase out. 

Let’s break down the key changes and what they mean for the ACA community. 

Tackling Improper Enrollments and Income Verification

Improper enrollments; often due to unverifiable income or automatic reenrollments; have long distorted the ACA risk pool. To combat this, CMS is tightening income verification requirements. Tax filers who fail to reconcile their Advanced Premium Tax Credit (APTC) after just one year (instead of the previous two-year window) will be deemed ineligible for future credits. 

CMS is also eliminating the automatic 60-day extension for resolving income inconsistencies and will now require more stringent documentation when income cannot be verified through tax records. Additionally, applicants can no longer self attest to income when no tax return data is found; trusted data sources or physical documentation will now be required. 

New Rules Around Enrollment and Reenrollment 

Automatic enrollment has been a point of vulnerability for the Marketplace. Starting in PY 2026, individuals auto-enrolled into plans with $0 premiums will now receive a $5 monthly premium bill; a small but symbolic step to ensure that consumers actively engage in their coverage decisions.

Furthermore, the rule repeals the policy that automatically shifted cost-sharing reduction (CSR)-eligible enrollees from bronze to silver plans without their consent, reinforcing the principle of consumer choice in plan selection.

CMS is also eliminating the Special Enrollment Period (SEP) for individuals with household incomes at or below 150% of the federal poverty level (FPL), citing concerns over unauthorized use and plan manipulation. To support this, 75% of new SEP enrollments on the federal platform will require pre-enrollment verification beginning in 2026.

Reining in Subsidy Abuse 

One of the most controversial aspects of the final rule is the removal of Deferred Action for Childhood Arrivals (DACA) recipients from the definition of “lawfully present,” making them ineligible for Marketplace coverage and subsidies. This reverses the 2024 rule that temporarily extended ACA access to this group. 

CMS is also reemphasizing that only eligible individuals—based on legal and income criteria—should receive subsidized coverage. This move, while contentious, aims to ensure that APTC funds are properly allocated and that federal dollars are protected from misuse.

Additional Updates: Coverage, Premiums, and Compliance

• Open Enrollment Period (OEP): Beginning in PY 2027, all Exchanges must set their OEP between November 1 and December 31, with a maximum duration of 9 weeks.
•  Premium Payment Rules: Insurers can now require both initial and past-due premiums before activating new coverage; encouraging continuous insurance and reducing adverse selection.
• Essential Health Benefits (EHBs): CMS is banning coverage of certain sex-trait modification procedures as an EHB, aligning Marketplace coverage more closely with typical employer-sponsored plans.
• Agent & Broker Accountability: A new evidentiary standard will guide when CMS may terminate agreements due to non-compliance, improving transparency and consumer protection.

Looking Ahead 

While some of the policies in the final rule are temporary, they reflect a broader push by CMS to recalibrate the ACA Marketplaces in favor of long-term sustainability and integrity. For agents, brokers and insurers, staying informed and compliant will be essential as these rules take effect; most starting August 25, 2025, unless otherwise noted. 

As always, we’ll continue to monitor updates and help our partners and clients navigate this evolving healthcare landscape. 

2025 Marketplace Integrity and Affordability Final Rule Slides