WASHINGTON, D.C. — The Centers for Medicare & Medicaid Services (CMS) has issued a new rule to strengthen standards for the Affordable Care Act (ACA) Health Insurance Marketplaces, aiming to improve market stability, reduce improper enrollments, and enhance consumer protections. Known as the “Marketplace Integrity and Affordability Final Rule,” the policy outlines detailed measures to ensure the integrity of ACA Exchanges, which connect millions of Americans to health insurance coverage.
The rule finalizes several changes, including stricter income verification processes and the introduction of pre-enrollment verification for special enrollment periods (SEPs). This is expected to reduce improper enrollments and stabilize risk pools. Other provisions address premium payment rules, automatic reenrollment procedures, and eligibility redetermination. CMS is also revising its method for calculating premium adjustments and limiting essential health benefit (EHB) coverage for certain procedures beginning in 2026.
“Stabilizing the ACA Marketplaces and improving affordability for consumers is a priority,” CMS stated, emphasizing its commitment to maintaining fiscal responsibility while ensuring Americans have access to quality health care plans.
One key change in the final rule is the decision to exclude Deferred Action for Childhood Arrivals (DACA) recipients from enrollment eligibility under the ACA Marketplaces and Basic Health Programs in states that offer them. This reverses the policy established in 2024 and aligns with statutory requirements, reserving subsidies for eligible individuals.
To increase accountability, CMS has reinstated policies that require individuals enrolling through federal platforms to pay a minimum $5 premium for automatic reenrollments unless they confirm their eligibility for $0 premium coverage. The policy is designed to improve consumer engagement and awareness while reducing unwarranted enrollments. States utilizing their own platforms will develop similar policies by 2027.
Additionally, CMS plans to standardize the annual Open Enrollment Period (OEP) beginning in 2027, aligning dates more closely with employer-sponsored plan enrollment periods to minimize confusion and foster broader continuous coverage.
Many of the finalized measures will apply through 2026 and target issues stemming from temporary premium subsidies introduced during the COVID-19 pandemic. CMS has highlighted potential risks tied to improper enrollments under these subsidies and is implementing reforms to address lingering vulnerabilities.
Other significant changes include the prohibition of coverage for certain sex-trait modification procedures under EHB requirements and updated standards for terminating agent and broker agreements for noncompliance with Marketplace terms.
The finalized rule represents a multi-faceted approach to improving affordability and transparency for consumers while reinforcing safeguards within the ACA Marketplaces. These reforms aim to protect taxpayers, promote stable insurance markets, and secure equitable access to health care for eligible individuals.
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