Key Takeaways From the 2025 Marketplace Integrity and Affordability CMS Final Rule

On June 20, 2025, the Centers for Medicare & Medicaid Services (CMS) released their “Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability Final Rule.”

If you’re interested, you can find the full Marketplace 2025 CMS Final Rule on the Federal Register. Keep reading for our summary of the changes in ACA insurance for agents effective August 25, 2025.

What Did the 2025 Marketplace Final Rule Repeal?

With the latest insurance news, CMS has repealed the ACA provisions below. Please note that these changes will especially affect your low-income clients, DACA recipients, and bronze QHP enrollees.

The 150% FPL SEP

Effective 60 days from the enactment of the final rule, households with projected incomes at or below 150 percent of the federal poverty level (FPL) will no longer have access to a monthly SEP to modify their ACA health plan. CMS is eliminating the SEP “due to concerns over increased unauthorized ACA enrollments and adverse selection risk.” However, they state that this provision will only be effective for Plan Year 2026 (PY2026).

With this change, low-income individuals in states that have not expanded Medicaid coverage may have to wait until the Open Enrollment Period to enroll in ACA coverage. A dramatic change in household income could mean months without coverage.

A dramatic change in household income could mean months without coverage for certain ACA enrollees.

ACA Insurance for DACA Recipients

CMS’ decision to revert the definition of “lawfully present” to its previous interpretation, adopted in the 2012 Interim Final Rule, is no surprise. This change reverses the 2024 DACA rule and makes Dreamers ineligible to enroll in a Qualified Health Plan (QHP) through the marketplace and state Basic Health Programs (BHPs). It will reserve federal subsidies for other individuals who still meet the eligibility requirements.

The Re-Enrollment Hierarchy Standard

Marketplaces can no longer automatically re-enroll CSR-eligible bronze QHP enrollees in silver QHPs. Formerly, exchanges could complete this type of auto-re-enrollment so long as the silver QHP was the same product, had the same provider network, and had a lower equivalent net premium as the bronze QHP. The choice is now in the hands of the consumer, which could lead to decreased confusion and fewer unexpected tax liabilities for enrollees.

Right to Coverage for Those with Unpaid, Past-Due Premiums

Insurers are no longer prohibited from denying coverage to those with unpaid past-due premiums. They may now require payment of past-due premiums and an initial premium amount to effectuate new coverage. Through this change, CMS could see more stable premiums for the issuer and the market.

Insurers are no longer legally prohibited from denying coverage to those with unpaid past-due premiums.

The Fixed-Dollar & Gross Percentage-Based Premium Payment Thresholds

Moving forward, insurers can only adopt the net percentage-based premium payment threshold. CMS is no longer permitting use of the Permit Fixed (fixed-dollar) payment threshold nor the gross-premium threshold. The goal of this change is to help ensure consumers are aware of their ACA enrollments and increase clarity and accountability in premium payments.

What Are New Requirements for Marketplace Health Insurance?

The health care policy changes below will lead to new, more stringent requirements for ACA coverage. These are changes you’ll want all your clients to be aware of. We urge you to take note of the new OEP end date.

New Income Verification Requirements for Premium Tax Credits

Through the end of PY2026, exchanges must, once again, deem an individual ineligible for the Advanced Premium Tax Credits (APTC) if they (or their tax filer) failed to file their federal income taxes and reconcile their APTC for one year. (The previous administration allowed a two-year grace period.) Marketplaces will be tasked with verifying applicants’ projected annual household incomes when their own attestations do not match IRS income data and fall under the 100 percent FPL mark.

Exchanges must verify an applicant’s self-attested projected annual household income with other data sources if attempts to verify the projection with the IRS are unsuccessful.

Furthermore, CMS is immediately removing the automatic 60-day extension, that was available after the 90-day required grace period, to resolve income inconsistencies.

Overall, these changes seek to properly allocate subsidies and reduce risk of tax liabilities for consumers.

$5 Monthly Premium Charge for Those Who Don’t Owe a Premium with APTC

Through PY2026, ACA enrollees who are automatically re-enrolled in coverage on the federal platform and have no premium responsibility with their APTC will owe a $5 monthly premium beginning in PY2026. The government will eliminate the bill if the individual confirms or updates their information and continues to be eligible for a $0 premium after application of their APTC.

Enrollees may receive a refund or reduction on the taxes they may owe when they reconcile their APTC on their federal income tax return.

The government will eliminate the $5 monthly premium if the individual confirms or updates their information and continues to be eligible for a $0 premium after application of their APTC.

This requirement does not apply to state-based marketplaces (SBMs). SBMs may adopt a similar framework beginning in PY2027.

With this change, CMS seeks to keep consumers engaged in their health coverage to reduce improper and unnecessary enrollments and future unexpected tax liabilities.

New Eligibility Verification Requirements for ACA Enrollments

To help immediately reduce improper enrollments, marketplaces on the federal platform will have to conduct pre-enrollment verification for SEP eligibility as well as 75 percent of new enrollments. These requirements are currently only for PY2026. State marketplaces do not have to meet these requirements at this time.

Standardizing the OEP

Starting with PY2027, all ACA-related Open Enrollment Periods (OEPs) must start no later than November 1, end no later than December 31, and last no longer than nine weeks. The coverage effective date of all OEP enrollments must be January 1. This change includes both on- and off-marketplace individual health coverage to limit consumer confusion and encourage continuous coverage. State exchanges may establish dates for their own OEPs within these parameters.

Starting with PY2027, all ACA-related Open Enrollment Periods (OEPs) must start no later than November 1, end no later than December 31, and last no longer than nine weeks.

The federal OEP will run from November 1 through December 15 for PY2027.

Evidentiary Standard for Broker Marketplace Agreement Terminations for Cause

When assessing agent, broker, and web-broker marketplace agreement terminations for cause, the Department of Health & Human Services (HHS) will use a “preponderance of the evidence” standard of proof. This means the broker’s noncompliance will need to be proven more likely than not for HHS to proceed with terminating their marketplace agreement.

Please remember, this is only a summary of the 2025 ACA Final Rule. There are a few other changes present in the full rule, which is available on the Federal Register. For more assistance with navigating these changes, please reach out to Ritter’s Sales team.

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