On March 10, the Centers for Medicare & Medicaid Services (CMS) released the Marketplace Integrity and Affordability Proposed Rule. It aims to improve consumer protections and increase the integrity of the marketplace.
This new proposed rule is the first of the Trump administration’s second term and comes shortly after the Marketplace Final Rule that was published on January 13, 2025. Here are the major reversals and highlights from the 2025 proposed rule.
Significant Reversals
The following protections were finalized in the 2026 Final Rule but will be reversed if the recent Proposed Rule is finalized as is.
Payment Thresholds
CMS is proposing to eliminate two of the three recently finalized payment thresholds — the Permit Fixed option, aka the fixed dollar threshold, and one of the Premium-Percent options, the gross-premium threshold. This leaves only the percentage-based net premium threshold.
The percentage-based net payment threshold allows clients who pay at least 95 percent (or another amount designated by the carrier) of their premium after their tax credits are applied to avoid being placed into a grace period. When left unresolved, grace periods can cause coverage gaps for low-income clients.
The goal of this change is to enhance marketplace integrity by holding clients responsible for paying their monthly premiums. With the previous rise in fraudulent enrollments, this may mitigate the risk for clients who were enrolled in marketplace coverage improperly or without their knowledge.
Reducing the Tax Reconciliation Requirement
Anyone who receives premium tax credits must reconcile them when filing their taxes. Previously, clients had two years to complete this process before re-enrolling or enrolling in new coverage. CMS is now proposing only one year for reconciliation.
By reinstating the 2015 policy, the marketplace aims to reduce improper enrollments and protect consumers from being liable for tax penalties.
Notable Marketplace Changes
Keep reading for changes we believe are critical for agents to be aware of!
Reducing the Open Enrollment Period
The proposed rule aims to change the federal annual Open Enrollment Period (OEP) to run from November 1 through December 15. Notably, the rule mentions that doing so will, “reduce consumer confusion, streamline the enrollment process, align more closely with open enrollment dates for many employer-based health plans, encourage continuous coverage, and reduce the risk of adverse election from consumers who otherwise may wait to enroll until they need health care services.”
It’s important to note that this proposal shortens the OEP by a month.
It’s important to note that this proposal shortens the OEP by a month. Agents who serve both Medicare and ACA clients will only have one week of the OEP that doesn’t overlap with Medicare’s Annual Enrollment Period, which runs October 15 to December 7. The new OEP dates are only for the federal marketplaces. Other state-based marketplaces could decide to adopt similar dates to mirror the federal exchange. Read our post on state-based marketplaces for more information.
Eliminating the 150 Percent FPL SEP
To “maintain program integrity” and reduce the strain on American taxpayers, CMS is seeking to eliminate the Special Enrollment Period (SEP) triggered when household income is less than 150 percent of the Federal Poverty Level (FPL).
This SEP is significant for states that have not extended Medicaid coverage. Low-income individuals who reside in a state that has not expanded Medicaid coverage may have to wait until the OEP to enroll in ACA coverage. If they’ve experienced a dramatic change in household income, this could mean months without coverage.
This change only affects the federal marketplace. We will continue to monitor state-based marketplaces and their adoption of this change.
Low-income individuals who reside in a state that has not expanded Medicaid coverage may have to wait until the OEP to enroll in ACA coverage.
Stringent Eligibility Verification
The Trump administration proposes to remove the requirement that marketplaces accept self-attestation of projected income when no tax return data is available. Income will have to be verified through documentation or other trusted data sources. Limited extensions to verify income will also be available if this proposed rule is finalized.
They also propose to require all marketplaces to verify eligibility for at least 75 percent of new enrollments through SEPs. CMS states this policy “would ensure more consistent application of eligibility criteria and reduce instances of improper enrollments, which can lead to a more balanced risk pool and potentially lower premiums, benefiting consumers.”
Automatic Enrollments to Have $5 Premium Responsibility
According to another proposed change, when an individual automatically re-enrolls in a plan, they will be responsible for a $5 monthly premium. In many cases, enrollees are placed into a plan that has a fully subsidized premium, whether they reaffirm their annual income or not. This new guidance will allow clients to be re-enrolled but will require them to assert their household income. The $5 premium responsibility would be eliminated after this process.
Removing Re-Enrollment Hierarchy Standard
Moving forward, CMS aims to remove the re-enrollment hierarchy requirement. Currently, consumers enrolled in a Bronze plan can be re-enrolled year over year to a Silver plan as long as they have the same network and the new plan has a lower or equal premium and is also a Qualified Health Plan. The Trump administration has proposed to remove this requirement to “respect consumer choice and reduce confusion.” Consumers who are re-enrolled in another metal tier may not realize that they will be liable for subsidies when it is time to file their annual taxes.
Amending the Lawfully Present Definition
The 2025 Proposed Marketplace Rule seeks to amend the definition of “lawfully present” to exclude Deferred Action for Childhood Arrivals (DACA) recipients. This change would block the demographic commonly called “Dreamers” from enrolling in a marketplace plan at the federal level and would make them ineligible for premium tax credits.
Things to Watch
We predict that some of these changes will have a significant impact on health insurance agents. There has not been any specific information about state exchanges adopting legislation that would mirror the federal exchange in regard to terminating agents, automatic re-enrollments, or altering OEP dates. If you’re an agent selling under-65 plans in a state marketplace, pay attention to changes that are a result of this proposed rule.
For agents selling ACA insurance and Medicare plans, the proposed change in enrollment period also means only one week between the Medicare Annual Enrollment Period (AEP) and the marketplace (OEP). This could mean an extremely demanding enrollment season for agents if finalized.
Also, agents who are not compliant could face termination. CMS proposes to add a definition of “preponderance of the evidence” to improve transparency and hold agents accountable. These changes would protect clients from bad actor agents.
This is the first wave of significant changes we’ve seen from President Trump’s second term. The adjustments in this Marketplace Proposed Rule aim to improve government efficiency, reduce spending, and reduce the number of fraudulent enrollments.
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