CMS Proposes New Rule to Strengthen Marketplace Integrity and Affordability

On March 10, 2025, the Centers for Medicare & Medicaid Services (CMS) issued the “Marketplace Integrity and Affordability Proposed Rule” to enhance standards for Health Insurance Marketplaces, health insurers, brokers, and agents connecting millions of consumers to Affordable Care Act (ACA) coverage.

The proposed rule introduces several measures to strengthen consumer protections, prevent improper enrollments, and maintain the integrity of the Marketplace.

These changes will affect how people sign up for coverage, who qualifies, and what benefits are included.

Key Changes Include:

• Pre-Enrollment Verification During Special Enrollment Periods:

  • To prevent improper enrollments and fraud, individuals must now prove that they lost coverage before submitting an application for a Special Enrollment Period.

  • The option to enroll year-round for individuals with incomes below 150% of the federal poverty level is being eliminated.

  • Income verification will no longer allow for self-attestation to project household income. Instead, documentary evidence will be required to resolve income inconsistencies.

  • CMS will remove the 60-day extension to the standard 90-day period for resolving income inconsistencies.

  • Financial help will be denied if tax filings from past years have not been reconciled.

  • Consumers who are automatically re-enrolled in a plan, without updating their eligibility information will be required to pay a $5 monthly premium, which can be refunded later. This aims to encourage timely confirmation of eligibility and reduce improper enrollments.

• Shortened Open-Enrollment Period:

  • The Open Enrollment will be reduced by one month, ending on December 15, instead of January 15.

• DACA Recipients:

  • While Texas had already disqualified DACA recipients from applying, CMS will now amend the definition of "lawfully present" to exclude DACA recipients nationwide.

• Gender-Affirming Care

  • The plan proposes to prohibit coverage for sex-trait modification as an Essential Health Benefit.

As the proposed rule undergoes review and potential finalization, it is crucial for consumers, advocates, and stakeholders to stay informed and engaged in the public comment process to ensure fair and equitable access to health coverage under the ACA.

If you have any questions about how these changes might affect you, or if you need assistance understanding your coverage options, please don’t hesitate to call us.