Health plans must prepare for changes after new rules

Health plans must prepare now for changes in the way Americans access individual market insurance now that the One Big Beautiful Bill has become law and the Centers for Medicare and Medicaid Services finalized the Marketplace Integrity and Affordability Rule.

Some of those changes include:

• Ending automatic re-enrollment in Affordable Care Act plans, meaning health plans must overhaul their retention strategies.
• A compressed open enrollment window that will cut a full month from the annual sign-up period.
• New documentation requirements, creating administrative bottlenecks that could derail enrollments at verification.

“The shorter enrollment period and the special election period restrictions will depress enrollment in ACA plans but those restrictions also will prevent fraud and abuse,” Josh Schultz, strategic engagement manager at Softheon, told InsuranceNewsNet. “I know a lot of insurers are concerned about the potential enrollment changes, but they may turn into an opportunity for more proactive outreach.”

How new laws impact health plans

Softheon shared some updates on how the new rules and legislation will impact the way health plans engage with enrollees, process applications and manage renewals.

Beginning in fall 2026 (for coverage effective in 2027), the annual open enrollment on HealthCare.gov and most state-based marketplaces will be shortened. The current window of November 1 through January 15 will change to November 1 through December 15.

This move is intended to accelerate plan selections, limit prolonged unpaid effectuation windows, and reduce churn caused by passive enrollments. All SBMs will be required to adhere to this change, with no enrollment period extending past December 31.

This does not affect the upcoming fall 2025 enrollment cycle (for Plan Year 2026), which will still run through January 15, 2026.

Starting in August, the ongoing special enrollment period for consumers earning less than 150% of the federal poverty level will be eliminated. This SEP allowed eligible consumers to enroll year-round — and its removal will reduce continuous enrollment flexibility for many low-income households.

Plans and enrollment platforms must disable this option, revise application logic, update training materials and communicate with those affected.

For Plan Year 2026, enrollees in plans that would have automatically renewed with a $0 net premium will now be required to pay at least $5 per month, unless they take active steps to confirm eligibility. The goal is to ensure that consumers regularly update application data rather than drifting through year-over-year auto-renewals.

For Plan Year 2027, the legislation calls for the complete elimination of automatic re-enrollment for all subsidy-eligible members. This means that unless consumers actively renew, they will not retain coverage — even if eligible.

These changes will require updates to renewal notices, passive renewal workflows, and outreach campaigns to prevent unnecessary coverage loss.

Stricter verification requirements

Stricter verification requirements for income and SEP eligibility take effect in August. These include removing the 60-day grace period for resolving income inconsistencies. All inconsistencies must now be addressed within 90 days. Consumers who attest to income above 100% FPL will be required to submit documentation if trusted data sources indicate income below that threshold. Consumers will also be required to submit income documentation if IRS tax data is unavailable for eligibility confirmation.

These new requirements could potentially reduce the number of enrollees in ACA coverage by 7 million to 8 million, said Marc Bryant, vice president of health care solutions at Softheon. But he said this reduction could be a positive thing for health insurers whose plans are sold on the exchange.

“I heard three payors say a few months ago that they saw it as a potential positive when it comes to the risk pool, because there will be stabilization again in the individual market after it grew so fast over the last couple of years,” he said. “So they saw it as a way to get stabilized again and then build back up. You don’t want to see people lose insurance but this could help restabilize the ACA marketplace.”

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at susan.rupe@innfeedback.com.