CMS rule impacts ACA enrollments

The Centers for Medicare & Medicaid Services is finalizing a major rule aimed at combating what it described as "the surge or improper enrollment in the Affordable Care Act exchanges."

The 2025 Marketplace Integrity and Affordability Final Rule

• Repeals the monthly special enrollment period for individuals with projected household incomes at or below 150% of the federal poverty level, a policy that CMS claimed is used by some agents and brokers to improperly enroll ineligible consumers and perform unauthorized plan switching to gain commissions.
• Requires income verifications to ensure people qualify for the premium subsidies they receive;
• Conducts eligibility verifications for the majority of enrollments through SEPs, closing loopholes that allowed people to wait to enroll until they needed care and improving the risk pool.
• Reduces advanced payments of the premium tax credit by $5 a month for individuals who are auto re-enrolled in fully-subsidized plans without eligibility verification, ensuring consumers are aware of and engaged in their health coverage.
• Standardizing the annual open enrollment period starting with the 2027 plan year so that it ends by Dec. 31 for all health insurance exchanges. CMS said this encourages people to maintain year-round health coverage rather than waiting until they get sick to enroll.

CMS said the rule will lower individual health insurance premiums by about 5% on average. It is also projected to save taxpayers up to $12 billion in 2026.