2025 Marketplace Integrity and Affordability Final Rule

Overview of the Final Rule

On May 31, 2025, the Centers for Medicare and Medicaid Services (CMS) issued the 2025 Marketplace Integrity and Affordability Final Rule, aimed at reducing improper enrollment in Affordable Care Act (ACA) plans and safeguarding taxpayer dollars.

Key Goals

• Reduce improper enrollments projected to have reached 5 million in 2024.

• Cut federal costs by up to $12 billion in 2026.

• Lower ACA premiums by an estimated 5%.

• Tighten eligibility enforcement to prevent waste, fraud, and abuse.

Major Policy Changes

1. Shortened Enrollment Periods

• Federal Marketplace: Open enrollment shortened to Nov. 1 – Dec. 15, beginning in 2027.

• State-Based Marketplaces: Limited to Nov. 1 – Dec. 31.

2. Stricter Eligibility and Verification

• Enhanced income and eligibility checks for subsidies and special enrollment periods (SEPs).

• Ends the low-income SEP (under 150% FPL) due to misuse by some agents/brokers.

• Introduces $5 reduction in premium tax credits for automatic re-enrollees without updated verification.

3. Premium Adjustment

• Adjustments may raise maximum annual cost-sharing.

4. Changes to Coverage Eligibility

• Reinstates exclusion of DACA recipients from ACA and Basic Health Program eligibility.

• Prohibits use of federal subsidies for specified sex-trait modification procedures.

5. Agent and Broker Oversight

• Strengthens CMS authority to terminate agents and brokers who fail to comply with rules.

• Repeals prior rule protecting individuals from losing coverage due to unpaid premiums.

6. Temporary Measures

• Several provisions are temporary and will sunset after the 2026 plan year.

Stakeholder Responses

• The American Hospital Association expressed concern that 750,000 to 2 million consumers could lose coverage due to the new verification requirements.

• CMS claims that the changes will improve the risk pool, benefiting unsubsidized consumers by lowering premiums.