The Centers for Medicare & Medicaid Services (CMS) has recently released the 2025 Marketplace Integrity and Affordability Proposed Rule, which would introduce several significant changes to the Affordable Care Act (ACA) marketplaces. This proposed rule has an aim to enhance program integrity and streamline enrollment processes and procedures. It is the first major action affecting the ACA markets by the Trump Administration since it took office in January 2025. Below are the key initiatives in the proposal:
- Strengthening Enrollment Integrity: By introducing pre-enrollment verification for special enrollment periods (SEPs) and refining income verification processes, CMS aims to ensure that those who need coverage can get it efficiently and accurately.
- Eligibility Changes: While some lower income groups may see changes in eligibility, this presents an opportunity for policymakers and stakeholders to reassess and focus on coverage and access, potentially leading to targeted support for those who need it most.
- Enrollment Period Adjustment: Shortening the annual Open Enrollment Period (OEP) could inadvertently reduce access to health insurance for many individuals. This change could result in reduced enrollment, particularly among those who are less aware of the deadlines or face difficulty with the enrollment process. To mitigate these risks, robust support during the enrollment period through various channels is critical, ensuring that eligible individuals are informed and can secure coverage.
- Special Enrollment Period Adjustments: Ending the monthly SEP for certain income levels and implementing pre-enrollment verification for new SEP enrollments can help ensure that those who need immediate coverage can access it while maintaining program integrity.
- Past-Due Premium Payments: Allowing health plans to require complete payment of past-due premiums before re-enrolling in a plan could result in better accountability for making payments while promoting smooth insurer operations.
While these changes aim to improve the ACA marketplaces, some may pose challenges for health plans and other stakeholders like individuals. For example, stricter enrollment verification processes could lead to new administrative tasks for marketplaces, and changes in eligibility criteria might affect certain populations’ ability to enroll as easily. It’s crucial for stakeholders to read, understand, and advocate for (or in opposition to) these proposals to ensure that any challenges are addressed.
Looking Ahead
As we navigate these updates, it’s also important to keep an eye on broader trends affecting the ACA marketplaces. For instance, the enhanced ACA premium subsidies introduced in 2021 are set to expire at the end of 2025 unless extended by Congress. If these subsidies lapse, millions of Americans could face increases in their net premium payments, potentially leading to a decline in enrollment over time and an increase in uninsured. At the same time, some of those consumers may enroll in an Individual Coverage Health Reimbursement Arrangement (ICHRA) related ACA plan with support from their employer. This underscores the need for continued monitoring and engagement with markets and individuals to ensure health insurance remain accessible and affordable for all Americans.
We encourage stakeholders to share their insights and ideas on how these changes can impact some of our communities. Sharing feedback on these proposed changes allows the government to have important insights as it works to shape the future of the ACA marketplace.
Full Proposed Rule
You can access the full proposed rule document on the CMS website here and comment on the proposal at Regulations.gov. Comments must be submitted by April 11, 2025, to be considered.
