A Short Review of the Proposed 2025 Marketplace Integrity & Affordability Changes for ACA Consumers

This week, the Centers for Medicare & Medicaid Services (CMS) issued a new proposed rule, the Marketplace Integrity and Affordability, which is sparking a lot of discussion throughout the industry. To read more about the ruling, visit the CMS Fact Sheet or read the entire proposed rule.

The goal of this proposed ruling aims to create “additional safeguards to protect consumers from improper enrollments and changes to their health care coverage, as well as establish standards to ensure the integrity of the Marketplaces.” This ruling follows an uptick in complaints after the 2023 benefit year regarding enrollment without consent. 

The Marketplace Integrity and Affordability Ruling includes the following proposed policies:

  • Removing the monthly Special Enrollment Period (SEP) for individuals with projected household incomes at or below 150% of the Federal Poverty Limit
  • Implementing pre-enrollment verification for SEP eligibility for all Marketplace coverage 
  • Requiring eligibility verification for at least 75% of new enrollments through SEPs
  • Expanding the eligibility verification requirements, meaning more or all consumers will need to submit tax and income documents to prove their eligibility for subsidies 
  • Shortening the annual Open Enrollment Period (OEP) to November 1st - December 15th, aiming to reduce confusion and create consistency
  • Reintroducing the requirement for payment of past-due premiums before starting new coverage (this policy would be similar to the 2017 Market Stabilization Rule, which was later reversed in the 2023 Notice of Benefit and Payment Parameters Final Rule)
  • Updating the “lawfully present” definition to exclude Deferred Action for Childhood Arrivals (DACA) recipients and make them ineligible to enroll in a Qualified Health Plan (QHP) and reduce eligible subsidies (this policy would align with the 2012 Interim Final Rule)
  • Removing sex-trait modification services from essential health benefit requirements 

Between these changes and other proposals on the table, it’s becoming increasingly important to ensure that you are the primary source of education for your clients to help eliminate confusion, ensure understanding, and reduce anxiety. For more industry-related news like this, join the newsletter that 30,000+ health, benefits, and senior insurance professionals receive every week.

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Posted by Allison Babberl on Thursday, March 13, 2025 in Insurance Agents/Agencies

  1. compliance management
  2. industry news

About The Author

Allison Babberl

Allison is the Content Marketing Manager at AgencyBloc. She manages the creation and schedule of all educational content for our BlocTalk and Member communities. Favorite quote: “Conversation is the bedrock of relationships. Without it, our relationships are devoid of substance.” ... read more