The Centers for Medicare & Medicaid Services (CMS) issued a final rule aimed at improving program integrity within ACA Marketplaces. Key changes include:
🔑 Major Policy Changes
- Open Enrollment Period Shortened: Starting in 2027, enrollment ends Dec. 15 (federal) or Dec. 31 (state).
- Monthly SEP for Low-Income Enrollees Eliminated: Ends the continuous enrollment option for individuals under 150% of the Federal Poverty Level (FPL).
- Stricter Income Verification:
- Missing tax filings for one year triggers loss of premium tax credit eligibility
- No automatic 60-day extension for income inconsistencies
- IRS data discrepancies now require immediate documentation
- $5 Premium Requirement for Auto-Reenrollment: Even for $0 plans, members must pay at least $5/month unless eligibility is reconfirmed.
- Denial of Coverage for Past-Due Premiums: Insurers may refuse coverage to applicants with unpaid past premiums (subject to state law).
- DACA Exclusion: DACA recipients will no longer qualify as “lawfully present” for ACA coverage or subsidies.
- Benefit Restrictions: Certain gender-modification procedures will no longer be considered Essential Health Benefits beginning in 2026.
Disclaimer: This article does not intend to serve as legal advice or constitute legal counsel. It should not be used as a substitute for guidance or instructions provided by CMS or other regulatory bodies. For specific legal advice or compliance concerns, please consult a legal professional or seek official guidance from CMS or the relevant authorities.
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Marketplace Integrity and Affordability Proposed Rule here