The Centers for Medicare & Medicaid Services (CMS) on Wednesday issued the Marketplace Integrity and Affordability final rule (PDF), which applies to issuers offering qualified health plans (QHPs) through federally facilitated Exchanges and state-based Exchanges on the federal platform. Exchanges are entities, established under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148, PDF), through which qualified individuals and qualified employers can purchase health insurance coverage in QHPs. Certain provisions of the final rule would go into effect only for the 2026 plan year, sunsetting in plan year 2027. However, many of these policies are also included in the House-passed reconciliation package (H.R. 1), which could codify and extend these changes.
The CMS finalized a proposal to end eligibility for QHP and Basic Health Program coverage for individuals with Deferred Action for Childhood Arrivals (DACA). The rule also prohibits individual and small group health plans from offering gender-affirming care as an essential health benefit. Neither policy would sunset after plan year 2026.
Other proposals finalized by the rule would:
- Shorten the open enrollment period by two weeks, to run from Nov. 1 to Dec. 31, instead of the current end date of Jan. 15.
- End the monthly special enrollment period for individuals with incomes below 150% of the federal poverty guidelines.
- Impose pre-verification procedures before an individual can enroll during special enrollment periods.
- Require additional income verification checks for premium tax credits.
- Add limitations on reenrollment, such as by denying enrollment until an enrollee pays past-due premiums and charging a $5 premium for individuals with fully subsidized coverage who are automatically enrolled before confirming their plan.
The CMS estimates that between 725,000 and 1.8 million people would lose coverage as a result of the final rule.