New ACA Rule Blocks Coverage for Sex-Trait Modifications in Health Plans
Published Date: 3/19/2025
Proposed Rule
Summary
This rule updates how health insurance marketplaces handle late payments, who counts as 'lawfully present,' and how agents are checked for rule-breaking. It also changes how income is verified for discounts, when people get re-enrolled, and how special sign-up times work. These updates affect anyone using the marketplace and aim to keep coverage fair and affordable starting soon after the rule is final.
Analyzed Economic Effects
10 provisions identified: 0 benefits, 2 costs, 8 mixed.
Exclude DACA From 'Lawfully Present'
The rule would exclude Deferred Action for Childhood Arrivals (DACA) recipients from the definition of 'lawfully present.' This change specifically affects people with DACA status.
Changes to Past-Due Premium Rules
The rule revises standards for past-due premium payments for marketplace coverage. If you buy insurance through the marketplace, these revised standards will change how late payments are treated and may affect whether your coverage continues or is terminated.
Income Verification for Premium Help
The rule changes how income is verified for premium tax credits and cost-sharing reductions (CSRs). If you apply for marketplace premium help, the verification steps for your income and eligibility will be different under this rule.
Annual Eligibility Redetermination Updates
The rule updates annual eligibility redetermination processes for marketplace enrollees. If you have marketplace coverage, the rules about checking your eligibility each year will change.
Open Enrollment Period Revisions
The rule modifies the annual open enrollment period for marketplace coverage. If you shop for marketplace insurance, the timing or rules of the annual enrollment window will change.
Special Enrollment Period Rules Changed
The rule changes how special enrollment periods (SEPs) work for the marketplace. If you rely on a SEP to enroll outside open enrollment, the qualifying events or process may be different.
Premium Adjustment Percentage Methodology Changed
The rule changes the premium adjustment percentage methodology used for marketplace coverage. If you buy marketplace insurance, the way premiums are adjusted for certain calculations will be different.
Prohibit EHB Coverage for Sex-Trait Modification
The rule would prohibit issuers of coverage that are subject to essential health benefits (EHB) requirements from providing coverage for sex-trait modification as an EHB. If your plan is subject to EHB rules in the marketplace, those services could be excluded from EHB coverage.
Automatic Reenrollment Hierarchy Changed
The rule changes the automatic reenrollment hierarchy used for marketplace coverage. If you are automatically reenrolled in a plan, the order or criteria used to pick your plan will be changed.
De Minimis Actuarial Value Thresholds Updated
The rule changes de minimis thresholds for actuarial value for plans subject to essential health benefits (EHB) and for income-based CSR plan variations. This affects how small differences in plan value are treated for compliance.
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