Obamacare Marketplaces Tighten Up: Comment by April 11
Published Date: 3/19/2025
Proposed Rule
Summary
This proposed rule updates how health insurance marketplaces handle payments, eligibility checks, and enrollment to keep things fair and affordable for everyone. It affects people using marketplace plans, agents, and insurers by tightening rules on premium payments, income verification, and special enrollment periods. Comments are open until April 11, 2025, so stakeholders have a chance to weigh in before changes take effect.
Analyzed Economic Effects
15 provisions identified: 1 benefits, 12 costs, 2 mixed.
DACA Recipients Excluded From Eligibility
The rule would change the definition of "lawfully present" to exclude Deferred Action for Childhood Arrivals (DACA) recipients for the purpose of enrolling in a qualified health plan through an Exchange, and for eligibility for premium tax credits (APTC), cost-sharing reductions (CSR), and Basic Health Programs (BHP) in States that operate a BHP.
Issuers May Require Past‑Due Premiums
Issuers would be allowed, subject to State law, to add past-due premium amounts owed to the initial premium an enrollee must pay to start new coverage and to refuse to effectuate new coverage if the past-due and initial premium amounts are not paid in full. This reverses a restriction that previously prevented issuers from attributing payment for new coverage to past-due premiums.
Stricter ‘Failure to File and Reconcile’ Rule
Exchanges must determine a tax filer ineligible for advance premium tax credits (APTC) if HHS notifies the Exchange that the tax filer (or spouse) received APTC for a prior year and the tax filer did not file a Federal income tax return and reconcile that APTC for that year. This replaces a rule that required two consecutive years of non-filing before ineligibility could be determined.
No 60‑Day Extension for Income Verification
The proposal would remove a rule that automatically granted a 60-day extension to the 90-day period for applicants to provide documentation when there is an income inconsistency. If applicants do not verify income within 90 days, APTC payments would end.
Generate Income Inconsistencies at 100%–400% FPL
All Exchanges would be required to generate annual household income inconsistency checks when a tax filer's attested projected annual household income is greater than or equal to 100 percent and not more than 400 percent of the Federal poverty level (FPL), but trusted data sources indicate projected household income is under 100 percent of the FPL.
No Automatic Acceptance When IRS Tax Data Missing
The rule would remove the exception allowing Exchanges to accept an applicant's attestation of household income and family size without verification when the IRS lacks tax return data. Exchanges would generally be required to verify income with other trusted data sources when a tax return is unavailable.
Shorten Open Enrollment to Dec. 15
For benefit years starting January 1, 2026, the annual Open Enrollment Period for individual market Exchanges and non-grandfathered off-Exchange coverage would change from November 1 through January 15 to November 1 through December 15 of the calendar year before the benefit year.
Repeal Monthly SEP for ≤150% FPL
The proposal would remove the monthly special enrollment period that currently allows qualified individuals or their dependents who are eligible for APTC and have projected household income at or below 150 percent of the Federal poverty level (FPL) to enroll monthly.
Pre‑Enrollment Verification for SEPs (75%)
HHS would be enabled to reinstate pre-enrollment verification for all categories of individual market special enrollment periods (SEPs), and Exchanges would be required to conduct pre-enrollment verification for at least 75 percent of new SEP enrollments.
Ban Sex‑Trait Modification as an EHB
Beginning with Plan Year 2026, issuers of coverage subject to essential health benefits (EHB) requirements may not provide sex-trait modification as an EHB.
Change Premium Growth Measure for 2026
The proposal would update the premium adjustment percentage methodology by re-adopting the premium growth measure used for plan years 2020 and 2021 and apply it starting with plan year 2026. This measure is used to adjust parameters such as the maximum annual limitation on cost sharing, required contribution percentages for affordability exemptions, and employer shared responsibility amounts.
Wider AV De Minimis Ranges Starting 2026
Beginning in plan year 2026, the de minimis thresholds for actuarial value (AV) for most individual and small group market plans subject to essential health benefits would change to +2/-4 percentage points. Expanded bronze plans would have a +5/-4 percentage point range. The rule would also establish wider de minimis thresholds for income-based cost-sharing reduction plan variations.
Auto‑Reenrollment With $5 Monthly Premium
For enrollees who are automatically reenrolled and whose APTC would make their enrollee portion of the premium $0, Exchanges must reduce APTC so the enrollee owes $5 for the first month and every following month the enrollee does not confirm eligibility. Federally-facilitated Exchanges must implement this for annual redeterminations for benefit year 2026; State Exchanges must implement by benefit year 2027.
Stop Automatic Bronze→Silver Plan Switches
The proposal would remove the rule that allowed Exchanges to automatically move a CSR-eligible enrollee from a bronze plan into a silver plan for the next year without the enrollee's active consent, even when the silver plan had a lower or equivalent net premium after APTC.
Limit Premium Payment Threshold Options
The rule would remove issuer options to use fixed dollar or gross percentage-based premium payment thresholds and limit issuers to using the net percentage-based premium payment threshold. The change is intended to prevent enrollees from remaining enrolled after only making a binder payment in some cases.
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Key Dates
Department and Agencies
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