The Centers for Medicare & Medicaid Services (CMS) has issued the "Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability Final Rule." This rule establishes standards for Health Insurance Marketplaces, which provide access to Affordable Care Act (ACA) coverage. The rule aims to protect consumers from improper enrollments and changes in their health care coverage while ensuring the integrity of ACA Exchanges.
Key policies include strengthening income verification processes, modifying eligibility redetermination procedures, and excluding Deferred Action for Childhood Arrivals (DACA) recipients from eligibility in certain programs. The rule also addresses pre-enrollment verification for special enrollment periods to reduce improper enrollments.
Additionally, CMS has set standards for terminating agreements with agents, brokers, or web-brokers due to non-compliance. It prohibits issuers from covering specified sex-trait modification procedures as essential health benefits and revises actuarial value thresholds for plans subject to these requirements.
The rule also requires Exchanges to deny eligibility for advance payments of the premium tax credit if a tax filer fails to reconcile these credits. Other changes include adjusting open enrollment period dates and eliminating certain special enrollment periods based on income projections.
In response to COVID-19, temporary premium subsidies were expanded but have since expired. CMS acknowledges that this led to conditions exploited for improper enrollments. The final rule includes temporary measures aimed at reducing such enrollments while stabilizing the risk pool and lowering premiums.
The finalized policies are designed to improve healthcare affordability and access while maintaining fiscal responsibility. They include repealing rules prohibiting denial of coverage based on unpaid premiums, eliminating fixed-dollar premium payment thresholds, standardizing open enrollment periods, affirming previous interpretations of "lawfully present" definitions, verifying consumer income eligibility more rigorously, and requiring pre-enrollment verification for special enrollment periods.
These measures aim to enhance program integrity by ensuring proper allocation of subsidies and reducing surprise tax liabilities. Most policies will be implemented temporarily through plan year 2026.
Information from this article can be found here.
