On June 25, 2025, the U.S. Department of Health and Human Services (HHS) published a final rule to implement new
standards for the Affordable Care Act’s (ACA) Marketplaces (or Exchanges). According to HHS, improper Exchange
enrollments, enabled by weakened verification processes and expanded premium subsidies, have triggered “widespread
fraud.” The final rule’s changes are intended to address these problems with the goal of improving health care affordability
and access while maintaining fiscal responsibility.
Key Changes
Many of the final rule’s changes are effective 60 days after its publication date, or Aug. 25, 2025, although some provisions
have a later effective date. Also, some changes are temporary measures that sunset at the end of the 2026 plan year. Key
changes include the following:
- Ending the availability of the monthly special enrollment period for individuals with household incomes below 150% of
the federal poverty level (sunsets at the end of the 2026 plan year); - Standardizing the annual open enrollment period (OEP) for all individual market coverage. Beginning with the OEP for
the 2027 plan year, each OEP must start no later than Nov. 1 and end no later than Dec. 31 and cannot exceed nine
calendar weeks. For Exchanges on the federal platform, the OEP will run from Nov. 1 through Dec. 15 preceding the
coverage year, beginning with the OEP for plan year 2027; - Eliminating eligibility for Deferred Action for Childhood Arrivals (DACA) recipients;
- Requiring Exchanges to determine an individual ineligible for the advance premium tax credit (APTC) if they failed to file
their federal income tax return and reconcile APTC for one year (effective for 2026 only); - Allowing insurers to require payment of past-due premiums before effectuating new coverage, to the extent permitted
by state law; - Requiring individuals who are automatically renewed in coverage through a federal platform Exchange with no premium
(i.e., consumers who are eligible for APTC that fully cover their premiums) to pay $5 per month until they confirm their
eligibility information (effective for 2026 only); and - Prohibiting non-grandfathered individual and small group market plan issuers from covering specified sex-trait
modification procedures as an “essential health benefit” (effective beginning with the 2026 plan year).
Impact on Employers
Although these changes do not directly affect employers, they may make it more difficult for employees to enroll in Exchange
coverage. Employers that offer individual coverage health reimbursement arrangements (ICHRAs) may find this problematic.
In contrast, employers subject to the ACA’s employer shared responsibility penalties (“pay-or-play” penalties) may reduce
their penalty risk if fewer employees enroll in Exchange coverage. - We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance specialists at (215)-355-2121 or fill out the contact form below. We are available to answer any questions or address any concerns you may have.