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CMS has released the 2025 Marketplace Integrity and Affordability Proposed Rule, outlining important changes that could significantly impact enrollment processes, consumer eligibility, and agent compliance requirements. As your partner, we want to ensure you’re informed and prepared.

What You Need to Know

Special Enrollment Periods (SEPs)

• Monthly SEP for individuals under 150% FPL is proposed for removal.
• SEP eligibility verification will be required for all categories across all Exchanges by 2026.

Open Enrollment Period (OEP)

• OEP would be shortened to run from November 1 through December 15, starting with Plan Year 2026.

Premium Payments

• Issuers may be allowed to require payment of past-due premiums before activating new coverage.
• Proposed changes would eliminate certain premium payment thresholds.

Automatic Re-enrollment

• Consumers who are automatically re-enrolled without updated APTC info may be required to pay a minimum $5 monthly premium until eligibility is verified.
• Proposed changes also impact how CSR enrollees are re-enrolled.

Income & Eligibility Verification

• Increased scrutiny for income verification.
• Exchanges could disqualify individuals for APTC after just one year of failure to file and reconcile taxes.

Agent & Broker Oversight

• CMS plans to apply a “preponderance of the evidence” standard when terminating Exchange agreements for cause.
• More precise conduct guidelines are expected in the 2026 Exchange agreements.

- Elyse Y. Robinson

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