The Centers for Medicare & Medicaid Services (CMS) released the 2025 Marketplace Integrity and Affordability Final Rule. Its stated aim is to reduce individual health insurance premiums by approximately 5% on average and save taxpayers up to $12 billion in 2026. The rule addresses what CMS describes as widespread fraud in Affordable Care Act (ACA) Exchange enrollments.
CMS states that an estimated five million people may have been improperly enrolled in 2024, potentially costing taxpayers $20 billion. The rule includes temporary measures that will sunset at the end of the 2026 plan year to address immediate concerns while ensuring legitimate enrollees maintain coverage access.
The rule implements several measures to combat improper enrollments:
- Eliminates monthly special enrollment periods for individuals with incomes at or below 150% of the federal poverty level
- Requires income verification to ensure proper subsidy eligibility
- Conducts eligibility verification for most special enrollment period enrollments
- Reduces advanced premium tax credits by $5 monthly for auto-enrolled individuals in fully-subsidized plans without verification
- Standardizes the Annual Open Enrollment Period to end by December 31 starting in 2027
The rule also prohibits federal subsidies from covering certain sex-trait modification procedures, and reinstates a 2012 interpretation that excludes Consideration of Deferred Action for Childhood Arrivals (DACA) recipients from ACA Exchange coverage eligibility
This was reported by CMS on June 20, 2025 (accessed July 8, 2025).
Contact information: Office of Communications, U.S. Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Website: https://www.cms.gov/
August 2025 00US25EUA0023