- 1,193
Shortening the Annual Open Enrollment Period for Individual Market Coverage
CMS proposes changing the annual OEP for all individual market coverage to run from November 1 through December 15 preceding the coverage year, instead of through January 15 of the coverage year. This adjustment would apply to both on- and off-Marketplace individual market coverage. This proposal aims to reduce consumer confusion, streamline the enrollment process, align more closely with open enrollment dates for many employer-based health plans, encourage continuous coverage, and reduce the risk of adverse selection from consumers who otherwise may wait to enroll until they need health care services.
Verifying Consumer Income Eligibility for Insurance Affordability Programs
Addressing Failure to File and Reconcile
CMS proposes to reinstate its 2015 policy requiring Exchanges to determine an individual ineligible for APTC if they (or their tax filer) failed to file their federal income tax and reconcile APTC for one year, instead of for two consecutive tax years as implemented in the 2024 Payment Notice. Under this proposed change, the Marketplace must determine a tax filer ineligible for APTC if (1) CMS notifies the Marketplace that the tax filer or someone in their household received APTC for a prior year for which tax data would be utilized for verification of income and (2) the tax filer or someone in their household did not comply with the requirement to file a tax return and reconcile APTC for that year. This change aims to minimize improper enrollments and protect consumers from accumulating tax liabilities.
Verifying Income When Data Sources Indicate Household Income Less than 100% of the Federal Poverty Level
CMS proposes to require Marketplaces to generate annual income inconsistencies in certain circumstances when a tax filer's attested projected annual household income is equal to or greater than 100% of the FPL and no more than 400% of the FPL, while the income data returned by the Internal Revenue Service (IRS), Social Security Administration, or current income data sources are less than 100% of the FPL. This proposed policy would improve program integrity, reduce the burden of APTC on the federal taxpayer, and benefit consumers by ensuring subsidies are appropriately allocated and reducing their risk of improper tax liabilities.
Verifying Income When Tax Data is Unavailable
CMS proposes changes to strengthen the verification process for income eligibility by removing the requirement that Marketplaces accept an applicant's or enrollee's self-attestation of projected annual household income when the Marketplace requests tax return data from the IRS to verify attested projected annual household income but the IRS confirms there is no such tax return data available. Under this proposal, Marketplaces would be required to verify income with other trusted data sources (if available) and follow the alternative verification process, which requires applicants to submit documentary evidence or otherwise resolve the income inconsistency. This proposed policy would improve program integrity by reducing the risk of improper enrollments, benefit consumers by helping reduce surprise tax liabilities, and reduce annual APTC expenditures.
Reducing Improper Enrollments through Annual Eligibility Redeterminations and SEPs
Requiring $5 Premium Responsibility
CMS proposes to modify the annual eligibility redetermination process by requiring Marketplaces to ensure that consumers who are automatically re-enrolled without affirming or updating their eligibility information, and who would have been automatically re-enrolled in a QHP with a fully subsidized premium after the application of APTC, to instead be automatically re-enrolled with a $5 monthly premium. Once consumers confirm their eligibility, the $5 monthly bill could be eliminated. Any premium paid would potentially be rebated to the enrollee when they file and reconcile their APTC on their taxes if they remain eligible for a fully-subsidized premium. This proposed policy would potentially reduce improper enrollments and surprise tax liabilities, benefiting consumers by increasing awareness and engagement in their health coverage decisions, ensuring that their coverage aligns with their current needs and eligibility.
Removing Re-enrollment Hierarchy Standards
CMS proposes to remove the provision of current regulations that allows Marketplaces to automatically re-enroll CSR-eligible enrollees from a bronze to a silver QHP if the silver QHP is in the same product, has the same provider network, and has a lower or equivalent net premium as the bronze plan into which the enrollee would otherwise have been re-enrolled. This proposal benefits consumers by respecting consumer choice and reducing confusion caused by changing a consumer's plan from bronze to silver, even when their existing bronze plan remains available. The proposed changes also decrease the likelihood of unexpected tax liabilities related to re-enrolling bronze enrollees into a silver plan without their knowledge.
[EXTERNAL LINK] - 2025 Marketplace Integrity and Affordability Proposed Rule | CMS
CMS proposes changing the annual OEP for all individual market coverage to run from November 1 through December 15 preceding the coverage year, instead of through January 15 of the coverage year. This adjustment would apply to both on- and off-Marketplace individual market coverage. This proposal aims to reduce consumer confusion, streamline the enrollment process, align more closely with open enrollment dates for many employer-based health plans, encourage continuous coverage, and reduce the risk of adverse selection from consumers who otherwise may wait to enroll until they need health care services.
Verifying Consumer Income Eligibility for Insurance Affordability Programs
Addressing Failure to File and Reconcile
CMS proposes to reinstate its 2015 policy requiring Exchanges to determine an individual ineligible for APTC if they (or their tax filer) failed to file their federal income tax and reconcile APTC for one year, instead of for two consecutive tax years as implemented in the 2024 Payment Notice. Under this proposed change, the Marketplace must determine a tax filer ineligible for APTC if (1) CMS notifies the Marketplace that the tax filer or someone in their household received APTC for a prior year for which tax data would be utilized for verification of income and (2) the tax filer or someone in their household did not comply with the requirement to file a tax return and reconcile APTC for that year. This change aims to minimize improper enrollments and protect consumers from accumulating tax liabilities.
Verifying Income When Data Sources Indicate Household Income Less than 100% of the Federal Poverty Level
CMS proposes to require Marketplaces to generate annual income inconsistencies in certain circumstances when a tax filer's attested projected annual household income is equal to or greater than 100% of the FPL and no more than 400% of the FPL, while the income data returned by the Internal Revenue Service (IRS), Social Security Administration, or current income data sources are less than 100% of the FPL. This proposed policy would improve program integrity, reduce the burden of APTC on the federal taxpayer, and benefit consumers by ensuring subsidies are appropriately allocated and reducing their risk of improper tax liabilities.
Verifying Income When Tax Data is Unavailable
CMS proposes changes to strengthen the verification process for income eligibility by removing the requirement that Marketplaces accept an applicant's or enrollee's self-attestation of projected annual household income when the Marketplace requests tax return data from the IRS to verify attested projected annual household income but the IRS confirms there is no such tax return data available. Under this proposal, Marketplaces would be required to verify income with other trusted data sources (if available) and follow the alternative verification process, which requires applicants to submit documentary evidence or otherwise resolve the income inconsistency. This proposed policy would improve program integrity by reducing the risk of improper enrollments, benefit consumers by helping reduce surprise tax liabilities, and reduce annual APTC expenditures.
Reducing Improper Enrollments through Annual Eligibility Redeterminations and SEPs
Requiring $5 Premium Responsibility
CMS proposes to modify the annual eligibility redetermination process by requiring Marketplaces to ensure that consumers who are automatically re-enrolled without affirming or updating their eligibility information, and who would have been automatically re-enrolled in a QHP with a fully subsidized premium after the application of APTC, to instead be automatically re-enrolled with a $5 monthly premium. Once consumers confirm their eligibility, the $5 monthly bill could be eliminated. Any premium paid would potentially be rebated to the enrollee when they file and reconcile their APTC on their taxes if they remain eligible for a fully-subsidized premium. This proposed policy would potentially reduce improper enrollments and surprise tax liabilities, benefiting consumers by increasing awareness and engagement in their health coverage decisions, ensuring that their coverage aligns with their current needs and eligibility.
Removing Re-enrollment Hierarchy Standards
CMS proposes to remove the provision of current regulations that allows Marketplaces to automatically re-enroll CSR-eligible enrollees from a bronze to a silver QHP if the silver QHP is in the same product, has the same provider network, and has a lower or equivalent net premium as the bronze plan into which the enrollee would otherwise have been re-enrolled. This proposal benefits consumers by respecting consumer choice and reducing confusion caused by changing a consumer's plan from bronze to silver, even when their existing bronze plan remains available. The proposed changes also decrease the likelihood of unexpected tax liabilities related to re-enrolling bronze enrollees into a silver plan without their knowledge.
[EXTERNAL LINK] - 2025 Marketplace Integrity and Affordability Proposed Rule | CMS
