Understanding the CMS’ 2025 Marketplace Integrity and Affordability Proposed Rule: What Consumers, Brokers, and Marketers Should Expect

by Farzin Espahani, GM Health & Medicare, Quinstreet, and Board Member, IMC

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule aimed at addressing improper enrollments in the Affordable Care Act (ACA) Health Insurance Marketplaces. This rule introduces several key changes designed to enhance the integrity of the marketplaces, stabilize the risk pool, and improve health care affordability and access. In this summary, we will explore the major provisions of the proposed rule and their impact on consumers, brokers, and marketers.

Key Provisions and Their Impact

1. Ending Monthly SEP for Low-Income Individuals:

   • Consumers: Individuals with household incomes below 150% of the FPL will no longer have a monthly SEP, which means they need to enroll during the annual Open Enrollment Period or qualify for other SEPs.

   • Brokers: This change will require brokers to emphasize the importance of enrolling during the Open Enrollment Period to avoid gaps in coverage.

   • Marketers: Marketers should develop campaigns that highlight the importance of enrolling during the Open Enrollment Period and the consequences of missing this window.

2. Strengthening Pre-Enrollment Verification:

   • Consumers: More rigorous verification processes for SEPs and additional income verification when tax data is unavailable will be implemented. This aims to reduce improper enrollments and ensure eligibility accuracy.

   • Brokers: Brokers will need to assist clients in navigating these verification processes and ensure all necessary documentation is provided.

   • Marketers: Marketers should create educational content that explains the new verification requirements and the importance of providing accurate information.

3. New Enrollment Verification Measures:

   • Consumers: A small $5 monthly premium will be required until enrollees confirm or update their eligibility for full subsidies. This measure is intended to encourage timely verification and reduce fraudulent enrollments.

   • Brokers: Brokers should inform clients about this new requirement and help them complete the verification process promptly to avoid unnecessary costs.

   • Marketers: Marketers should communicate the new premium requirement clearly and emphasize the need for timely verification to avoid additional costs.

4. Adjusting the ACA Open Enrollment Period:

   • Consumers: The Open Enrollment Period deadline will be moved to December 15, ensuring coverage selections are finalized before the new year. This change aims to prevent potential gaps in coverage.

   • Brokers: Brokers will need to adjust their timelines and outreach strategies to ensure clients are aware of the new deadline and enroll on time.

   • Marketers: Marketers should launch targeted campaigns to inform consumers about the new deadline and the importance of enrolling before December 15.

Overall Impact

The proposed rule is designed to stabilize the risk pool, lower premiums, and reduce improper enrollments, ultimately improving health care affordability and access while maintaining fiscal responsibility. For brokers, this means greater emphasis on educating clients about the importance of timely enrollment and verification processes. For consumers, it highlights the need for proactive engagement with the enrollment process to ensure continuous and accurate coverage. For marketers, it underscores the importance of clear communication and targeted campaigns to ensure consumers and brokers are well-informed about the new rules and deadlines.