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New federal rule brings immediate changes to Marketplace enrollment

Pausing of the low-income special enrollment period, loss of eligibility for DACA recipients are among changes in effect by August 2025

Author: Louise Norris | Date Posted: July 10, 2025

Enrollment in Marketplace health insurance 2026 plans

A federal rule published in June 2025¹ will deliver significant changes to Affordable Care Act Marketplace enrollment, with some of the regulations becoming effective in August 2025. Here’s a look at the Marketplace Integrity and Affordability final rule’s changes and when they will take effect.

What is the federal rule and when does it take effect?

The Trump administration proposed the Marketplace Integrity and Affordability rule in early 2025, citing the need for new standards to ensure the integrity of the Marketplaces – including safeguards to protect consumers from improper enrollments.² The proposed rule drew more than 26,000 public comments.³

The final rule’s effective date is August 25, 2025,⁴ with some of the rule’s provisions taking effect immediately on that date. Other provisions are applicable for the 2026 plan year or the 2027 plan year.

And, although the proposed rule called for the changes to be permanent, several are only applicable through the end of 2026.⁵

The first wave of changes – effective August 25, 2025

1. Pausing the special enrollment period for low-income individuals

Who’s affected: This will apply nationwide, meaning low-income people will no longer have year-round access to enroll in Marketplace plans.⁶

Permanent? No. This is a pause rather than a termination. HHS has clarified that the low-income SEP will once again be available, at the option of each exchange, for plan year 2027.⁷

Rationale for rule: HHS stated that the low-income SEP played a significant role in allowing fraudulent enrollments that made headlines in 2024,⁸ and is potentially resulting in adverse selection, with people waiting until they’re sick to enroll in coverage.⁹

2. DACA recipients lose eligibility for coverage

Who’s affected: HHS estimates that 10,000 DACA recipients will lose Marketplace coverage as a result of this rule, and 1,000 people will lose Basic Health Program (BHP) coverage.¹⁰ DACA recipients became eligible for Marketplace coverage in November 2024, but access to enroll in Marketplace plans was soon revoked in 19 states that sued to prevent DACA recipients from enrolling.¹¹ DACA recipients in the rest of the country have continued to be eligible, but that will end in August 2025.

What changes: Deferred Action for Childhood Arrivals (DACA) individuals who are currently enrolled in the Marketplace will be disenrolled as of August 25, 2025.¹² Under the same rule DACA recipients will also become ineligible for BHP coverage because they will no longer be considered “lawfully present” for the purpose of accessing Marketplace or BHP coverage, although only Minnesota and Oregon operate BHPs.

3. Stricter income verification for Marketplace applications

Who’s affected: Applicants with income mismatches or missing IRS data.

What changes: Marketplace applicants will need to provide proof of household income if the applicant attests to an income that doesn’t match the information the exchange gets from its trusted data sources (such as the Internal Revenue Service).¹³

This will include scenarios in which there are inconsistencies between what’s attested and what the Marketplace obtains from trusted data sources, such as the IRS, as well as scenarios in which the IRS doesn’t have tax return data on file for the applicant. It will also apply to situations in which the applicant attests to having a household income of at least 100% of the federal poverty level, but the exchange’s data sources indicate that’s not the case. In other words, the data sources show that the applicant is potentially in the coverage gap, but the applicant is attesting that they aren’t. The applicant will need to provide proof of their income to qualify for Marketplace financial assistance.

The final rule also permanently removes the current automatic 60-day extension to the regular 90-day window that applicants are given to provide requested income documentation.¹⁴

Permanent change? This rule change is temporary – through the end of 2026.¹³

4. Required payment of new coverage premiums if applicant has past-due premiums

Who’s affected: Enrollees who owe past-due premiums to an insurer and submit an application for a new policy with that insurer.

What changes: In this situation, the insurer will be allowed to add the past-due premium to the amount the applicant must pay to effectuate the new policy, as long as this is allowed under state law.¹⁵ If the applicant doesn’t pay the past-due premium, the insurer will be allowed to refuse to effectuate the new policy.

4 changes effective for enrollment in 2026 health plans

Open enrollment for 2026 coverage begins November 1, 2025. The following changes will apply to 2026 plans and/or the enrollment process that starts in November 2025:

1. Higher maximum out-of-pocket limits

Who’s affected: All Marketplace plan enrollees.

What changes: Starting in 2026, the new rule finalizes a methodology change for how maximum out-of-pocket limits are calculated. The result is that the highest allowable out-of-pocket limit for a single individual will be $10,600 in 2026.¹⁶

Under the previous methodology, the Biden administration had finalized a 2026 maximum out-of-pocket limit of $10,150, but that has been replaced by the new limit in this final rule.¹⁶

Impact: Higher out-of-pocket costs and less generous premium subsidies. Because the IRS uses the same premium indexing methodology to determine the percentage of income that Marketplace enrollees pay in after-subsidy premiums, the new methodology will also have the effect of reducing premium subsidies. This is because it will increase the percentage of income that people pay in after-subsidy premiums.¹⁷

2. $5 minimum premium for auto-renewed $0 premium plans

Who’s affected: Auto-renewed enrollees in $0 premium plans on HealthCare.gov. Although auto-renewal is not a consumer’s best option (it’s better to actively compare plan choices each year), it’s widely used. During the open enrollment period for 2025 coverage, nearly 20.2 million people renewed their Marketplace coverage, and 10.8 million of those people used auto-renewal.¹⁸

What changes: Under the new rules, if a person is enrolled in a $0 premium plan (meaning their premium subsidy covers the entire premium) and relies on auto-renewal for 2026, they will not have $0 premium coverage in 2026 until they reconfirm their eligibility information in their Marketplace account. Instead, they will have a minimum net premium of at least $5/month.¹⁹

Duration: This rule change is temporary, just for the 2026 plan year¹⁹ and does not apply to state-run exchanges.²⁰

But H.R.1, the budget bill that was enacted on July 4, 2025 (known as the One Big Beautiful Bill Act), effectively calls for Marketplace auto-renewal to end altogether, starting with the 2028 plan year (the open enrollment period in the fall of 2027). From that point on, Marketplace enrollees will have to verify their ongoing eligibility for coverage and premium subsidies each year. Marketplaces will have the option to rely on automatic verification protocols for confirming enrollee information, in cases where it’s available via the Marketplace’s trusted data sources.²¹ ²² ²³

3. Bronze-to-Silver auto-renewal banned

Who’s affected: Marketplace enrollees with Bronze plans who are eligible for cost-sharing reductions (CSR) and let their coverage auto-renew.

What changes: The final rule permanently removes an auto-renewal protocol that HealthCare.gov adopted in 2024, allowing the Marketplace to switch a consumer from a Bronze plan to a Silver plan in some circumstances.

Impact: Enrollees may miss out on CSR unless they take action.

Details: Under the existing guidance, if an applicant is eligible for CSR, enrolled in a Bronze plan, and a Silver plan is available in the same product (HMO, PPO, etc.), with the same provider network, and with equal or lesser after-subsidy premiums, the exchange can auto-renew the enrollee into the Silver plan. This allows the enrollee to take advantage of their CSR benefits, which are only available on Silver plans.

The final rule prohibits this protocol, starting with the 2026 plan year. Instead, the auto-renewal will keep the enrollee in their existing plan if it continues to be available.²⁴

State-run exchanges “may retain their flexibility regarding their re-enrollment hierarchies at the discretion of the Secretary of Health and Human Services.” So a state-run exchange can seek HHS approval for a different approach to auto-renewal protocols.²⁴

4. Pre-enrollment SEP eligibility verification

Who’s affected: Special enrollment period applicants in states with exchanges that use HealthCare.gov for enrollment.

What changes: In recent years, HealthCare.gov applicants using a SEP have only been required to provide proof of their SEP eligibility if the qualifying life event was the loss of other qualifying coverage.²⁵ The final rule removes that limitation, allowing pre-enrollment eligibility verification for any qualifying life event.

The exchange will be required to conduct pre-enrollment SEP eligibility verification for at least 75% of new SEP enrollments.²⁶

Permanent? No. This requirement will be in place only for the 2026 plan year.²⁷

All states? The proposed rule called for this to apply nationwide, but it was only finalized for states that use HealthCare.gov.²⁸ State-run exchanges will continue to have the option to verify applicants’ SEP eligibility or not (some already do so, while others do not).²⁹

Changes effective for enrollment in 2027 health plans

Shorter open enrollment period

Who’s affected: Almost all Marketplace enrollees.

What changes: HHS had initially proposed a shorter open enrollment period starting in the fall of 2025, but the final rule pushes this out until the fall of 2026.³⁰

So, the open enrollment period for plan year 2026 begins on November 1, 2025 and will continue through January 15, 2026 in most states. State-run exchanges will have the option to extend it even later than that, which several have historically done.

But starting in the fall of 2026, and for future years, open enrollment will be shorter:

In states that use gov, it will run from November 1 to December 15.
States that run their own exchanges will have the option to extend open enrollment, but only within certain parameters:
- It must begin no later than November 1
- It can’t continue past December 31
- It can’t last longer than nine weeks.

All policies selected during open enrollment will take effect January 1.³¹

As is already the case, the open enrollment period will continue to apply both on-exchange and off-exchange.³²

Why are some of the rule’s changes temporary?

HHS notes that the decision to make some of the rules temporary is due largely to the fact that the current premium subsidy enhancements are scheduled to sunset at the end of 2025. This will result in smaller premium subsidies and fewer people eligible for $0 premium plans, which HHS believes will mitigate “improper and fraudulent enrollment concerns.”³³

But it’s also noteworthy that most of the provisions in the final rule were also incorporated (permanently) in the budget reconciliation bill passed by the U.S. House in May 2025, and some of them were in the Senate’s version that was ultimately enacted in July 2025²¹ ³⁴ ²²

If the final rule made all of its provisions permanent, Congressional Republicans would not have been able to claim any tax savings from incorporating those changes into their budget bill, as the changes would already have been made via regulations.²¹

But for rules that sunset at the end of 2026, lawmakers might be able to claim budgetary savings for 2027 and subsequent years, since the budget bill incorporated some of the same provisions but on a longer-term basis. The budget bill includes a combination of measures that would increase federal spending and others that will decrease federal spending; reductions in federal spending are counted as budgetary savings when determining the total economic impact of the bill.²¹

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

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