By: HUB’s EB Compliance Team

On June 20, 2025, the Centers for Medicare & Medicaid Services (“CMS”), an agency of the Department of Health and Human Services (“HHS”), released the final version of the Marketplace Integrity and Affordability Rule. This final rule revises various existing standards and methodologies in the Affordable Care Act (“ACA”) with a focus on reducing waste, fraud and abuse in the ACA’s eligibility and enrollment systems. Most changes affect access to plans on the exchange and access to subsidies. Some changes go into effect in 2025, and some start in 2026 or later.

Changes Effective August 25, 2025

Many changes of the final rule will go into effect immediately:

  • The special Marketplace enrollment period for low-income individuals is paused. Currently, these individuals have year-round access to enroll in Marketplace plans. This provision is paused until the end of 2026.
  • Requirements for income verification when applying for Marketplace coverage will be more strictly applied. Namely, when an inconsistency exists between the attested income level and the data from sources like the IRS, applicants will need to provide proof of household income. This new restriction will apply through the end of 2026.
  • Deferred Action for Childhood Arrivals (“DACA”) recipients are no longer eligible for Marketplace coverage, and individuals currently enrolled will be disenrolled as of August 25, 2025.
  • The final rule prohibits the coverage of specified sex-trait modification procedures as an Essential Health Benefit (“EHB”).

Changes Effective for 2026 Enrollment or Later (NOTE: Open Enrollment for 2026 begins November 1, 2025)

  • The highest allowable out-of-pocket limit for a single individual Marketplace enrollee will go from $10,160 to $10,600 in 2026.
  • Auto-renewed Marketplace enrollees in $0 premium plans will not have the $0 premium coverage in 2026 unless they reconfirm eligibility. They will instead have a minimum net premium of at least $5/month. This applies only for the 2026 plan year and does not apply to state-run exchanges. NOTE: H.R.1, the “One Big Beautiful Bill Act,” calls for Marketplace auto-renewal plans to end entirely starting in the 2028 plan year.
  • Auto-renewal from a bronze plan to a silver plan if the Marketplace enrollee is eligible for cost-sharing reductions is removed.
  • Marketplace enrollees applying under a special enrollment period must provide eligibility verification for all events, not just loss of other qualifying coverage. This applies only for the 2026 plan year and does not apply to state-run exchanges.
  • Effective for 2027, open enrollment for the Marketplace will go from November 1 to January 15, to November 1 to December 15 (shortening the window by a month).

Employer Takeaways

Any time Marketplace coverage is restricted, either by tightening enrollment rules or changing eligibility parameters, more individuals either go uninsured or, if they are eligible, enroll in employer-based coverage as an alternative. Accommodating uninsured individuals puts more pressure on the emergency care system, and the financial stability of hospitals and other providers.

If you have any questions, please contact your HUB Advisor. View more compliance articles in our Compliance Directory.

NOTICE OF DISCLAIMER
Neither Hub International Limited nor any of its affiliated companies is a law or accounting firm, and therefore they cannot provide legal or tax advice. The information herein is provided for general information only, and is not intended to constitute legal or tax advice as to an organization’s or individual's specific circumstances. It is based on Hub International's understanding of the law as it exists on the date of this publication. Subsequent developments may result in this information becoming outdated or incorrect and Hub International does not have an obligation to update this information. You should consult an attorney, accountant, or other legal or tax professional regarding the application of the general information provided here to your organization’s specific situation in light of your or your organization’s particular needs.