The highly anticipated 2025 CMS Marketplace Proposed Rule offers a glimpse into the Trump administration’s evolving approach to healthcare policy. These latest updates provide important insights into the administration’s priorities and potential impact on the health insurance landscape.
At Agility Insurance Services, we go beyond business—we’re committed to advocating for you where it matters most. Our team actively engages with key legislators in Washington, D.C., and across the states, ensuring that the voices of insurance professionals like you are heard.
Our own Jesse Hendon tackled this subject on the Agility Insurance Podcast,.
But advocacy isn’t just about what we do—it’s about what we can do together. We encourage all agents to take an active role in shaping the future of our industry. Your insights and experiences are powerful! Reach out to your local U.S. House and U.S. Senate representatives to share your perspective and influence the policies that directly impact your work.
You can voice your opinion with CMS on the CMS Rule Comments.
What’s Changing in 2025?
The new proposed rule brings updates that could significantly impact insurers, agents, and consumers. Here’s what you need to know about the key provisions shaping the future of the Affordable Care Act (ACA) Marketplace in 2025.
Debt for Past-Due Premiums
- Issuers may require enrollees to pay past-due premiums before obtaining new coverage.
- Intended to reduce adverse selection and promote continuous coverage.
- It appears this is at the will of the carrier.
Premium Payment Thresholds
- Eliminates fixed-dollar and gross percentage-based thresholds, keeping only net percentage-based thresholds.
- Aims to improve program integrity and prevent improper enrollments.
Open Enrollment Period (OEP) Shortening
- Proposed change: Nov. 1 – Dec. 15 instead of extending into January.
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- This means that as an agent or agency owner, you must become very strategic in your approach to OE. Agility is here to help. Make sure we’re connecting prior to OE to consider renewal rather than attacking new business.
- Seeks to reduce consumer confusion and align with employer-based plans.
Subsidies and Eligibility Verification
- DACA Recipients: Excluded from Qualified Health Plans (QHPs) and subsidies, reversing a 2024 rule
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- This expands on the 12/2024 ruling impacting DACA recipients in 19 states
- Income Verification: Stricter policies to prevent improper APTC allocations.
- Tax Compliance: Reinstates ineligibility for APTC if tax reconciliation is missed for one year (down from two years).
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- We can’t iterate enough to ensure your members are filing their taxes to reconcile against their APTC. Stated income will no longer play, and these rules are making the case. Since ARPA, members haven’t had to reconcile, and 2025 is the first year they must.
Eligibility and Enrollment Changes
- Consumers automatically re-enrolled in $0 premium plans would have to pay a minimum of $5/month unless they actively confirm eligibility.
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- The gist is that members at the $0 premium tier can no longer be passively renewed.
- Removes automatic re-enrollment from bronze to silver plans.
- Tightens eligibility verification for Special Enrollment Periods (SEPs) to prevent unauthorized enrollments.
- The SEP for enrollees under the 150% FPL would be removed.
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- While this ultimately creates a more stable risk pool, it will generate fewer enrollment opportunities for brokers throughout the year.
- 75% SEP Verification
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- Marketplaces now must verify at least 75% of SEP enrollments (FFM & SBE).
Essential Health Benefits (EHBs) Adjustments
- Prohibits sex-trait modification services as an EHB but allows states or insurers to cover them voluntarily.
Cost-Sharing and Plan Design
- Updates the premium adjustment percentage methodology for better alignment with market trends.
- Expands de minimis ranges for actuarial value requirements, giving issuers more flexibility in plan design.
Agent and Broker Accountability
- Introduces a “preponderance of the evidence” standard for terminating agreements due to noncompliance.
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- We’re optimistic this will create a “rules of the game” standard for terminations.
Agility is here to help you with all ACA questions, like how this CMS final rule impacts your ACA world. Contract now with top ACA carriers on our ACA contracting website to maximize your current ACA revenue. Register now for the latest ACA training courses by visiting our events page to improve your ACA revenue.
Contact Agility at (866) 590-9771 or email [email protected] to discuss these ACA contracting and training opportunities. Agility can also add you to our weekly free email list for more tips and other vital information, like updates on the final CMS rules for ACA!
