Welcome back to our second article that continues our analysis of the “Big, Beautiful Bill” and its changes and agent impacts to the ACA world. You can see our first article and the KFF article that discusses this in depth, too.
Here are more items in the bill that agents need to know about:
Verifying personal information (effective January 1, 2026)
- If household data isn’t available from the Treasury Department, ACA enrollees must provide documents verifying changes in household income and family size.
- A complete income verification by the ACA Exchange is required when all of the following conditions are true:
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- An individual attests to being subsidy-eligible
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- Government and third-party data suggest an individual’s income is lower than needed to qualify for a subsidy
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- The individual isn’t Medicaid eligible.
- The automatic 90-day extension for enrollees to verify their household income is eliminated.
- Income, immigration status, health coverage status, place of residence, family size, and any other information the Secretary of Health and Human Services deems necessary must be verified before coverage begins. Prospects cannot receive premium tax credits or CSRs until they verify this information, effectively ending auto-renewals.
Opportunity for Agents
- Increase your technology platform capabilities to include AI automation to reach ACA clients regarding these documents confirming family size and household income.
- Emphasize with ACA clients that document submissions are not extended and that they must meet deadlines to keep their applications active.
Filing and Reconciling (effective January 1, 2026)
Enrollees receiving any premium tax credit must file and reconcile their premium tax credits annually. Failure to do so will lead to ineligibility for premium tax credits.
Opportunity for Agents
- Increase your technology platform capabilities to include AI automation to remind ACA clients of this requirement.
- Finding tax return resources to partner with to assist your ACA clients on this may be an excellent value-add for agents to consider.
Recapture of Excess Premium Tax Credits (effective taxable years beginning after December 31, 2025)
It requires all premium tax credit recipients to repay the full amount of any excess, regardless of their income.
Opportunity for Agents
Increase your technology platform capabilities to include AI automation to remind ACA clients of this requirement and to update any income change for their household with the Exchange as soon as it happens.
Premium Underpayments and Effectuation of Coverage (effective for plan years on or after January 1, 2026)
- Insurers can require enrollees to pay their first month’s premium in full to effectuate coverage.
- Insurers can require the full premium to be paid each month to retain coverage.
- Permits insurers to require payment for the first month’s premium and any unpaid, past-due premiums before effectuating coverage.
Opportunity for Agents
- Inform your ACA clients who enroll on ACA plans that utilize one or more of these capabilities of these changes at the time of enrollment.
- Schedule ongoing follow-ups using automation tools to remind clients of these requirements moving forward so they can work to avoid them.
Automatic Re-enrollment (effective January 1, 2026)
Requires enrollees with $0 premium after-tax credits who are automatically reenrolled in Marketplace coverage to proactively verify their ongoing eligibility for a $0 plan or face a $5 monthly reduction in their tax credits until they confirm their eligibility.
Opportunity for Agents
Set automation reminders for your $0 Premium clients to receive about verifying their eligibility with the Marketplace. If a client falls out of compliance, contact them directly, walking them through what they must do, maybe even as they do it with you on the phone.
Prohibits Coverage of Gender Affirming Care as an Essential Health Benefit (EHB) (effective January 1, 2027)
- Prohibits “coverage of gender transition procedures,” including puberty blockers, hormone treatment, and surgery, as an EHB.
- This may also apply to other plans subject to EHB requirements, such as non-grandfathered individual and small group plans off the marketplaces and Alternative Benefit Plans impacting Medicaid expansion adults.
Opportunity for Agents
- Not a concern until January 1, 2027.
Limitation on Use of CSR Funds for Abortions (effective January 1, 2026)
CSR funds can’t be used for health plans covering abortion services except if abortion is necessary to save the mother’s life or if the pregnancy results from an act of rape or incest.
Opportunity for Agents
Inform any client who has discussed with you the possible need for coverage of this provision and what other options are available to the client for covering the cost of this healthcare service.
At this time, Agility cannot confirm if these provisions will continue in the bill being approved by the U.S. Senate or in the final bill passed by both the U.S. House and U.S. Senate. We will keep you informed on the latest news about this bill in our blogs.
Sebastian Alcantara, our ACA and ICHRA product specialist, is here to help you with any questions about these changes and the opportunities they present to agents. Contact Agility Producer Support at (866) 590-9771 or email support@enrollinsurance.com for answers to any insurance questions. Agility can also add you to our free weekly email list for tips and vital information!
Our next article next Friday will cover the “Big, Beautiful Bill” changes and agent impacts on Medicare.
