Breaking News – The CMS Marketplace Compliance Guidance Presentation Agents and Brokers Must Read and Use

On June 25, the Centers for Medicare and Medicaid Services (CMS) published its new rules. Referred to as the Patient Protection and Affordable Care Act (PPACA), Marketplace Integrity and Affordability Final Rule, this rule is effective as of August 25.

Here is the CMS presentation on the rule. Agility provides a summary of the final rule below, along with its impact on ACA insurance agents.

Satisfaction of Debt for Past-Due Premiums

• Repeals the rule that prohibits ACA carriers from denying coverage due to unpaid past-due premiums.

• If applicable and state laws allow, carriers may require payment of both the initial and past-due premium amounts to start new coverage.

Opportunity For Agents

• Closely monitor clients’ monthly premium payments to promptly notify them of any missed payments.

• Use automated systems to send clients reminders to pay their monthly premiums on time.

Eliminating Gross Premium Percentage-Based and Fixed-Dollar Premium Payment Thresholds

• Eliminates the fixed-dollar and gross percentage-based premium payment thresholds, allowing carriers to use only the net percentage-based threshold.

• It will end at the end of 2026.

Opportunity For Agents

• This could potentially lower disenrollments as clients are more aware of their enrollment and clearer about their premiums and other responsibilities.

• Regularly use automated systems to send phone, text, or email reminders to clients, including their monthly premium amount and other important plan details.

Standardizing the Annual OEP for Individual Market Coverage

This change is effective with the OEP for PY 2027 and applies to on- and off-marketplace individual market exchanges. Allows all Exchanges the flexibility to set their own OEPs within defined timing and duration.

Each OEP must:

• start no later than November 1

• end no later than December 31

• not exceed nine (9) calendar weeks

• and have all OEP enrollments begin on January 1. 

• Federal platform exchanges’ OEP will be November 1 through December 15, beginning with the OEP for plan year 2027. 

Opportunity For Agents

• ACA prospects have a greater sense of urgency to make choices quickly.

• Agents need sharper focus, better organization, and proactive communication to achieve higher conversion rates. This urgency generates more ACA sales activity and revenue.

• On January 1, 2027, ACA agents should contact their ACA clients, the ones with supplemental products, to address coverage gaps (vision, dental), high cost shares (hospital indemnity), and any other issues your clients need to address.

Affirming the Previous Interpretation of the “Lawfully Present” Definition

DACA recipients can no longer enroll in ACA coverage or in Basic Health Plan (BHP) coverage in states that operate a BHP, including APTC, premium tax credits, and cost-sharing reductions.

Opportunity For Agents

• Inform any DACA clients about their loss of eligibility and work with them to find group coverage and cooperative health coverage they may access in their area.

• If none of the above options are available, investigate fixed indemnity and other supplemental policy options.

Failure to File and Reconcile (ends at the end of 2026)

• Reinstates the 2015 policy requiring Exchanges to declare an individual ineligible for APTC if they (or their tax filer) fail to file their federal income taxes and reconcile APTC for one year.

• Under this change, a marketplace must declare a tax filer ineligible for APTC if:

• • CMS notifies the marketplace that the tax filer or someone in their household received APTC for a prior year, that the tax data confirms, and

• • The tax filer or someone in their household didn’t file a federal income tax return and didn’t reconcile the APTC for that year.

• This will end at the end of 2026.

Opportunity for Agents

• Enhance your capabilities to send automated reminders to ACA clients regarding this requirement. 

• Providing tax return resources as a partner to assist your ACA clients can be a valuable add-on for agents.

60-Day Extension to Resolve Income Inconsistency

Removes the automatic 60-day extension of the required 90-day period for resolving income inconsistencies.

Opportunity for Agents

• Remind clients to verify their incomes within the 90-day window to maintain coverage.

• Utilize the full length of the verification period to periodically remind clients to fix any income inconsistencies.

Income Verification When Data Sources Indicate Household Income Less than 100% of the FPL

• Finalizes the process for Marketplaces to verify household income when actual IRS reports show less than 100% of the FPL annual household income and doesn’t match the annual household income attested to by the enrollee.

• It will end at the end of 2026.

Opportunity For Agents

• Communicate immediately with clients in this situation. 

• Partner with tax professionals to assist tax filers and offer assistance for your clients to file their taxes.

Income Verification When Tax Data is Unavailable

• Removes enrollee self-attestation of projected annual household income when no tax returns are available. Exchanges must use available, trusted data to verify household income, and applicants must submit documentation to substantiate their household income.

• It will end at the end of 2026.

Opportunity For Agents

• Communicate immediately with clients in this situation to help resolve the issue for their benefit.

• Partner with tax professionals to assist your clients.

Requiring a $5 Premium Responsibility

• Requires marketplaces on the federal platform to automatically verify that no-premium clients using the APTC are eligible for the full APTC. 

• Any client who does not confirm APTC eligibility before re-enrolling with no premium will be required to re-enroll with a $5 monthly premium, effective in PY 2026.

• When clients confirm or update their information, the $0 monthly premium will be restored if they’re eligible after applying for the APTC. These clients will receive a tax refund or reduction when they file and reconcile their APTC on their federal income tax return.

• This doesn’t apply to state marketplaces.

• It will end at the end of 2026.

Opportunity For Agents

• Regularly communicate with APTC no-premium clients to remind them to confirm their eligibility for the no-premium APTC before their re-enrollment date.

• Work with clients who don’t confirm their eligibility and therefore move to the $5 monthly APTC premium, to quickly confirm eligibility for the no-premium APTC premium amount.

Re-enrollment Hierarchy Standards

• Repeals marketplaces automatically re-enrolling CSR-eligible bronze QHP enrollees in a silver QHP if the silver QHP is the same product, has the same provider network, and has a lower or equivalent net premium as the bronze QHP plan.

• State marketplaces can continue to design and conduct their own annual eligibility redetermination process.

Opportunity For Agents

Identify clients you believe may be in this situation and provide them with information about the possible opportunity to transition to a silver QHP plan.

Monthly SEP for APTC-Eligible Individuals with Household Incomes at or Below 150% of FPL

• Eliminates the year-round, Low-Income Special Election Period (SEP) enrollment opportunity for people with incomes up to 150% of the federal poverty level, effective 60 days after enacting the rule.

• HHS also clarifies that a change in income is not an Exceptional Circumstance under 45 CFR 155.420(d)(9), so marketplaces may not offer income-based SEPs under this authority.

• This provision only applies to the year 2026.

Opportunity For Agents

• Higher quality clients and better retention of ACA clients with regular, proactive communication. 

• Develop a robust supplement product portfolio to support ACA clients with higher cost-sharing and premiums. 

• Medicare and ICHRA are markets to add to your portfolio to broaden your product reach and client base.

All Marketplaces Conducting Eligibility Verification for SEPs

• Requires marketplaces on the federal platform to conduct pre-enrollment SEP eligibility verification for PY 2026. This requirement does not currently apply to state marketplaces.

• This requirement ends for marketplaces on the federal platform at the end of 2026.

Opportunity For Agents

• Learn the details of all SEP requirements so you can execute these SEPs flawlessly for clients. 

• Develop your product portfolio to address client needs during the year that can’t use SEPs to enroll in marketplace plans, such as short-term medical and fixed indemnity.

Marketplaces Conducting Eligibility Verification for 75% of New Enrollments through SEPs

• Requires marketplaces on the federal platform to verify a minimum of 75% new SEP enrollments for PY 2026. This requirement does not currently apply to state marketplaces.

• This requirement ends for marketplaces on the federal platform at the end of 2026.

Opportunity For Agents

Prepare to address any issues identified in rejected SEP enrollments as quickly as possible to minimize client impact. Designating a dedicated resource to focus on this issue may be a good idea for agents.

Prohibiting Coverage of Specified Sex-Trait Modification Procedures as an EHB

• Effective at the beginning of the 2026 plan year, “specified sex-trait modification procedures” are no longer an Essential Health Benefit (EHB) that non-grandfathered EHB plans must cover in 2026 health coverage.

• The Final Rule does clarify that certain services are not “specified sex-trait modification procedures.”

• Non-grandfathered EHB plans can choose to cover “specified sex-trait modification procedures.”

Opportunity for Agents

Inform clients interested in this health benefit which available plans cover “specified sex-trait modification procedures.” 

Premium Adjustment Percentage (PAPI) Methodology

• Establishes a premium growth measure capturing premium changes in both the individual and employer-sponsored insurance markets beginning in 2026.

• Finalizes the 2026 maximum annual limitation on cost sharing, reduces the maximum annual limitation on cost sharing, and requires the use of the final premium adjustment percentage methodology for contribution percentage calculations.

Opportunity for Agents

Agents need a robust supplemental product portfolio that addresses high-cost shares, such as hospital indemnity, to help your ACA clients manage future cost increases.

Verifying Income Information for Premium Subsidies (effective January 1, 2026)

ACA clients receiving a premium subsidy must verify their household income to qualify. 

Opportunity for Agents

Enhance automated communication capabilities to deliver these documents to ACA clients who confirm household income. 

De Minimis Thresholds

• Widens the de minimis ranges to +2/-4 percentage points for all individual and small group market plans subject to the AV requirements under the EHB package.

• Expanded bronze plans will have a de minimis range of +5 to -4 percentage points.

• Removes from the conditions of QHP certification the de minimis range of +2/0 percentage points for individual market silver QHPs and specifies a de minimis range of +1/-1 percentage points for income-based silver CSR plan variations.

Opportunity For Agents

• Agents may see more plan design diversity within each metal tier and coverage level, affecting deductibles, copays, and out-of-pocket limits.

• Tighter AV ranges for Silver Plans should result in less benefit fluctuation and more predictable coverage.

• Agents should be able to tailor coverage more easily to meet a client’s needs.

Termination of Agent, Broker, Web-Broker Marketplace

Adopts a “preponderance of the evidence” standard of proof on issues of fact for HHS to assess whether an agent, broker, or web-broker’s Marketplace Agreement should be terminated due to noncompliance with applicable HHS rules and the terms of their Marketplace Agreements.

Opportunity for Agents

Enhance your compliance resources to ensure adherence to the applicable HHS rules and terms referenced above. 

Mike Berglund, our ACA product specialist, will be available to answer any questions you may have about the rule changes and the opportunities they present for agents. Mike can also refer you to our Medicare and Supplement product specialists for any questions about these products.

Contact Agility Producer Support at (866) 590-9771 or email support@enrollinsurance.com to schedule a meeting or call with Mike or to get answers to any insurance questions. Agility can also add you to our free, weekly email list for tips and vital information!