June 20th, 2025
Rule Cracks Down on Improper ACA Enrollments, Protects Patient and Taxpayer Dollars, and Restores Marketplace Integrity
The Centers for Medicare & Medicaid Services (CMS) is finalizing a major rule that will lower individual health insurance premiums by approximately 5% on average. It is also projected to save taxpayers up to $12 billion in 2026 by combating the surge of improper enrollments in the Affordable Care Act (ACA) Exchanges, reining in wasteful federal spending, and refocusing on making health insurance markets more affordable and sustainable for hardworking American families. The 2025 Marketplace Integrity and Affordability Final Rule restores oversight, strengthens accountability, and ensures taxpayer dollars are used only for those who are truly eligible.
“We are strengthening health insurance markets for American families and protecting taxpayer dollars from waste, fraud, and abuse,” said U.S. Health and Human Services Secretary Robert F. Kennedy, Jr. “With this rule, we’re lowering marketplace premiums, expanding coverage for families, and ensuring that illegal aliens do not receive taxpayer-funded health insurance.”
Improper ACA enrollments, enabled by weakened verification processes and expanded premium subsidies, have triggered widespread fraud. Research shows that in 2024 alone, an estimated 5 million people may have been improperly enrolled, costing taxpayers as much as $20 billion[1].
“CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it,” said CMS Administrator Dr. Mehmet Oz. “This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline.”
CMS is taking swift and targeted action to address improper enrollments and deliver better coverage for working families:
Repealing the monthly special enrollment period (SEP) for individuals with projected household incomes at or below 150% of the federal poverty level, a policy used by some agents and brokers to improperly enroll ineligible consumers and perform unauthorized plan switching to gain commissions;
Requiring income verifications to ensure people qualify for the premium subsidies they receive;
Conducting eligibility verifications for the majority of enrollments through SEPs, closing loopholes that allowed people to wait to enroll until they needed care and improving the risk pool, which can lower premiums for middle-class families not receiving subsidies;
Reducing advanced payments of the premium tax credit (APTC) by $5 a month for individuals who are auto re-enrolled in fully-subsidized plans without eligibility verification, ensuring consumers are aware of and engaged in their health coverage; and
Standardizing the Annual Open Enrollment Period starting with the 2027 plan year so that it ends by December 31 for all health insurance exchanges, encouraging people to maintain year-round health coverage rather than waiting until they get sick to enroll, which helps keep insurance affordable for everyone.
A number of the policies CMS is finalizing are temporary measures to immediately tamp down on improper enrollments and the improper flow of federal funds. These policies will sunset at the end of the 2026 plan year. This approach will help to ensure that eligibility verification processes work efficiently and allow qualified enrollees to access ACA Exchange coverage without fear of coverage gaps or surprise tax liabilities resulting from the improper actions of third parties.
CMS is taking further action to ensure federal subsidies for coverage through ACA Exchanges only support the statutory requirements and goals of the ACA:
Prohibiting federal subsidies from being used to help cover the cost of specified sex-trait modification procedures to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex; and
Reinstating HHS’ longstanding 2012 interpretation of “lawfully present” to exclude Deferred Action for Childhood Arrivals (DACA) recipients from eligibility and enrollment in ACA Exchange coverage and Basic Health Program (BHP) coverage in States that elect to operate a BHP, including APTC, premium tax credits, and cost-sharing reductions.
The final rule can be downloaded from the Federal Register at https://www.federalregister.gov/d/2025-11606 back...
The Centers for Medicare & Medicaid Services (CMS) is finalizing a major rule that will lower individual health insurance premiums by approximately 5% on average. It is also projected to save taxpayers up to $12 billion in 2026 by combating the surge of improper enrollments in the Affordable Care Act (ACA) Exchanges, reining in wasteful federal spending, and refocusing on making health insurance markets more affordable and sustainable for hardworking American families. The 2025 Marketplace Integrity and Affordability Final Rule restores oversight, strengthens accountability, and ensures taxpayer dollars are used only for those who are truly eligible.
“We are strengthening health insurance markets for American families and protecting taxpayer dollars from waste, fraud, and abuse,” said U.S. Health and Human Services Secretary Robert F. Kennedy, Jr. “With this rule, we’re lowering marketplace premiums, expanding coverage for families, and ensuring that illegal aliens do not receive taxpayer-funded health insurance.”
Improper ACA enrollments, enabled by weakened verification processes and expanded premium subsidies, have triggered widespread fraud. Research shows that in 2024 alone, an estimated 5 million people may have been improperly enrolled, costing taxpayers as much as $20 billion[1].
“CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it,” said CMS Administrator Dr. Mehmet Oz. “This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline.”
CMS is taking swift and targeted action to address improper enrollments and deliver better coverage for working families:
Repealing the monthly special enrollment period (SEP) for individuals with projected household incomes at or below 150% of the federal poverty level, a policy used by some agents and brokers to improperly enroll ineligible consumers and perform unauthorized plan switching to gain commissions;
Requiring income verifications to ensure people qualify for the premium subsidies they receive;
Conducting eligibility verifications for the majority of enrollments through SEPs, closing loopholes that allowed people to wait to enroll until they needed care and improving the risk pool, which can lower premiums for middle-class families not receiving subsidies;
Reducing advanced payments of the premium tax credit (APTC) by $5 a month for individuals who are auto re-enrolled in fully-subsidized plans without eligibility verification, ensuring consumers are aware of and engaged in their health coverage; and
Standardizing the Annual Open Enrollment Period starting with the 2027 plan year so that it ends by December 31 for all health insurance exchanges, encouraging people to maintain year-round health coverage rather than waiting until they get sick to enroll, which helps keep insurance affordable for everyone.
A number of the policies CMS is finalizing are temporary measures to immediately tamp down on improper enrollments and the improper flow of federal funds. These policies will sunset at the end of the 2026 plan year. This approach will help to ensure that eligibility verification processes work efficiently and allow qualified enrollees to access ACA Exchange coverage without fear of coverage gaps or surprise tax liabilities resulting from the improper actions of third parties.
CMS is taking further action to ensure federal subsidies for coverage through ACA Exchanges only support the statutory requirements and goals of the ACA:
Prohibiting federal subsidies from being used to help cover the cost of specified sex-trait modification procedures to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex; and
Reinstating HHS’ longstanding 2012 interpretation of “lawfully present” to exclude Deferred Action for Childhood Arrivals (DACA) recipients from eligibility and enrollment in ACA Exchange coverage and Basic Health Program (BHP) coverage in States that elect to operate a BHP, including APTC, premium tax credits, and cost-sharing reductions.
The final rule can be downloaded from the Federal Register at https://www.federalregister.gov/d/2025-11606 back...
