Health care providers treating patients covered by the Heathcare Marketplace insurance plans created under the Patient Protection and (“ACA”) should prepare for fallout from a new Department of Health and Human Services (“HHS”) Final Rule that tightens subsidy and other eligibility and makes other reforms. Providers should anticipate and begin planning for fallout upon their organizations from the effect of these enrollment and coverage changes impacting their patients.

The 2025 Marketplace Integrity and Affordability Final Rule (“Rule”) reverses Biden Administration rules that loweredrequirements for individuals to receive subsidies to pay costs for purchasing health coverage and eased other requirements for Exchange coverage.

According to the now Trump Administration-led Centers for Medicare & Medicaid Services (“CMS”), improper ACA enrollments enabled by weakened verification processes and expanded premium subsidies triggered widespread fraud. Research shows that in 2024, an estimated 5 million people may have been improperly enrolled, costing taxpayers as much as $20 billion^[1].

To address these concerns, the new Rule:

• 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.

CMS says many changes are “temporary” measures set to sunset at the end in 2026 to immediately tamp down on the outflow of funds 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.

To ensure federal subsidies for coverage through ACA Exchanges only support the statutory requirements and goals of the ACA, CMS also is:

• 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.

CMS says these reforms address “improper enrollments and the improper flow of federal funds implemented during the Biden Administration.

Regardless of the reason and duration of these changes, the Rule will trigger loss or other changes in enrollment or coverage for many patients reliant on the Marketplace for coverage. Health care practices should anticipate and prepare to deal the probable effects of these changes on their practices. While effects may vary, consequences foreseeable from these changes might include

• More uninsured or underinsured patients;
• Care adjustment and transitions by patients experiencing losses or reductions in coverage ;
• Increased demand for cash pay, financing and other special arrangements;
• Declines or delays in patient medication or other care compliance;
• Enhanced accounts receivables and collections issues;
• Lost revenue; and
• More.

Anticipating and planning for the effects of the changes can help health care providers mitigate disruptions from the impending changes.

For More Information Or Help

We hope this update is helpful. For more information about these or other health or other employee benefits, human resources, insurance, or health care legal developments, please contact the author, Cynthia Marcotte Stamer, via e-mail or telephone at (214) 452-8297.

Solutions Law Press, Inc. invites you to receive future updates by registering on our Solutions Law Press, Inc. Website and participating in and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

About the Author

Cynthia Marcotte Stamer is a Martindale-Hubble AV-Preeminent (highest/top 1%) practicing attorney nationally celebrated as a “Top Woman Lawyer,” “Top Rated Lawyer,” and “LEGAL LEADER™” in Health Care Law and Labor and Employment Law; among the “Best Lawyers In Dallas” in “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law recognized for her experience, scholarship, thought leadership and advocacy on health and other employee benefits, insurance, healthcare, workforce, HIPAA and other data and technology and other compliance in connection with her work with health care and life sciences, employee benefits, insurance, education, technology and other highly regulated and performance-dependent clients.

Board certified in labor and employment law by the Texas Board of Legal Specialization and a Fellow in the American College of Employee Benefits Counsel, Ms. Stamer is nationally recognized for her decades of leading edge experience on the design, sponsorship, administration and defense of health and other employee benefit, workforce, insurance, healthcare , data and technology and other operations to promote legal and operational compliance, reduce regulatory and other liability and promote other operational goals.

Along with her decades of legal and strategic consulting experience, Ms. Stamer also contributes her leadership and experience to many professional, civic and community organizations. She currently serves as Co-Chair of the ABA Real Property Trusts and Estates (“RPTE”) Section Welfare Plan Committee, Co-Chair of the ABA International Section International Employment Law Committee and its Annual Meeting Program Planning Committee, Chair Emeritus and Vice Chair of the ABA Tort Trial and Insurance (“TIPS”) Section Medicine and Law Committee, and Chair of the ABA Intellectual Property Section Law Practice Management Committee. She also has served as Scribe for the Joint Committee on Employee Benefits (“JCEB”) annual agency meetings with the Department of Health and Human Services and JCEB Council Representative, International Section Life Sciences Committee Chair, RPTE Section Employee Benefits Group Chair and a Substantive Groups Committee Member, Health Law Section Managed Care & Insurance Interest Group Chair, as TIPS Section Medicine and Law Committee Chair and Employee Benefits Committee and Workers Compensation Committee Vice Chair, Tax Section Fringe Benefit Committee Chair, and in various other ABA leadership capacities. Ms. Stamer also is a former Southwest Benefits Association Board Member and Continuing Education Chair, SHRM National Consultant Board Chair and Region IV Chair, Dallas Bar Association Employee Benefits Committee Chair, former Texas Association of Business State, Regional and Dallas Chapter Chair, a founding board member and Past President of the Alliance for Healthcare Excellence, as well as in the leadership of many other professional, civic and community organizations. She also is recognized for her contributions to strengthening health care policy and charitable and community service resolving health care challenges performed under PROJECT COPE Coalition For Patient Empowerment initiative and many other pro bono service involvements locally, nationally and internationally.

Ms. Stamer is the author of many highly regarded works published by leading professional and business publishers, the ABA, the American Health Lawyers Association, and others. Ms. Stamer also frequently speaks and serves on the faculty and steering committee for many ABA and other professional and industry conferences and conducts leadership and industry training for a wide range of organizations.

For more information about Ms. Stamer or her health industry and other experience and involvements, see http://www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides health care, human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on health care, leadership, governance, human resources, employee benefits, data security and privacy, insurance, and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources including the following recent publications about related emerging developments:

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• Medicare Advantage Plans, Brokers Face Justice Department FCA & Antikickback Suit
• 6/16 Deadline To Recommend On Patient-Centric Technology Design With CMS and ONC
• Health Care Organizations Urged To Strengthen Right Of Conscience Defenses As HHS Opens 2 Right Of Conscience Investigations Within 1 Month Of Opening New Child Chemical Or Surgical Mutilation Whistleblower Portal
• CMS Suspends 8 Quality Improvement Measures
• HHS Harvard University Action & Dear Colleague Letter Clarify Civil Rights Merit-Based Action & DEI Ban
• Nurse Practitioner Likely To Get Lengthy Prison Sentence For Health Care Fraud Conviction

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©️2025 Cynthia Marcotte Stamer. Reprinted by permission pursuant to non-exclusive license to Solutions Law Press.