April 9, 2025
On March 10, CMS announced a proposed rule impacting the Affordable Care Act (ACA) Marketplaces and health insurance brokers, agents, and issuers. The 2025 Marketplace Integrity and Affordability Proposed Rule includes several impactful proposals centered around eligibility, enrollment, and coverage intended to address improper enrollments in Marketplace coverage and reduce improper federal spending on advanced premium tax credits (APTCs).
Notably the rule would eliminate the special enrollment period for persons with annual household incomes below 150% of the federal poverty level – a position Cigna has advocated for to reduce anti-selection and stabilize the Marketplaces. The bulk of CMS’s proposals are designed to tighten eligibility and enrollment standards in Marketplaces: a shorter open enrollment period, more stringent income verification process, stricter premium payment rules, and stricter agent/broker oversight standards.
CMS also proposes to prohibit carriers from providing coverage for sex-trait modification as an essential health benefit, which likely conflicts with certain state laws that require coverage of gender-affirming care. Additionally, CMS proposes to amend eligibility rules to exclude Deferred Action for Childhood Arrivals (DACA) recipients from APTC eligibility. Cigna is working with impacted business teams to develop comments by the mid-April deadline.
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