The ruling affects communities already facing structural barriers, such as low-income adults, by raising the maximum out-of-pocket costs to 15% above 2025 levels. It eliminates eligibility for DACA recipients and increases documentation requirements for consumers with incomes below 100 percent of the federal poverty level (FPL). The rule shortened the open enrollment period, ended the low-income Special Enrollment Period, and tightened verification requirements for those earning less than 150% of the FPL. It also ends the Advanced Premium Tax Credit (APTC) for individuals who haven't filed a tax return in the past two years. The Centers for Medicare & Medicaid Services (CMS) and independent analysts estimate that up to 2 million people could lose Marketplace coverage due to these changes. Most of the loss will occur among lower-income households. Additionally, the rule terminates gender-affirming care unless required by state law.
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A legally binding directive issued by a federal agency to implement, interpret, or enforce laws passed by Congress. Rules go through a formal rulemaking process, including public notice and comment, before taking effect.
Who It Impacts: Businesses, organizations, and individuals subject to federal agency oversight. For example, a new environmental regulation could impact manufacturing companies, or a healthcare rule could affect providers and insurers.
Who Is Not Impacted: People or entities not subject to the agency’s jurisdiction. For example, a rule by the Environmental Protection Agency (EPA) regulating industrial emissions would not directly impact a restaurant owner unless they operate in an affected industry.
Summary
The 2025 Marketplace Integrity and Affordability Proposed Rule revises Affordable Care Act (ACA) Marketplace eligibility and enrollment by focusing on program integrity. It impacts enrollment and eligibility, income verification and tax reconciliation, plan and benefit design, reenrollment, premium requirements, and policies that affect LGBTQIA+ and rural communities, immigrants, and individuals with Deferred Action for Childhood Arrivals (DACA) status.
