health insuraNce news

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As you may have heard in the news, federal laws are changing for the Affordable care Act marketplaces. Below is a high-level summary of the expected changes. Please know that many of these provisions are temporary in nature, and are subject to changes.

Open Enrollment Period

For 2026: Nov 1st 2025-Jan 15th 2026

From 2027 onwards: Nov1st to Dec 15th

Special Enrollment Periods(SEP)

Low-Income SEP: Beginning August 25, 2025, members at or below 150% FPL will no longer have the ability to change plans and/or issuers monthly, across all Exchanges.

Income Verifications

Beginning Aug. 25, 2025, all Exchanges are required to generate annual income Data Matching Issues (DMIs) in circumstances when applicants report a household income above 100% FPL, but federal data sources show annual income less than 100% FPL. 

Income Verification When Tax Data is Unavailable 

Beginning Aug. 25, 2025, Exchanges can no longer accept a consumer’s self-attestation of projected annual household income when the IRS cannot verify it due to lack of tax return data. Instead, Exchanges must verify household income using other trusted data sources and follow the full alternative verification process. 

Failure to File and Reconcile (FTR)

Beginning in the fall of 2025 for the 2026 OEP, all Exchanges are required to deem enrollees ineligible for APTC after one tax year of FTR status, instead of the current two year flexibility. 

60-Day Extension to Resolve DMIs - Beginning Aug. 25, 2025, the automatic 60-day extension has been removed for members to resolve a DMI(s). Consumers can still request a 60-day extension if they demonstrate that a good faith effort has been made to obtain the required documentation during the 90-day period. 

Marketplaces Conducting Eligibility Verification for 75% of New Enrollments through SEPs Beginning with Plan Year 2026, all ACA exchanges will verify at least 75% of new SEP enrollments for those not already enrolled in Exchange coverage. If eligibility cannot be verified, the Exchange must terminate enrollment or cancel the pended plan selection, depending on the verification process. 

All Marketplaces Conducting Eligibility Verification for SEPs  - Beginning with Plan Year 2026, pre-enrollment verifications have been reinstated for all categories of SEPs.

Premiums on the ACA Marketplaces

Enhanced APTC(eAPTC) and APTC

Enhanced APTC(eAPTC) is a ‘temporary expansion’ of the regular APTC under the American Rescue Plan Act(ARPA) of 2021, and was further extended by the Inflation Reduction Act(IIRA). This provided additional subsidies to some members.

APTC is the original subsidy program under the ACA. 

The eAPTCs will expire Dec. 31, 2025. Marketplace members will no longer receive eAPTCs in Plan Year 2026, which could result in an increase of 2026 monthly premium payments. Please note: The original APTCs as part of the Affordable Care Act remain in place.

Requiring $5 Premium Responsibility - Beginning Plan Year 2026, members currently enrolled in a fully subsidized 2025 plan($0 premium plans) will be re-enrolled into the same plan with a $5 monthly premium responsibility until they update their application to confirm Advanced Premium Tax Credit (APTC) eligibility and re-confirm their plan selection. For PY2026, a re-enolling member who continues to be eligible for a $0 premium must submit their application for updated eligibility determination and re-confirm plan selection by Dec. 15, 2025

Satisfaction of Debt for Past-due Premiums  - Beginning Aug. 25, 2025, consistent with applicable state law, plans will be allowed to attribute a premium payment for new coverage to past-due premiums owed for coverage under the same issuer before effectuating enrollment for the new policy.

ELIGIBILITY AND COVERAGE 

Affirming Previous Interpretation of “Lawfully Present” Definition (Deferred Action for Childhood ArrivalsDACA)  - Beginning Aug. 25, 2025, DACA recipients are excluded from the definition of "lawfully present" for purposes of QHP enrollment, APTC and CSR eligibility, and Basic Health Program coverage. 

Prohibiting Coverage of Specified Sex-trait Modification Procedures as an EHB (Gender Affirming Care -  Beginning with Plan Year 2026, issuers subject to Essential Health Benefit (EHB) requirements are prohibited from covering specified sex-trait modification procedures as EHB.