Final Rule:

2025 Marketplace Integrity and Affordability

The Centers for Medicare & Medicaid Services (CMS) finalized a rule that may have a significant impact on individual health coverage available through public Marketplaces beginning in 2026. Amongst other things, the rule shortens the open enrollment window to Nov. 1 – Dec. 15 for federally-run Marketplaces and requires that no Marketplace offer an open enrollment longer than Nov. 1 – Dec. 31; increases eligibility verification and reconciliation requirements for premium tax credits; and adjusts the methodology used to set premiums. It is estimated that some of these changes may result in lower overall premiums and will reduce improper enrollments and payment of premium tax credits. However, the changes might also make it more difficult to obtain individual coverage and qualify for premium tax credits through public Marketplaces.

In addition to the Marketplace changes, the rule prohibits individual and small group fully-insured plans from providing coverage for specified sex-trait modification procedures as an essential health benefit and provided the 2026 out-of-pocket (OOP) maximums for ACA group health plans. The 2026 maximum OOP is $10,600 for self-only coverage and $21,200 for other than self-only coverage (currently $9,200 and $18,400 for 2025).  

A link to the final rule fact sheet can be found here.

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