Apr 03, 2025
Current Administration Proposes Changes to Regulations Governing Insurance Subject to ACA
On March 10, 2025, the Trump administration issued a ‘proposed rule’ amending regulations that govern ACA insurance coverages. Public comments on this Proposed rule are being accepted for consideration until April 11, 2025.
As of the publishing of this article, over 10,500 comments have been received.
The Proposed Rule includes the following:
- Allows insurers to deny coverage to individuals who have past-due premium from prior coverage, allowing insurers to consider past due premium amounts as owed as the initial premium for new coverage.
- Excludes persons who are Deferred Action for Childhood Arrivals (“DACA”) from eligibility to enroll in any of the health insurance plans offered on the Marketplace or access premium tax credits and cost-sharing reductions.
- Requires CMS to apply a “preponderance of the evidence” standard (to prove that something is more likely than not) before terminating an agent for cause as to their agreement with CMS to solicit and sell Marketplace coverage.
- Eliminates the ability of an individual to certify to their income when applying for premium tax credits and cost-sharing reductions, instead requiring income determinations be reconciled with tax filing or other information potentially creating coverage delays and administrative barriers. In addition, if an individual does not file a Federal income tax return for two years, the individual will not be eligible for premium tax credits and cost-sharing reductions.
- Institutes income eligibility verifications for premium tax credits and cost-sharing reductions and charges people auto-reenrolled into zero-premium plans a small monthly payment until they confirm their eligibility information.
- Adjusts the automatic enrollment hierarchy for individuals.
- Shortens the annual open enrollment period from the current period, November 15 to January 15, reducing it by one month, to November 15 to December 15.
- Removes the monthly special enrollment period (“SEP”) for qualified individuals who become eligible for premium tax credits and cost-sharing reductions because their projected household income falls to or below 150% of the federal poverty level, resulting with individuals having to wait before they can access premium tax credits and cost sharing reductions.
- Changes de minimis thresholds for the actuarial value for plans subject to essential health benefits (“EHB”) requirements and for income-based cost-sharing reduction plan variations.
- Updates the annual premium adjustment percentage methodology to establish a premium growth measure that according to the Proposed Rule reflects premium growth in all affected markets, increasing the cost of coverage.
- Prohibiting insurance companies subject to ACA requirements from providing coverage for services related to a sex-trait modification as an essential health benefit.
These changes will not take effect immediately, as the Proposed Rule now faces a public comment period that stays open until April 11, 2025. After receipt of public comments, CMS may revise the Proposed Rule before issuing it in final form.
While every effort has been taken in compiling this information to ensure that its contents are totally accurate, neither the publisher nor the author can accept liability for any inaccuracies or changed circumstances of any information herein or for the consequences of any reliance placed upon it. This publication is distributed on the understanding that the publisher is not engaged in rendering legal, accounting, or other professional advice or services. Readers should always seek professional advice before entering into any commitments.
