CMS Issues Final Rule on Marketplace Integrity and Affordability

• The Centers for Medicare and Medicaid Services (CMS) finalized a rule on Marketplace Integrity and Affordability. The Final Rule has not yet been published in the Federal Register but will take effect 60 days after such publication.
• The Final Rule adopts several program integrity measures and revises standards for denial of coverage due to failure to pay a past-due premium, including requiring payment of both the initial and past-due premium amounts in order to effectuate new coverage.
• CMS has finalized changes to the annual Open Enrollment Period (OEP), beginning with plan year 2027, for both on- and off-Exchange individual market coverage. Exchanges can set their own timing and duration for OEPs so long as each OEP starts by November 1 and ends by December 31, and the OEP may not exceed 9 calendar weeks. For Exchanges on the Federal platform, the OEP runs from November 1 through December 31 preceding the coverage year.
• The Final Rule also includes provisions:
  • on verifying income eligibility for affordability programs and reducing enrollment through eligibility redeterminations and special enrollment periods (SEPs); 
  • excluding Deferred Action for Childhood Arrivals (DACA) recipients from the definition of “lawfully present” for eligibility and enrollment purposes in Exchanges and Basic Health Program (BHP) coverage, and 
  • prohibiting issuers subject to essential health benefits (EHB) requirements from providing coverage as an EHB for specified sex-trait modification procedures—or gender affirming care—effective plan year 2026. Health plans may nonetheless voluntarily opt to cover this type of care as a non-EHB, consistent with applicable State law.

More on This Topic: 

• Final Rule (unpublished)
• Fact Sheet

For questions, please reach out to Vicky Jucelin.