CMS Finalizes Rule Tightening ACA Enrollment, Aiming to Reduce Premiums
The Trump Administration has finalized the 2025 Marketplace Integrity and Affordability Final Rule, significantly altering the enrollment processes for the Affordable Care Act (ACA) Exchanges to address improper enrollment claims. The Centers for Medicare and Medicaid Services (CMS) aims to reduce individual health insurance premiums by approximately 5% through measures that tighten verification processes and adjust premium subsidies. However, the rule is expected to reduce coverage for an estimated 725,000 to 1.8 million individuals, reflecting a significant impact on enrollment numbers.
CMS justifies these changes as necessary interventions to curb waste, fraud, and abuse within ACA Exchanges, citing a conservative think tank's estimate of around 5 million improper enrollments resulting in $20 billion in taxpayer costs. The agency emphasizes restoring market integrity by implementing stricter eligibility verification and fiscal discipline, positioning the rule as a means to safeguard taxpayer dollars and protect coverage for those truly eligible.
Key provisions of the rule include new restrictions on federal subsidies, notably excluding coverage for gender-affirming care and barring Deferred Action for Childhood Arrivals (DACA) recipients from obtaining coverage through ACA Exchanges or the Basic Health Program. These policies are largely designated as temporary, with sunset provisions set for the end of the 2026 plan year, indicating a phased approach dependent on future regulatory reviews or legislative actions.
These regulatory changes arrive amid ongoing debates about program integrity and the balance between affordability and comprehensive coverage in the health insurance marketplace. The rule signals a shift towards prioritizing enrollment verification and subsidy controls to manage program costs, possibly influencing the dynamics of ACA exchanges nationwide. The expected premium reductions and coverage losses will be closely monitored by insurers, policymakers, and stakeholders concerning market stability and access to care.
Overall, the finalized rule reflects CMS's strategic focus on enhancing ACA Exchange market stability through targeted regulatory adjustments addressing eligibility, subsidies, and coverage scope. Its implementation is poised to shape the operational framework of the ACA Exchanges by leveraging enrollment integrity and fiscal oversight as central tenets.