In late June, CMS issued a final rule addressing “integrity and affordability” for the Affordable Care Act (ACA) Health Insurance Marketplaces. The final rule’s changes are driven by concerns that policies adopted to expand coverage during COVID-19 have allowed individuals to enroll and receive subsidies for which they were ineligible. Below, we discuss key provisions and implications of the final rule for covered individuals and healthcare organizations. Note that many of the policies discussed below are finalized only for 2026.
Estimated Impact on ACA Exchange Coverage
As a result of the final rule, CMS estimates between 725,000 and 1.8 million individuals will lose Marketplace coverage in 2026. On a per-member, per-month basis, premiums are estimated to increase by approximately 2% to 7%. While all states will experience coverage losses, CMS expects them to be most concentrated in nine states “where erroneous and improper enrollment is most noticeable.” These states include Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Utah.
The loss of Exchange coverage could increase the likelihood of adverse selection in the federally facilitated and state-based Exchanges. Most of the changes in the final rule were finalized as proposed, so many health plans have likely already accounted for them in their 2026 rate filings. However, to the extent there is still time, plans should update their filings to reflect the final rule.
In the final rule, CMS acknowledges that the number of uninsured will increase as a result of the changes in Exchange coverage. Provider organizations should consider the following strategies to prepare for the increase:
- Collaborate with community organizations to educate affected individuals about eligibility changes to help minimize coverage loss in advance.
- Increase efforts to connect individuals who lose Exchange coverage with other sources of health insurance.
- Establish (or review and update) upfront collection policies for individuals who lose coverage and do not qualify for financial assistance.
- Take steps to make sure those who do qualify for financial assistance receive it.
Key Provisions for ACA Enrollment & Eligibility
In addition to the projected impact on coverage, below is a summary of select provisions in the final rule that will impact healthcare organizations.
Shortened Open Enrollment: For plan years (PY) 2026 and 2027, all open enrollment periods must begin by November 1, end by December 31, and not exceed nine calendar weeks. This applies to both the federal Exchange and state-facilitated Marketplaces.
In 2025, open enrollment lasted from November 1 to January 15 in the 31 states that use federally facilitated Marketplaces. Nineteen other state-based Exchanges had open enrollment periods that ended after December 31.
Cost Sharing Maximum: The maximum 2026 cost sharing limit for individual coverage is $10,600. For other than self-only policies, the limit is $21,200. This is a 15.2% increase from the PY 2025 limits of $9,200 for individual coverage and $18,400 for other than self-only coverage.
End to Low-Income Special Enrollment Period (SEP): For PY 2026, CMS eliminates the monthly SEP for individuals with projected household incomes at or below 150% of the federal poverty level (FPL). This policy is effective 60 days after the enactment of the final rule. The final rule clarifies that a change in income is not an exceptional circumstance, and therefore, Marketplaces may not offer income-based SEPs under this authority. In 2025, about half (47%) of Marketplace enrollees had an income of less than 150% of the FPL.1
Eligibility Verification for SEPs: Federal Exchanges will be required to conduct pre-enrollment verification for SEP eligibility. Further, CMS mandates pre-enrollment eligibility verification for at least 75% of new SEP enrollments. Both requirements apply only to PY 2026, and CMS did not finalize these requirements for state-based Exchanges.
Past-Due Premiums: CMS repeals the rule prohibiting plans from denying coverage to individuals based on past-due premiums. As allowed by state law, plans may require payment of both the initial and past-due premium amounts for individuals to obtain coverage.
Affirming Prior Interpretation of “Lawfully Present” Definition: Starting in 2026, Deferred Action for Childhood Arrivals (DACA) recipients are no longer eligible to enroll in qualified health plans in the Marketplace, receive premium tax credits, or receive cost sharing reductions, as CMS has redefined “lawfully present” to exclude these individuals.
Failure to File & Reconcile: For 2026 only, CMS will deem individuals ineligible for future premium tax credits if they fail to file their federal income tax return and reconcile premium tax credits for one year. Previously, since 2024, individuals would only be deemed ineligible if they failed to file taxes and reconcile for two consecutive years.
Removing Extension to Resolve Income Inconsistency: The final rule removes the automatic 60-day extension of the 90-day period for enrollees to resolve income inconsistencies.
Income Verification: For 2026, when verification results indicate an enrollee’s income is less than 100% of the FPL but the enrollee attests to income between 100% and 400% of the FPL, they will be required to provide additional documentation and answer verification questions to confirm income.
In addition, for 2026, the final rule removes the requirement that Exchanges accept a self-attestation of projected annual household income when the IRS is unable to verify income. In these circumstances, Exchanges must verify income with other “trusted data sources” and require applicants to submit documentary evidence.
Re-Enrollment Hierarchy Standards: Marketplaces are no longer allowed to re-enroll low-income Bronze plan enrollees into a Silver plan if the network for that plan is the same product, has the same provider network, and has an equal or lower premium.
How Forvis Mazars Can Help
In a rapidly evolving regulatory environment, Our healthcare consulting team can help healthcare organizations understand and navigate the latest policy changes and their impacts. We work with payors and providers across the care continuum to help them develop regulatory excellence and support the goal of achieving health for their enterprises and those they serve. If you have questions about the Marketplace Integrity and Affordability final rule or other recent healthcare policy updates, please reach out to our professionals at Forvis Mazars today.
- 1“Marketplace Plan Selections by Household Income,” kff.org, 2025.