Stay ahead of ACA changes

AGENT RESOURCES

Agent training webinar: Proposed ACA changes

Join our Proposed ACA changes training webinar where we'll walk through the key rule changes and show you HealthSherpa features designed to help you successfully navigate the updates.

POLICY UPDATES

What may be changing

These are proposed and potential changes that depend on the contents of the CMS Final Rule and activity around the expiration of enhanced subsidies (eAPTC).

Expiration of enhanced subsidies (eAPTC)

Effective: January 1, 2026

• Extended APTC (eAPTC) will expire at the end of 2025 without further legislative action. 

• Premium payments for subsidized enrollees will increase nationwide when eAPTC subsidies expire. eAPTC expiration will affect all FPL tiers.

End of 150% FPL SEP

Effective: TBD, but likely as soon as the final rule is published

• The monthly Special Enrollment Period (SEP) for individuals under 150% FPL will be discontinued.
  
• This change will restrict SEP eligibility for folks unless they experience a Qualifying Life Event (QLE). Many agents may decide to shift their work to should shift to a more seasonal operation vs a year-round operation.

$5 monthly premium for $0 passive renewals

Effective: TBD, but likely PY 2026

• Consumers eligible for fully subsidized ($0 premium) plans who don’t actively confirm their income may be required to pay $5/month until they verify.
• The rules heavily favor active renewals. You will need to actively enroll your clients with $0 premiums or they will have to pay $5/month for their passively renewed plan.
• Prepare and stage your active renewals pre-OE to make the enrollment process easier and more efficient

Failure to Reconcile (FTR) 

Effective: TBD, but likely PY 2026

• Consumers will become ineligible for advance payments of the premium tax credit (APTC) if they didn't file their taxes and reconcile their APTC for one year (current regulations stipulate two years).
• Remind your clients to file taxes. Your current clients who are eligible for APTC may lose eligibility if they haven't filed taxes and reconciled APTC.
• If APTC eligibility is lost, Cost Share Reduction (CSR) eligibility would also be lost.

Shorter Open Enrollment Period (Nov 1–Dec 15)

Effective: TBD, but likely PY 2026

• The annual Open Enrollment Period (OEP) will be shortened to November 1–December 15 (currently OEP is November 1–January 15).
• You will have less time to enroll and renew clients for plan year 2026 and beyond, making efficiency more important than ever.

SEP pre-enrollment verification

Effective: TBD, but likely May 16

• Consumers are often asked to submit documentation proving they’ve experienced a qualifying life event (QLE) in order to verify their eligibility for a Special Enrollment Periods (SEPs).
• If the Marketplace can’t verify your client’s SEP, they may lose eligibility to enroll outside of OE. You will need to ensure you have proper documentation to avoid SEP verification issues.
• You will need to ensure you have proper documentation to avoid SEP verification issues.

DMI for certain income variances

Effective: TBD, but likely as soon as the final rule is published

• The Marketplace checks a consumers projected annual household income against data from previous tax returns and other federal data sources.
• A Data Matching Issue (DMI) will be triggered and the applicant should be prepared to provide supporting documents if they fall into the Medicaid gap and are self-reporting a higher income.

Other notable proposed changes 

• Revising standards relating to past-due premium payments
• Excluding Deferred Action for Childhood Arrivals (DACA) recipients from the definition of “lawfully present”
• Removing the automatic 60-day extension for applicants to provide documentation to verify household income inconsistencies
• Removing the requirement for Exchanges to accept self-attestation of projected annual household income when IRS tax data is unavailable
• And more. Marketplace Integrity and Affordability Proposed Rule