This year enrollment in the Affordable Care Act (ACA) Marketplaces is at an all-time high, hitting 24.3 million during the most recent open enrollment season. This insurance coverage provides a critical source of financial protection and access to care for a wide range of low- and moderate-income people, from entrepreneurs and gig economy workers, to small business owners and early retirees. In March 2025, the Centers for Medicare & Medicaid Services (CMS) released a set of proposals that would change Marketplace benefits, enrollment, and eligibility rules such that, by its own estimates, between 750,000 and 2 million people would lose health insurance. More recently, the U.S. House Energy & Commerce and Ways & Means Committees advanced legislation that would put many of the provisions of this proposed rule into federal statute.
Although CMS offered just 23 days for public comment on its proposed rule, the agency received almost 26,000 comments. To better understand how different stakeholders view the administration’s proposals and how they might be impacted, CHIR reviewed a sample of comments from four major categories of commenters: Health plans and brokers, providers, state-based Marketplaces (SBM) and departments of insurance, and now, consumer advocates. For this finale in our four-part series, we focus on comments submitted by consumer advocate groups. Specifically, we reviewed comments from:
The proposed Marketplace rule covers a wide range of policies (a detailed summary of its provisions, in two parts, is available on Health Affairs Forefront here and here). This summary of consumer advocate feedback focuses on the following selected provisions: (1) Changes to open and special enrollment periods; (2) Eligibility determination and verification; (3) Essential Health Benefits and gender affirming care; (4) Coverage for DACA recipients; and (5) Premium adjustments and premium debt.
Shared Concerns – Misplaced Burden of Fraud
An overarching theme of the comments submitted by the consumer advocate organizations is the shared concern that CMS is basing its decision making on a flawed analysis and over-estimate of fraud in the ACA Marketplaces. CMS relies heavily on a Paragon Institute report estimating up to 5 million fraudulent enrollments. CBPP and Community Catalyst criticized this analysis as methodologically flawed, relying on mismatched data sets and misinterpreting how income projection in the Marketplace works, thereby exaggerating claims of fraud.
While advocates acknowledged that fraud undermines the integrity of the Marketplace, they emphasized that honest income fluctuations and a complex enrollment process are more likely sources of alleged discrepancies. They argued CMS is mistakenly focusing its anti-fraud efforts on consumers, instead of trying to address the actions of a relatively small number of unscrupulous brokers and lead generators using Enhanced Direct Enrollment (EDE) systems to exploit consumers. They called for greater oversight of brokers, stricter enforcement against EDE abuse, and a reduction in consumer burdens.
Changes to Open and Special Enrollment Periods
The proposed rule would shorten the annual open enrollment period (OEP) from 76 to just 44 days. CMS further proposes to narrow enrollment opportunities by eliminating a special enrollment period (SEP) that allows low-income individuals (earning below $23,475 per year) to enroll any time during the year. CMS would also require people enrolling in the Marketplace through a SEP to submit extra paperwork to prove their eligibility. In a departure from past practice, CMS would require SBMs to adhere to the federally set timeline and SEP policies.
Shortening OEP & Eliminating the Low-Income SEP
Consumer and patient advocates broadly opposed the proposed reduction of the OEP from 76 to 44 days. For example, Community Catalyst and Families USA argued this would limit access to coverage — especially for low-income individuals, people of color, and those requiring additional time or assistance. NHeLP referenced vulnerable groups navigating complex decisions during the holiday season while AARP acknowledged the intent to reduce adverse selection but shared their fears that these changes may hinder access to coverage, especially amid reduced outreach funding.
UnidosUS, along with ACS-CAN and Community Catalyst, also expressed their concerns about reduced enrollment periods at a time when funding for ACA Navigators and caseworker personnel have been reduced as well, saying that this change, combined with cuts to Navigator funding, would further limit enrollment assistance. Community Catalyst highlighted the vital role that Navigators play in helping underserved communities enroll and urged the restoration and expanded funding of these programs, especially given the need for their services as consumers grapple with the new paperwork requirements under the rule.
Most advocate groups also opposed eliminating the low-income SEP, with Families USA saying that it would disrupt coverage for millions, especially those cycling between Medicaid and Marketplace plans or living in states that haven’t expanded Medicaid. TLC asserted that this move would disproportionately hurt transgender and nonbinary people, who are statistically more likely to live in poverty, along with other marginalized groups such as Black, brown, and disabled communities. NHeLP cited improved enrollment and reduced racial disparities in coverage as a result of this SEP, without evidence of adverse selection.
Eligibility Determination & Verification
$5 Premium for Passive Re-enrollment
The proposed $5 premium for passively re-enrolled individuals currently eligible for $0 premiums was widely criticized. UnidosUS, CBPP, ACS CAN and NHeLP argued it could lead to unnecessary disenrollment, negatively affect risk pools, and cause confusion and financial hardship for low-income enrollees. They criticized the proposal as confusing, burdensome and expressed concerns that it could trigger coverage terminations and increased premium debt for low-income enrollees.
Income Documentation Requirements
CMS proposes to require consumers to submit documentation proving their income if third-party data sources suggest their income is below 100 percent of the federal poverty level (FPL). Consumers would also be required to submit additional documentation proving their income if the IRS lacks tax data.
AARP and CBPP criticized the proposal, arguing that income discrepancies are usually the result of unpredictable work conditions, not fraudulent behavior as CMS suggests. CBPP and Families USA further stated that these verification burdens would disproportionately impact those with volatile or low incomes, young people, and communities of color while UnidosUS pointed to gig workers and immigrants with fluctuating incomes at particular risk of losing coverage if this provision goes into effect. Community Catalyst and NHeLP support maintaining automatic 60-day extensions and self-attestation processes, arguing that the proposed reduction in the time period to submit documentation proving eligibility would wrongfully strip over a million individuals of premium tax credits without sufficient justification.
Essential Health Benefits & Gender-Affirming Care
The proposed rule would prohibit insurers from covering items and services that treat gender dysphoria (referred to in the rule as “sex trait modification”) as part of essential health benefits. States would still be permitted to mandate such coverage, but would need to defray the costs of such coverage using state funds.
A majority of organizations in our sample condemned this provision, and shared concerns about the implications for not only transgender and nonbinary individuals, but for anyone receiving medical care that could potentially be considered “sex trait modification.” Many organizations, including UnidosUS, NILC, and Families USA, cited the medical consensus that gender-affirming care is necessary and protected under ACA nondiscrimination laws – Section 1557. NHeLP similarly viewed the proposal as discriminatory, medically unsound, and contrary to legal and clinical standards. TLC drew attention to the financial implications this could have for individuals, saying that forcing transgender individuals to pay out-of-pocket for medically necessary care would strip such care of ACA protections (e.g., cost-sharing caps), disproportionately harming low-income transgender people and people of color. AARP voiced their support for the current EHB structure, which they say maintains a consistent quality baseline while allowing state flexibility, and opposed the proposed changes that could restrict this flexibility.
Coverage for DACA Recipients
The proposed rule would exclude DACA recipients — certain undocumented individuals who entered the United States as children and are currently protected from deportation — from the definition of “lawfully present” for purposes of health coverage, thus making DACA recipients in all states ineligible for Marketplace coverage, premium subsidies, and cost-sharing assistance. This proposal reverses a 2024 Biden Administration regulation that extended the definition of “lawfully present” to DACA recipients and enabled these individuals to enroll in Marketplace plans. Litigation against this rule has blocked DACA recipients from enrolling in Marketplace plans in 19 states.
All organizations in our sample that commented on this proposed policy change (nine out of ten) opposed it. These groups expressed their ongoing support for providing DACA recipients with access to Marketplace plans, premium subsidies, and cost-sharing assistance, while also sharing concerns about the effects of stripping people of coverage eligibility mid-year. PIF argued that DACA recipients have historically been recognized as lawfully present in various health programs, and that reversing the 2024 regulation would harm DACA recipients. PIF further asserted that DACA recipients face disproportionately high uninsured rates, and that removing their eligibility would worsen access to care, increase financial hardship and negatively impact individual and community health. NILC cited research saying many DACA recipients forgo necessary care due to cost, contributing to worse public health outcomes and, along with Families USA, mentioned the potential for higher uncompensated care burdens on the health system due to coverage losses. Community Catalyst, CBPP, ACS-CAN and NHeLP echoed and supported those sentiments, noting the proposal would exacerbate health inequities and harm risk pool stability. Finally, PIF claimed that CMS grossly underestimated the amount of DACA recipients that would be affected – 11,000 – saying that this underestimates the harm due to legal barriers and limited awareness, putting the number closer to 100,000.
Premium Affordability and Coverage Denials
The proposed rule would adjust the methodology for determining the amount Marketplace enrollees contribute to their premium. This same methodology also determines the maximum annual out-of-pocket cost for people in both individual and employer-based coverage. If finalized as proposed, deductibles and other cost-sharing for the typical family could increase by $900 in 2026 (including for those with employer-sponsored insurance). Families enrolled in the Marketplace could face an additional $313 in premiums. Additionally, CMS proposes to give insurers more flexibility to offer plans at each metal level with lower actuarial values than permitted under current rules.
The proposed rule also includes a provision that would permit insurers to deny an applicant insurance if the person had past-due premiums from a previous policy. This proposal is similar to but stricter than the first Trump Administration’s policy on past due premiums, which also allowed insurers to deny coverage but limited the look-back period for past due premiums to 12 months. In contrast, this proposal permits insurers to deny coverage if the applicant has past-due premiums from any point in time.
Premium Adjustments
A little over half of our sample organizations shared concerns about the implications of increasing premium and out-of-pocket costs for people in both individual and employer-based coverage. ACS-CAN specifically felt that this would disproportionately affect cancer patients who already face high early-year expenses, and Community Catalyst felt similarly about the effects on people with chronic conditions and those in rural areas. UnidosUS shared specific concerns that this policy would have a disproportionate impact on low-income Latino families, as the resulting increase in costs would push people out of care.
Premium Debt
Of the organizations that commented on the proposal to allow insurers to deny coverage for past-due premium debt (roughly half our sample), all argued that the provision was punitive and unnecessary. NHeLP further argued that the basis upon which CMS attempts to justify its proposal is flawed, ast premium debt is often due to insurer errors rather than enrollee non-payment.
CBPP and NHeLP argued that allowing insurers to deny coverage on this basis violates the ACA’s guaranteed availability requirement and would disproportionately harm low income enrollees. ACS CAN highlighted that it could disproportionately harm patients with serious illnesses like cancer. Families USA warned that the proposal could push families into medical debt and increase uncompensated care burdens on providers. ACS CAN urged flexibility such as installment payments and forgiveness of minor debts.
Note on Our Methodology
This blog is intended to provide a summary of comments submitted by state departments of insurance, state-based marketplaces, and representative associations. This is not intended to be a comprehensive review of all comments on every provision in the proposed rule, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/.
