Sabrina Corlette
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.
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, consumers and patients, and state-based Marketplaces and departments of insurance. For this first in our four-part series, we focus on comments submitted by health plans and brokers. Specifically, we reviewed comments from:
America’s Health Insurance Plans (AHIP)
Association of Community Affiliated Plans (ACAP)
Blue Cross Blue Shield Association (BCBSA)
National Association of Benefits and Insurance Professionals (NABIP)
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 insurance company and broker feedback focuses on selected CMS proposals: (1) Changes to open and special enrollment periods; (2) Coverage denials for failure to pay premiums; (3) Broker fraud; (4) Documentation requirements for data matching issues; (5) New $5 charge for certain enrollees automatically renewed; (6) Coverage of treatment for gender dysphoria; and (7) Changes to coverage affordability via premium adjustment percentages and actuarial value targets.
One overarching recommendation submitted by these carriers is for CMS to slow down its proposed timeline for implementing several of its policy changes. They argue that some of the effective dates are not “workable” given operational limitations. For example, AHIP’s letter observes that, “[w]ithout adequate time for implementation and testing, these policies may result in delayed enrollment, unnecessary coverage terminations, and adverse impacts on consumers.”
Another consistent recommendation from insurers, applicable to multiple provisions of the proposed rule, is that CMS should retain its traditional deference to state autonomy and refrain from mandating that state-based Marketplaces (SBM) adopt these policy proposals. Oscar, for example, commented that “state regulators and SBMs know their own markets, enrollment patterns, and consumers best.”
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. In a departure from past practice, CMS would require SBMs to adhere to the federally set timeline and SEP policies.
Shortening OEP
Most of the insurers generally supported a shortened OEP, although those that did urged CMS to delay doing so until the OEP for plan year 2027. AHIP and other carriers noted that uncertainty over the expiration of the enhanced premium tax credits would necessitate a longer OEP so that consumers would have time to understand the impact and adjust their coverage choices. As BCBSA put it: “We are concerned that the expiration of the enhanced tax credits…will be confusing for enrollees and chaotic for other stakeholders. We do not recommend shortening the OEP on top of the…uncertainty and changes that consumers, issuers, and Exchanges will be managing.” These insurers also urged CMS to continue longstanding deference to SBMs in setting OEP dates.
ACAP was the only insurer in this sample to fully oppose the proposal, noting that in their experience it is healthier consumers that sign up later in the OEP. They argue that shortening OEP risks “degrading the risk pool.”
The brokers in our sample express concerns that the shortened time period would “strain agents” and risk “overloading the distribution channel” (NAPIB). HealthSherpa also notes that many brokers assist both Medicare and Marketplace consumers, and a shorter OEP will “reduce agents’ ability to balance these overlapping enrollment periods.”
Eliminating the Low-income SEP
All of the commenters in our sample supported CMS’ proposal to eliminate the low-income SEP, although one (Cigna) urged CMS to delay implementation to plan year 2026. The insurers argued that the low-income SEP has increased the risk of adverse selection and fraud. AHIP, for example, wrote: “While well-intentioned…this expansive SEP is easily abused.” ACAP reports that its member plans “have noticed a trend of high utilizers enrolling through an SEP only to shortly thereafter receive a costly procedure, such as an organ transplant, dialysis, cancer treatment, or utilize a high-cost specialty drug.”
Broker commenters also supported jettisoning the low-income SEP. NAPIB points to “clear evidence of misuse, particularly in non-[Medicaid] expansion states.”
Pre-enrollment Verification for SEPs
While the commenters in our sample generally supported requiring consumers to document their eligibility for SEPs, they had several caveats. First, many expressed concerns that the Marketplaces do not have the operational capabilities to make the verification process smooth and efficient for consumers. AHIP noted: “When Exchanges are unable to perform timely verification, issuers often receive complaints of consumer confusion and abrasion.”
Insurer and broker commenters urged CMS to invest in technologies that would allow for automation of the SEP verification process. Some further asked that CMS give the SBMs greater flexibility over implementation of this requirement. For example, ACAP urged that SBMs be allowed to determine the SEPs most at risk of abuse and set their own verification standards.
Coverage Denials and Terminations
The proposed rule contains a provision that would permit insurers to deny an applicant insurance if the person had past-due premiums from a previous policy. Another provision would require insurers to terminate an enrollee’s coverage if they underpay their premium by a de minimis amount.
Coverage Denials for Failure to Pay Premiums for Prior Coverage
The insurers in our sample generally supported this proposal, and strongly urged that issuers retain flexibility to set payment policies. BCBSA noted that insurers have to weigh the costs and benefits of “chasing past-due premiums, member abrasion, and the risk environment in their area when setting their billing policies.” ACAP also recommended that CMS limit the policy to premiums due from the past 12 months of coverage, noting that “if consumers do experience a significant financial hardship that leaves them unable to pay significant premiums…that should not prevent them from being able to purchase coverage into perpetuity.”
Coverage Terminations for Failure to Meet a Premium Payment Threshold
Insurers had concerns with CMS’ proposal to take away their flexibility to decide when to terminate coverage. AHIP asked CMS “to continue deferring to issuers regarding their billing policies,” noting further that the current policy helps to promote coverage continuity. However, NAPIB supported this proposal, arguing that it would enhance “accountability and program integrity.”
Combatting Broker Fraud
The proposed rule includes a provision to codify a “preponderance of the evidence” standard of proof for CMS’ adjudication of cases involving broker misconduct. In addition, CMS requests commenters to provide recommendations for measures the agency could adopt to further discourage fraud among agent and brokers.
The insurers in our sample supported codifying the preponderance of the evidence standard, but NAPIB did not. The broker association argued it would result in CMS’ adjudications being too subjective, noting that the recent reinstatement of 70 percent of previously suspended brokers was indicative of “major flaws” in CMS’ enforcement efforts.
Commenters also provided several suggestions to better prevent fraud. AHIP recommended using two-factor authentication, standardized consumer consent forms, and creating a centralized hub for brokers to upload those forms. CVS Health similarly encouraged the use of mandatory, standardized consent forms. AHIP also asked CMS to share more information with insurers about SEP triggering events and the numbers of SEPs assisted by brokers. In addition to some technical upgrades, HealthSherpa suggested using identity proofing at the Marketplace call center when it receives a request to change the Agent of Record on a policy. They note that currently, a bad actor can easily impersonate a consumer over the phone. ACAP recommended imposing a requirement that brokers act “in the best interests” of their customers, such as through a fiduciary responsibility.
Documentation Requirements for Data Matching Inconsistencies
CMS proposes to eliminate a 60-day extension of the time period for consumers to resolve an inconsistency between income and other data provided on their application and the data available via third-party data sources. The agency further would 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 for them.
The commenters in our sample were generally supportive of these changes, but with some significant exceptions and caveats. AHIP, for example, urged CMS to, at minimum, delay implementing some of the requirements and to make them optional for SBMs. The association observed that requiring people who are very low income to submit additional documentation would create “excessive administrative burden for enrollees…and will be detrimental to the risk pool.”
ACAP also flagged the potential risk pool effects of additional paperwork requirements, which primarily deter healthy people from enrolling. They warn CMS that their plans would “need to adjust premiums accordingly.” Oscar further argued that “this additional administrative barrier will fall onto consumers on the border of poverty and could prevent them from qualifying for affordable coverage because of a good faith projection.”
AHIP expressed concerns about “all the additional verifications” that Marketplaces will be required to conduct, placing strains on IT systems and customer support capacity and leading to delays that could cause eligible people to lose coverage. CVS Health urged CMS to inform insurers before terminating coverage, so that they can intervene to help consumers resolve the issue.
NAPIB opposed CMS’ proposal to lower the threshold for determining a consumer has a data matching inconsistency, arguing that the change would “disproportionately impact small businesses and lawfully present immigrants” who may have uneven, unpredictable income or lack necessary tax data.
New $5 Premium Charge for Certain Individuals Automatically Re-enrolled
The proposed rule would require Marketplace to impose a new $5 premium on individuals eligible for a $0 premium, unless they actively update their Marketplace application during open enrollment.
Insurers and brokers had mixed views about this proposal. AHIP and ACAP expressed significant concerns with both the coverage and operational effects of this policy; BCBSA, NAPIB, CVS Health and Cigna were more supportive, although BCBSA and Cigna urged the agency to delay implementation by a year. Several also encouraged CMS to make this policy optional for the SBMs, with BCBSA for example noting that “there is insufficient justification” for extending the policy to the SBMs, since only FFM states have been the source of improper enrollments. ACAP also emphasized the significant operational costs of this change for insurers, noting that these costs would need to be passed on in the form of higher premiums. The association also urged CMS, if it finalizes the policy, to provide guidance to insurers on consumer notification requirements so that consumers know what they need to do and to discourage some insurers from using it as “a back-door way to cherry-pick enrollees.”
Coverage of Treatment for Gender Dysphoria
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.
Not all the organizations in our sample expressed views on this provision, but those that did urged CMS to preserve the existing regulatory structure in which states have flexibility to determine essential health benefits, within broad federal guardrails. The proposed federal directive to exclude specific services from the benefit package based on diagnosis is unprecedented. ACAP and BCBSA also noted that many of the items and services used to treat gender dysphoria are also deployed to treat other conditions and diseases, such as cancer, menopause, and other endocrine disorders. It could also affect access to treatments to prevent conception, such as vasectomies and tubal ligations. These insurers noted that prohibiting coverage for these services for one diagnosis but not others would create significant operational burdens for insurers and headaches for many enrollees.
Changes to Premium and Benefit Affordability
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.
ACAP was the only insurer in our sample to oppose the change to the premium adjustment percentage methodology. AHIP and BCBSA did not oppose it but asked CMS to delay it for one year.
The insurers all supported greater flexibility to submit plans with lower actuarial values. They further requested that CMS finalize this policy as quickly as possible to account for product filing deadlines with state insurance departments.
Note on Our Methodology
This blog is intended to provide a summary of comments submitted by insurance companies, representative associations, and brokers. 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/.
