The marketplace “integrity and affordability” rule, which the U.S. Department of Health and Human Services (HHS) finalized on June 20, 2025, will roll back over a decade of work to expand access to health coverage and improve health care affordability. The rule implements new eligibility criteria that restricts access to coverage, raises costs for enrollees, and imposes administrative complexities that will be burdensome for enrollees to navigate and marketplaces to implement. HHS justifies many of the provisions by stating they are necessary to combat fraud, waste, and abuse. In actuality, these policies are designed to cut people off coverage. By HHS’ own estimate, up to 1.8 million people could lose coverage in 2026 alone.
The rule goes into effect on August 25, 2025, despite many commenters recommending that the rule’s implementation be delayed. Thirteen of the 17 policies must be implemented in a matter of months, and oddly, eight policies will sunset at the end of 2025. Although the justification for rolling back these eight provisions does not align with the reasons for imposing them in the first place, it is a convenient opportunity for Congress to potentially permanently implement these changes and use the “savings” to pay for tax cuts.
The Rule Needlessly Restricts Enrollment Opportunities
The rule implements policies that severely limit the ability to enroll in marketplace coverage. Beginning with the 2027 open enrollment period (OEP), all exchange OEPs must “begin no later than November 1” and “end no later than December 31,” and must not exceed 9 weeks in duration. Unfortunately, this opens the door for shorter OEPs. The rule also limits state flexibility to expand enrollment opportunities sufficiently broadly to capture the most people possible. All but one of the state-based marketplaces (SBMs) currently run OEPs that are longer than nine weeks and extend into January. This means that 19 out of 20 SBMs will be forced to shorten their OEPs, limiting the enrollment opportunities to which people in those states have become accustomed.
As of August 25, 2025, the final rule eliminates the monthly special enrollment period (SEP) for individuals at or below 150% of the federal poverty line (FPL). This provision sunsets at the end of 2026. Additionally, for 2026, the final rule requires enrollees in the federally-facilitated marketplace (FFM) who are automatically re-enrolled in marketplace coverage with no premium to pay a $5 monthly premium penalty until they confirm their eligibility. Effective August 25, 2025, the rule also allows issuers to require payment of past-due premiums from prior coverage within any timeframe as a condition of effectuating new coverage. This is a more restrictive policy than what was permitted in the first Trump administration. The 2017 Market Stabilization rule only allowed a 12-month lookback (and the policy was altogether eliminated in the 2023 Notice of Benefit and Payment Parameters (NBPP)). This policy also does not sunset. All of these provisions, by design, restrict access to coverage and will lead consumers to drop off coverage.
The Rule Doubles Down on the Administration’s Efforts to Penalize Immigrant Populations and Bans Access to Gender Affirming Care
The final rule also continues the administration’s attacks on immigrants by redefining “lawfully present” to exclude DACA recipients, prohibiting them from enrolling in qualified health plans (QHPs) or receiving APTC or other cost-sharing reductions (CSRs). This provision takes effect on August 25, 2025 and does not sunset. Separately, beginning in 2026, the final rule also bans coverage of gender-affirming care as an essential health benefit in individual and small group market plans and excludes these services from annual and lifetime limits and cost sharing protections in all plans, including large group plans. These policy decisions take us backwards, undercut health equity principles, and cause deep harm.
The Rule Increases Administrative Complexities
The rule further restricts enrollment by creating administrative burdens that clearly serve no other purpose than to discourage people from enrolling in marketplace coverage and impede them from keeping it. The $5 premium penalty, for example, functionally eliminates automatic re-enrollment for people in $0 premium plans, instead requiring them to undertake multiple steps to retain their fully-subsidized coverage.
The rule also requires, for the 2026 plan year, that the FFM conduct pre-enrollment verification for SEPs, which will place a tremendous paperwork burden on people seeking to enroll in coverage following a life change like getting married or adopting a child. Similarly, the rule eliminates the requirement (established in the 2024 NBPP) that the FFM and SBMs accept self-attestation of income when an enrollee’s tax data is unavailable or it indicates their income is less than 100% FPL. This change takes effect on August 25, 2025 and sunsets at the end of 2026. Enrollees in this situation will be forced to provide pay stubs and other information to justify their income projections – a particularly tall order for people with lower incomes, who are more likely to work in volatile jobs with unpredictable schedules or limited formal payment documentation. These administrative complexities will also be prohibitively expensive for marketplaces to implement, and will take significant staffing and resources to maintain.
The Rule’s Focus is Anything but Affordability, as it Raises Costs for Consumers
Many of the changes in the final rule will impose significant costs on consumers. The rule’s changes to the premium adjustment percentage methodology will increase premium costs, and its changes to the de minimis actuarial value standards will broadly erode the generosity of coverage. In particular, the policies aimed at restricting enrollment threaten to destabilize the risk pool, increasing costs for everyone. Data shows over and over that younger, healthier people tend to enroll in coverage toward the very end of the OEP, contributing positively to the risk pool. Conversely, when faced with even minor administrative hassles (such as having to pay a small premium or actively re-enroll in coverage), those same “low-risk” enrollees who stabilize the risk pool are much more likely to drop their coverage. HHS even acknowledged this dynamic in discussing its proposal to broadly implement pre-enrollment verification for SEPs. And when healthier people exit the market, it concentrates around people with more significant health needs, raising costs for those who remain.
The Big, Bad Budget Reconciliation Bill Looks to Permanently Codify Many of the Time-Limited Provisions
While nearly half of the provisions in the final rule will sunset at the end of 2026, several provisions in the so-called “One Big Beautiful Bill” currently being considered by Congress seek to ensure that there will be no return to status quo in 2027. Both the House-passed and current Senate versions of the bill would permanently eliminate automatic re-enrollment and end the monthly SEP for individuals with income below 150% FPL. While it is impossible to know what the final, permanent changes will be if the final reconciliation bill is enacted, it is clear that this rule – already extremely harmful – is just one component of Republican efforts to gut the ACA and take health care from millions.
