CMS Proposed Changes: What You Need to Know
The new CMS Proposed Rule introduces major ACA changes such as ending the ≤150% FPL Special Enrollment Period (SEP), ending $0 passive renewals, and shortening the Open Enrollment period. In addition, extended APTC (eAPTC) will expire at the end of 2025 without further legislative action.
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)
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.
Effective: January 1, 2026
End of 150% FPL SEP
The monthly Special Enrollment Period (SEP) for individuals ≤ 150% FPL will be discontinued.
This change will restrict SEP eligibility for consumers unless they experience a Qualifying Life Event (QLE).
Effective: TBD, but likely as soon as the final rule is published
$5 monthly premium for $0 passive renewals
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.
Consumers with $0 premiums will need to actively enroll or they will have to pay $5/month for their passively renewed plan.
Effective: TBD, but likely PY 2026
Failure to reconcile (FTR)
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).
Consumers 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.
Effective: TBD, but likely PY 2026
Shorter Open Enrollment Period (Nov 1–Dec 15)
The annual Open Enrollment Period (OEP) will end on December 15 (currently OEP is November 1–January 15).
Effective: TBD, but likely PY 2026
SEP pre-enrollment verification
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 SEP, you might lose eligibility to enroll outside of OE. You will need to ensure you have proper documentation to avoid SEP verification issues.
Effective: May 16, 2025 for consumers reporting a loss of health coverage
TBD for other QLEs
