What Changed and What Remains
Satisfaction of Debt for Past-Due Premiums (vacated)
Would have permitted exchange insurers, to the extent permitted by applicable state law, to require payment of both the initial and past-due premium amounts in order to effectuate new coverage.
Standardizing the Annual Open Enrollment Period (OEP) (vacated)
Beginning with plan year (PY) 2027, the rule would have required the OEPs for all exchanges to start no later than Nov. 1, end no later than Dec. 31 and not exceed nine calendar weeks. In addition, all enrollments for the OEP would have been required to begin on Jan. 1. Under this rule, for federally-facilitated exchanges (FFEs), including the Kansas marketplace, the OEP for PY 2027 would have run from Nov. 1 through Dec. 15. However, on July 27, 2026, in response to the court’s decision, CMS announced that open enrollment for the federally-facilitated marketplace will begin on Nov. 1, 2026, and end on Jan. 15, 2027.
Definition of “Lawfully Present”
Amends the definition of “Lawfully Present” to exclude Deferred Action for Childhood Arrivals (DACA) recipients, meaning they are no longer eligible to enroll in exchange plans, to receive APTC and cost-sharing reduction (CSR) subsidies, or to enroll in Basic Health Programs in states that operate those programs. This provision became effective on Aug. 25, 2025, and remains in effect.
Failure to File and Reconcile (vacated)
Would have required exchanges to determine that individuals who fail to file their federal income tax returns and reconcile APTC for one year are ineligible for APTC if (1) CMS notifies the exchange that the tax filer or someone in their household received APTC for a prior year for which tax data would be utilized for verification of income; and (2) the tax filer or someone in their household did not comply with the requirement to file a federal income tax return and reconcile APTC for that year. This policy was set to sunset at the end of 2026 but will be implemented for PY 2028 under Section 71303 of H.R. 1 (see Part 1 of this blog series).
Removal of 60-Day Extension to Resolve Income Inconsistency (vacated)
Under the ACA, exchange enrollees have 90 days to provide additional information to resolve any income inconsistencies identified after they enroll. Under previous rules, enrollees were automatically given an additional 60-day extension of this statutory period but the 2025 Final Rule discontinues that automatic extension. Note: This is the only policy that went into effect for PY 2026. However, on July 27, 2026, CMS reimplemented the automatic 60-day extension.
Income Verification When Data Sources Indicate Household Income Is Less Than 100 Percent of the Federal Poverty Level (vacated)
Would have removed the requirement that exchanges accept an applicant’s or enrollee’s self-attestation of projected annual household income when it attempts to verify the attested projected income with the IRS, but no such IRS data is available. Under this new rule, exchanges would have been required in PY 2026 to verify income with other trusted data sources (if available) and to require applicants to submit documentary evidence or otherwise resolve the income inconsistency.
Requiring $5 Premium Payments (vacated)
Would have modified the annual eligibility redetermination process for PY 2026 to require federally-facilitated exchanges (FFEs) to ensure that consumers who are automatically re-enrolled in plans with no premium following application of APTC and without affirming or updating their eligibility information, are automatically re-enrolled with a $5 monthly premium. Once consumers confirm or update their eligibility information, the $5 monthly bill would have been eliminated if they continued to be eligible for a $0 premium after application of their APTC. They could have received a refund or reduction on the taxes they owed (or may have owed) when they filed and reconciled their APTC on their federal income tax return.
Re-Enrollment of Enrollees in Bronze Health Plans Into Silver Plans
Repeals for PY 2026 a previous regulation in effect beginning with PY 2024 that allowed FFEs to automatically re-enroll CSR-eligible bronze plan enrollees in a silver plan if the silver plan is in the same product, has the same provider network and has a lower or equivalent net premium as the bronze plan that the individual would have otherwise been re-enrolled.
Discontinuation of Monthly Special Enrollment Period (SEP) for Low-Income Individuals
Would have repealed the monthly SEP for individuals with projected household incomes at or below 150 percent of the federal poverty level. This rule became effective 60 days after the enactment of the Final Rule and is only effective for PY 2026. CMS/HHS also clarified that a change in income is not an “Exceptional Circumstance” under federal regulations, and exchanges may not offer income-based SEPs under this authority.
Exchanges Required to Conduct Eligibility Verification for SEPs (vacated)
For PY 2026, would have required FFEs to conduct pre-enrollment verification for SEP eligibility. The rule was set to sunset at the end of PY 2026.
Exchanges Required to Conduct Eligibility Verification for 75 Percent of New Enrollments Through SEPs (vacated)
Would have mandated pre-enrollment eligibility verification for at least 75 percent of new enrollments through SEPs beginning with PY 2026 for FFEs, with the policy set to sunset at the end of 2026.
Coverage for Sex-Trait Modification Procedures (vacated on August 14, 2026, by a Massachusetts federal district court judge in the separate case of State of California, et al., v. Robert F. Kennedy, Jr., et al.)
Beginning with PY 2026, would have prohibited issuers of coverage (insurers) subject to the ACA’s essential health benefits (EHBs) requirements from providing gender-affirming care, which the rule refers to as sex-trait modification procedures, as an EHB. Issuers in states in which the benefits are currently an EHB would have been prohibited from covering them as an EHB in PY 2026 but may have opted to continue covering the procedures consistent with state law, but not as an EHB. States that separately mandate coverage for the procedures outside of their EHB-benchmark plans would have been required to defray the cost of that benefit because it would have been considered in addition to EHB.
