CMS tightens exchange enrollment rules

Modern Healthcare – Friday, June 20, 2025
By Bridget Early

Health insurance exchange consumers will have less time to sign up each year and face more stringent sign-up procedures under a final rule the Centers for Medicare and Medicaid Services published Friday.

The regulation, which CMS proposed in March, shortens the open enrollment period, cancels a rolling special enrollment period for low-income people and institutes stronger income verification processes for subsidy applicants.

The regulation is the latest step in President Donald Trump and Health and Human Service Secretary Robert F. Kennedy Jr.’s efforts to reshape the insurance marketplaces. It also aligns with a broader campaign to limit spending in federal health programs. The Republican majority in Congress is pursuing similar goals.

“This is about putting patients first, stopping exploitation of the system and realigning the program with the values of personal responsibility and fiscal discipline,” CMS Administrator Dr. Mehmet Oz said in a news release Friday.

Open enrollment

For the 2027 plan year and beyond, the annual sign-up period will begin no later than Nov. 1, end by Dec. 31 and last no longer than nine weeks. The final deadline in most states had been Jan. 15. This part of the regulation applies to the federal exchanges and the state-run marketplaces.

Enrollment processes

CMS is enacting new eligibility checks, but some will only last through the 2026 plan year.

For instance, the federal exchanges and state-based exchanges that use the federal platform will require pre-enrollment eligibility checks for people who apply for premium tax credits under special enrollment period rules.

Exchanges must use IRS data to confirm incomes for subsidy applicants who earn below the federal poverty level — which is $15,650 for a single person in the contiguous states and slightly higher in Alaska and Hawaii — and not rely on enrollee attestations.

Also limited to next year is a revival of a policy that disqualifies people for advance payment of subsidies if they didn’t file income taxes and failed to reconcile their tax credits in a previous year.

Low-income special enrollment period

CMS is eliminating a monthly special enrollment period that enabled people with incomes below 150% of poverty to sign up year-round, which the agency implemented in 2022. The new policy applies only to the 2026 plan year.

The agency cites the actions of insurance brokers who fraudulently enrolled people without their consent as the justification. CMS took other steps to prevent these improper signs-ups in January.

$5 premium charge

Federal exchange customers who qualify for subsidies that cover their entire premiums and are automatically re-enrolled at the start of the year would pay $5 a month if they do not confirm their income data. This only applies to the 2026 plan year.

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