Big Changes Ahead: What the New Health Insurance Rule Could Mean for You

There’s a big, beautiful bill in the works—and it could change a lot about how health insurance through the Marketplace works in 2026 and beyond. The 2025 Marketplace Integrity and Affordability Final Rule has been released, and while things may still shift before Open Enrollment, we want to walk you through the major changes that are likely coming your way. Some provisions take effect for 2026 plans, while others begin in 2027. Either way, it’s more important than ever to stay informed and work closely with a local agent.

Here are the highlights:

🔎 Tighter Income and Eligibility Verifications

The Marketplace is cracking down on income and eligibility checks to prevent fraud and reduce wasted tax dollars.

• IRS Data Matching: Your reported income will now be checked against IRS data. If you’re flagged as being under 100% of the Federal Poverty Level (FPL), your application will require extra documentation. If your income is reported drastically higher or lower than the year before, you will need to submit proof of the income change. This could include a W-2 statement, a letter from your CPA, or a self-employment ledger that shows your adjusted income.

• No More 60-Day Income Extensions: Previously, if there was a mismatch, you had 90 days plus you had 60 days automatically added to resolve it. That’s gone. You’ll now get only 90 days total to submit your proof.

• Trusted Data Sources: Instead of just mailing letters and offering extensions, the Marketplace will start using verified data sources—meaning we’ll likely need a pay stub, tax return, or CPA letter upfront to clear income issues.

• Shorter Open Enrollment Period: CMS is also planning to shorten the annual open enrollment window, so being proactive about renewing your coverage each year is more important than ever.

🧾 You Must File & Reconcile Your Taxes

One of the biggest changes impacts anyone receiving subsidies (APTC). If you fail to file your taxes and reconcile your subsidies, you’ll lose eligibility for assistance the following year—even if you qualify otherwise. This is a major update and could catch many people off guard. The initially proposed that you had to reconcile on of the last 2 years of subsidies, but the new rule is limiting that to one year. This means that filing your taxes each year as early as you can is critical to ensure you don't see any lapse in your health insurance or eligibility for subsidies. 

🏥 Premium Changes & Auto-Reenrollment Rules

• Minimum Premium for Auto-Reenrollments: Even if your plan is set to auto-renew, you’ll now be required to pay at least $5/month. No more $0 plans slipping under the radar.

• Paying Past-Due Premiums: To start a new plan, you may be required to pay both the first premium and any missed payments on previous plans.

• Projected Premium Drop: CMS estimates that individual health insurance premiums will drop by about 5% in 2026, though how they’ll accomplish that remains to be seen.

🧾 Changes to Special Enrollment Periods (SEPs)

• Pre-Enrollment Verifications Required: At least 75% of SEP enrollments will now require full eligibility checks before a policy starts. That means delays if documents aren't submitted quickly.

• Elimination of 150% FPL SEP: This popular option is going away, reducing SEP access for lower-income individuals who don’t qualify for Medicaid. This means to qualify for a health plan outside of the regular open enrollment period, you will need to have a different special election period like recently moving or losing your group health plan. 

🚫 DACA and Gender-Affirming Care Changes

• DACA Recipients: Individuals with Deferred Action for Childhood Arrivals (DACA) status are no longer considered lawfully present for Marketplace coverage, making them ineligible unless other immigration statuses apply.

• Gender-Affirming Care: The rule now prohibits coverage of gender-affirming care as an Essential Health Benefit (EHB). While insurers may still voluntarily cover these services, it’s no longer required. We are already in contact with the carriers in Utah to see if any of them will have a plan that covers this benefit in 2026, but have not gotten any confirmation yet. We are watching this change closely and sad to see this change happen. 

💸 Combating Fraud, Saving Billions

This new rule is projected to save taxpayers up to $12 billion in 2026 by preventing improper ACA enrollments. According to CMS, recent fraud related to relaxed eligibility checks and expanded subsidies has cost as much as $20 billion. These new rules are designed to strengthen the system and restore trust.

What This Means for You

These changes aren’t just behind-the-scenes adjustments—they could directly impact your plan, your premiums, and your ability to qualify for coverage. Many of the provisions are already finalized, but others could still shift before Open Enrollment begins on November 1, 2025.

We’re watching all of this closely here at Utah Avenue Insurance. Our team is staying on top of the latest updates and rule changes to make sure you're always in the know. If your income changes, you move, or anything in your household changes this year, it's more important than ever to let us know.

📞 Need help verifying income or updating your information? We’ve got your back. Call or stop by and let your local health insurance experts help you get the coverage you need — with confidence.

🛡️ Better coverage starts here.