The Open Enrollment Period (OEP) for 2025 marked a milestone with record enrollment figures and yet, at the same time, the 2025 Marketplace Integrity and Affordability Final Rule issued by CMS (effective August 25, 2025) signals significant shifts ahead. Going into OEP/AEP for 2026, healthcare stakeholders—from consumers to brokers—face tightened rules, verification requirements, and policy reversals that will probably reshape access, costs, and coverage dynamics.
2025 Open Enrollment Outcome: Trends and Milestones
The 2025 OEPÂ shattered previous records with unprecedented participation, reflecting both increased healthcare demand and the lingering impact of enhanced subsidies. But beneath the surface, enrollment trends reveal deeper challenges ahead.
Record Enrollment Growth
The 2025 Open Enrollment Period shattered previous records with unprecedented participation, reflecting both increased healthcare demand and the lingering impact of enhanced subsidies. But beneath the surface, enrollment trends reveal deeper challenges ahead.
- Automatic reenrollment surged by 65 %, hitting 10.8 million.
- New consumer enrollments dropped 21 %, reflecting more passive renewals relative to active sign‑ups.
- 42 % of enrollees selected plans costing $10 or less/month after subsidies, while the average postsubsidy premium declined to $113 per month.
This overwhelming growth, especially in auto-renewals and low‑cost coverage, prompted CMS scrutiny over fraud potential and program integrity.
CMS's 2025 Marketplace Integrity and Affordability Rule: Overview
On June 20, 2025, CMS finalized sweeping regulations intended to curb improper enrollment, tighten subsidy eligibility, and reduce federal costs, aiming to cut marketplace premiums by approximately 5 % and save up to $12 billion in 2026.
Key Objectives
To strengthen program oversight and reduce federal spending, CMS introduced a range of strategic objectives in its 2025 Final Rule. These goals underpin the most significant regulatory shifts to the ACA marketplace in years:
- Crack down on alleged fraud, broker misconduct, and unauthorized plan switching— CMS aims to protect the integrity of the Marketplace by addressing widespread concerns about fraudulent applications and broker overreach during enrollment.
- Standardize open enrollment metrics—New federal standards seek to unify enrollment periods and reporting across states to reduce confusion and streamline the consumer experience.
- Reinforce income and identity verification—Stricter verification protocols are being reinstated to ensure that subsidies and special enrollment opportunities go only to those who qualify
- Refocus subsidies to confirmed eligible applicants—By refining subsidy eligibility, CMS plans to minimize waste, direct funds where they’re truly needed, and reduce taxpayer burdens.
Major Policy Changes and Timelines
In response to rising costs and concerns over program integrity, CMS has introduced a sweeping set of rule changes for the individual marketplace, many of which take effect as early as August 2025 and reshape the enrollment experience for Plan Year 2026.
Effective August 25, 2025 (Applies to 2026 Plan Year)
These changes are either immediate or tied to eligibility for Plan Year (PY) 2026 sign‑ups:
- Pause Special Enrollment Periods (SEPs) for individuals at or below 150% of FPL, eliminating the monthly SEP used previously for low-income applicants.
- Exclude DACA recipients from Marketplace eligibility and Basic Health Programs, reverting to pre‑2024 policy interpretations.
- Reintroduce $5 monthly “auto-renew premium,” replacing $0 auto-renewals: starting 2026, auto-enrolled consumers must pay at least $5/month unless they proactively reconfirm eligibility.
- Heightened income verification: reinstating preenrollment checks for at least 75 % of SEP applicants and stricter scrutiny of income attestation via IRS data.
- Broker accountability: enforcement standard shifts to “preponderance of evidence” in agent agreement terminations for market violations.
Changes for Plan Year 2027 and Beyond
Starting with PY 2027, CMS is standardizing OEP across all individual markets:
- All exchanges (federal and state) must open OEP no later than November 1 and close no later than December 31
- OEP limited to nine weeks in duration
- Coverage for new enrollments begins January 1 of the plan year
Temporary versus Permanent Policies
Most of the stricter rules such as the SEP pause, $5 auto-renew fee, and extensive verification are sunsetting after PY 2026 unless legislation cements them permanently. CMS anticipates reversion to earlier policies by PY 2027 barring congressional action.
Impacts and Controversies: What's at Stake
While CMS’s stated intent is to stabilize premiums and reduce improper enrollment, critics argue that these new policies could leave millions without coverage and disproportionately harm low-income or marginalized populations. The debate over these changes is already sparking legal challenges and political tension.
Projected Positive Effects
CMS anticipates several positive outcomes from these rule changes, especially related to cost containment and system integrity. Here are the expected benefits starting in 2026:
- Average marketplace premiums are expected to drop by ~5% in 2026—These rules are designed to curb unnecessary subsidy expenditures, which CMS projects will translate into lower premiums across many plans.
- Reduction in unauthorized or improper enrollments—Tightened verification processes are expected to decrease fraudulent enrollments, improving system fairness and sustainability.
Criticisms and Risks
Despite CMS’s stated goals, the new policies have sparked sharp criticism from advocacy groups, city governments, and healthcare providers. These are some of the most pressing concerns raised:
- 725,000 to 1.8 million individuals could lose coverage—Critics argue that the new rules disproportionately affect vulnerable populations, potentially stripping insurance from hundreds of thousands.
- Lawsuits filed argue the rule undermines ACA access goals—Major cities and advocacy groups are already challenging the rule in court, claiming it contradicts the ACA’s foundational aim of expanding healthcare access.
- Shortened OEP and increased documentation could discourage legitimate enrollees—Some fear that increased red tape may confuse or deter eligible consumers, particularly those with limited digital or financial resources.
"Open Enrollment 2025 shattered records, but CMS's new rules for 2026 may reshape who gets coverage and how."
Interplay Between APTC and eAPTC Subsidies and ACA Benefit Design
Changes to premium tax credits and the definition of essential health benefits add another layer of complexity to the evolving ACA landscape, especially as key provisions from the Inflation Reduction Act are set to expire.
Extended Premium Tax Credits (eAPTC) Ending
Enhanced premium tax credits from the Inflation Reduction Act—benefiting Americans up to 400 % FPL—are set to expire at end of 2025. Without renewal, premium costs could rise up to 15–28% in 2026, especially for those at or above 400 % FPL in some states.
Essential Health Benefits (EHB) Rule Changes
CMS is also restricting coverage of certain sex‑trait modification procedures by excluding them from EHB as early as PY 2026. That marks a significant shift in coverage options for transgender care.
Medicare-Related Changes
CMS updated enrollment guidance for Medicare Advantage and Part D effective 2026:
- Removes voluntary race/ethnicity/gender fields on enrollment forms
- Streamlines special election period instructions and updated model forms.
Looking Forward: Open Enrollment 2026 and 2027
As we approach the 2026 and 2027 plan years, stakeholders must prepare for a marketplace shaped by shortened enrollment periods, more rigid eligibility rules, and evolving coverage standards—all while legal and political outcomes remain uncertain.
OEP in 2026
While 2026’s enrollment period likely stays November 1 to January 15, some states may adjust within the new flexibility window (pre‑2027 rules). The low‑income SEP pause, tighter verifications, and auto-renew premium may cause participation shifts, particularly for vulnerable individuals.
OEP in 2027 and After
For Plan Year 2027, CMS will require broader standardization:
- All individual-market enrollments must occur within nine weeks between November 1 and December 31
- Coverage effective January 1 and auto-renewals only after confirmation, aligning with employer‑sponsored plan cycles
CMS hopes that this will reduce consumer confusion and reduce uninsured gaps, but critics worry it may lower flexibility and choke off late-year enrollments.
Strategic Outlook: What Consumers, Brokers, and Insurers Should Do Now
To succeed under the new regulatory regime, consumers, brokers, and insurers must proactively adjust their strategies, focusing on early enrollment, documentation readiness, and compliance to avoid pitfalls during the tighter OEP/AEP cycles.
For Consumers
Individuals navigating the ACA Marketplace should take these proactive steps to stay compliant and avoid unintentional coverage gaps during the 2026 plan year:
- Plan ahead. With SEPs limited and verification more complex, consumers will need to act early and prepare documentation in advance.
- If eligible, confirm eligibility updates. Passive renewal may not be enough; proactive confirmation will be required to avoid automatic premium charges or loss of coverage.
- Estimate income carefully. With enhanced IRS checks, accurate income reporting is more important than ever to avoid subsidy repayment or ineligibility.
- Watch for changes affecting marginalized groups. DACA recipients and others should stay updated on shifting eligibility rules and explore alternate public health programs if needed.
For Agents and Brokers
With compliance requirements tightening and enrollment behaviors shifting, agents and brokers should take note of these strategic adjustments to stay competitive and avoid regulatory pitfalls:
- Adapt to more seasonal workflows—With fewer year-round SEP options, agents will need to concentrate efforts within shorter enrollment windows and reduce reliance on low-income leads.
- Ensure that systems support income verification—Automation and back-end tracking will be key to helping clients meet the new documentation standards during enrollment.
- Review broker agreements—As CMS increases oversight and lowers the evidence threshold for contract termination, maintaining compliance has never been more critical.
For Insurers and Marketplace Operators
Health plans and marketplace platforms must also prepare for operational and compliance updates. Here’s how insurers and exchange administrators can adapt:
- Update auto-renewal logic—Carriers must adjust backend systems to account for the $5 minimum premium rule and updated eligibility validation processes.
- Educate consumers proactively—Clear outreach and messaging around new enrollment rules can help reduce confusion and improve consumer retention.
- Monitor litigation outcomes—Legal developments in response to the 2025 rule could affect implementation timelines and force rapid policy shifts midcycle.
Why Open Enrollment 2025 and 2026 Will Be Very Interesting
This transitional period blends record-breaking enrollment numbers with some of the most dramatic policy changes since the ACA’s launch—setting the stage for a truly transformative, and potentially contentious, healthcare coverage landscape.
- Tension between expansion and contraction—Record enrollments in 2025 versus rollback of flexibility in 2026.
- Compliance and enforcement—Brokers and carriers must navigate verification and documentation hurdles.
- Consumer confusion risk—SEP loss, tightened windows, and new fees could cause eligible people to miss coverage.
- Policy unpredictability—Lawsuits and legislative outcomes may modify or delay these rules; 2026 may be a transitional year.
- Potential shift in demographic mix—Younger, auto-renewed, subsidy-dependent enrollees may dominate if new rules deter active enrollment among vulnerable groups.
Sources:
- Federal Register: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability
- Healthinsurance.org: ACA Open Enrollment 2025 Guide
- Healthinsurance.org: New federal rule brings immediate changes to Marketplace enrollment
- HealthSherpa: Stay ahead of ACA changes
- Politico: RFK Jr. is making it more difficult to enroll in Obamacare
- Ritter Insurance Marketing: Key Takeaways From the 2025 Marketplace Integrity and Affordability CMS Final Rule
- The Associated Press (AP): Mayors, doctor groups sue over Trump’s efforts to restrict Obamacare enrollment
- The Conference Board: Major Changes to Affordable Care Act Enrollment Policies
- The Washington Post: As GOP eyes ACA cuts, a conservative group highlights rampant fraud
- U.S. Centers for Medicare & Medicaid Services (CMS): CMS Finalizes Major Rule to Lower Individual Health Insurance Premiums for Americans
- U.S. Centers for Medicare & Medicaid Services (CMS): Health Insurance Exchanges 2025 Open Enrollment Report
- U.S. Centers for Medicare & Medicaid Services (CMS): Medicare Managed Care Eligibility and Enrollment
- U.S. Centers for Medicare & Medicaid Services (CMS): 2025 Marketplace Integrity and Affordability Final Rule
"CMS claims to be tightening ACA access to reduce fraud, but critics warn millions could lose coverage. 2026 is a turning point."
Further Thoughts
The intersection of OEP outcomes in 2025 with unprecedented enrollment volume and the new CMS integrity rules sets the stage for a dramatically altered Open Enrollment experience in 2026 and beyond. While CMS claims to strengthen oversight and reduce fraud, policymakers and health advocates warn that these changes could restrict access for many eligible consumers.
Planning ahead whether you’re applying for coverage, advising as a broker, or administering plans is now critically important. Understanding the timeline shifts, document requirements, and subsidy changes will be key to maximizing coverage access in the years ahead.
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