The Centers for Medicare & Medicaid Services (CMS) recently proposed sweeping changes to the 2025 CMS Marketplace rules.
For brokers and agents, these updates bring both challenges and opportunities and will affect how you do business during the next open enrollment.
Shortened Open Enrollment Period
Open enrollment periods would be shortened in all states. The CMS has proposed that open enrollment should run from Nov. 1 through Dec. 15, which is similar to open enrollment for private employer plans.
Additionally, the low-income open enrollment period for individuals is set to be removed, which could limit options for some consumers.
Maximum Out of Pocket Changes (MOOP)
The MOOP levels are proposed to change with those insured seeing higher out-of-pocket expense. For an individual, the MOOP is currently $9,200 and could rise to $10,600. Higher MOOP limits would also apply to family plans.
End to Auto-Renew $0 Coverages
Enrollees can no longer auto-renew coverage that costs nothing after subsidies. The enrollee must pay a $5 a month premium, but this can be avoided if the enrollee updates their financial information by Dec. 15 and remains eligible for the $0 premium.
Income Verification
Requirements to verify income will become stricter for those who cannot verify income through federal data sources. The Marketplace will not accept self-attested income statements without generating a Data Matching Issue (DMI) to resolve the income issue.
Past Due Premiums
The CMS is proposing to allow insurers to collect on past-due premiums before issuing new insurance. Insurers would add the amount owed to the new insurance premium payment. The CMS says, “This change is expected to reduce adverse selection and encourage continuous coverage, potentially leading to more stable premiums and fostering a more stable insurance market.”
Agent Termination
CMS wants to introduce a “preponderance of the evidence” standard when terminating agent agreements with the Marketplace. This standard aims to add transparency and clarity when holding brokers accountable for compliance issues.
Comment Period
These rules changes are in what the CMS calls the “comment period,” where the agency accepts input from the public on these proposals. Comments are accepted through April 10 and you can comment here.
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