On August 22, 2025, a federal judge in Maryland paused the enforcement of select provisions—though not all—within the 2025 Marketplace Integrity and Affordability Final Rule.
Here’s a breakdown of what this development means for health insurance agents and the clients they serve under the Affordable Care Act (ACA).
Challenging the CMS 2025 ACA Final Rule
On June 20, 2025, the Centers for Medicare & Medicaid Services (CMS) released the 2025 Marketplace Integrity and Affordability Final Rule. Soon after, on July 1, 2025, the cities of Columbus, Chicago, and Baltimore, joined by advocacy organizations Doctors for America and the Main Street Alliance, filed a lawsuit against the Department of Health and Human Services (HHS).
The lawsuit claims that HHS violated the Administrative Procedure Act in the way the rule was implemented and argues that the changes conflict with the Affordable Care Act (ACA). According to the plaintiffs, the rule could create new obstacles to obtaining health coverage and may put more than two million people at risk of losing insurance.
Before the case proceeds, Judge Brendan A. Hurson of the U.S. District Court for the District of Maryland temporarily halted certain parts of the Final Rule, noting that the plaintiffs have a strong chance of success in their legal challenge.
2025 ACA Rule Changes Put on Pause
Several elements of the 2025 Marketplace Integrity and Affordability Final Rule were scheduled to take effect on August 25, 2025. However, key provisions have been delayed pending the outcome of ongoing litigation. The paused changes include:
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Income Verification Requirements
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When an applicant attests to premium tax credit (PTC) eligibility but federal data shows income below 100% of the federal poverty level (FPL).
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When no tax records are available to confirm income.
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Past-Due Premiums
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Permitting insurers, if allowed under state law, to deny new enrollment until past-due premiums with that insurer are paid.
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$5 Monthly Fee for Passive Enrollment
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Applying a $5 fee to enrollees in $0 premium plans who fail to actively reenroll during open enrollment, starting with Plan Year 2026.
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De Minimis Adjustments
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Allowing insurers to design plans with actuarial values below the standard benchmark, beginning with Plan Year 2026.
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Stricter SEP Verification
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Adding new verification steps for some of the most frequently used special enrollment periods (SEPs), effective Plan Year 2026.
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Shorter Reconciliation Window for PTC
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Reducing the timeframe from two years to one year before individuals who fail to reconcile advanced PTCs (APTCs) on their tax returns lose eligibility, starting in Plan Year 2026.
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Marketplace Integrity & Affordability Rules Now Active
As of August 25, 2025, several provisions of the ACA Final Rule have officially taken effect:
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Income Inconsistencies
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Marketplaces can no longer grant applicants an automatic 60-day extension beyond the standard 90-day window to resolve income verification issues.
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Special Enrollment Period (SEP) Removal
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The SEP for individuals with incomes at or below 150% of the federal poverty level (FPL) has been eliminated nationwide.
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DACA Coverage Changes
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Recipients of Deferred Action for Childhood Arrivals (DACA) are no longer eligible for marketplace coverage or premium tax credits (PTCs).
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In HealthCare.gov states, their coverage will end on September 30, 2025.
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Stricter Oversight of Agents and Brokers
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A new “preponderance of evidence” standard has been established, requiring HHS to apply this threshold when determining whether to terminate an agent, broker, or web-broker for cause.
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Marketplace Still Awaits Legislative Certainty
The impact of the court-ordered stay on the health insurance marketplace remains unclear, particularly with the ACA subsidy cliff drawing nearer. One major area of concern is how the lawsuit might influence ongoing debates about whether to extend enhanced advance premium tax credits (APTCs)—a decision that insurers, agents, and consumers under 65 have been anxiously awaiting.
If the enhanced subsidies are not renewed, millions of ACA enrollees could lose their coverage. Enrollment could also decline further if the paused rule changes are eventually allowed to take effect, as these provisions may create additional hurdles for individuals trying to obtain or keep ACA coverage.
Staying Informed and Guiding Clients Will Be Essential This OEP
Some of the provisions currently on hold in the 2025 ACA Final Rule also appear in the One Big Beautiful Bill (OBBB), though with later effective dates. For instance, beginning January 1, 2028, exchanges will be required to verify eligibility for premium tax credits before enrollment. Depending on how the court ultimately rules, certain provisions may simply be deferred until their OBBB start date. This overlap creates another layer of complexity for both clients and the broader marketplace.
Given the uncertainty, it’s especially important for agents to stay on top of ACA updates as the Open Enrollment Period approaches. Resolutions could emerge closer to OEP, and agents will play a critical role in helping clients understand what’s changing. The challenge will be striking the right balance—offering clarity without overwhelming clients with too much technical detail.
Looking Ahead
Right now, many questions remain unanswered, and there’s no set timeline for when Judge Hurson will issue a final decision on the 2025 ACA Final Rule lawsuit or when discussions around premium tax credits (PTCs) will be resolved.
To keep up with the latest developments in ACA and Medicare, we invite you to subscribe to our blog and sign up with Essential Care.
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