As the Affordable Care Act Marketplaces enter their 12th year, enrollment is at an unprecedented high, insurer competition is robust, and four out of five Marketplace enrollees can find a plan for $10 per month or less. This has also been a year of relative stability, without dramatic policy reforms or market disruptions. However, there are several important policies and programmatic changes that could impact Marketplace consumers next year.
New Coverage Options for the Dreamers
“Dreamers” are individuals who came to the U.S. as children without documentation. Many have received “Deferred Action for Childhood Arrivals” or DACA status from the U.S. Department of Homeland Security, which provides temporary protection from deportation and authorization to work in the U.S. In May 2024, the Biden Administration finalized a rule allowing DACA recipients to sign up for subsidized Marketplace and Basic Health Program coverage (sometimes referred to as the “ACA DACA” rule). While the administration declined to adopt a similar policy for Medicaid and the Children’s Health Insurance Program (CHIP), DACA recipients who would be otherwise eligible for Medicaid and CHIP may qualify for Marketplace financial assistance.
Beginning November 1, DACA recipients will be eligible to enroll in one month of coverage for December 2024 and/or coverage for plan year 2025. However, several state attorneys general have sued to block the ACA DACA rule, and a federal court is considering their request.
A Standard Open Enrollment Period
The federally facilitated Marketplace (FFM) and State-based Marketplaces (SBMs) must now adhere to a standardized open enrollment period, from November 1 to January 15, with one exception. The Centers for Medicare & Medicaid Services (CMS) granted an exception to Idaho’s SBM, which begins its open enrollment period on October 15. Under federal rules, Idaho’s open enrollment period must last for a minimum of 11 weeks.
New Efforts to Crack Down on Broker-Driven Fraud
In the past year, the FFM has experienced an increase in unauthorized enrollment and plan switching. Between January and August, 90,000 Marketplace enrollees reported that they were switched to a new plan without their consent, and over 180,000 consumers reported that they were enrolled in a Marketplace plan without authorization. These enrollments are driven by unscrupulous agents and brokers who receive a financial commission from insurers when they enroll someone in a new plan. CMS has taken several steps to protect consumers. In particular, if a broker or agent is not associated with a consumer’s previous enrollment, they must participate in a 3-way call with the Marketplace before they can switch the consumer to a new plan. CMS has also been working to unwind the coverage of consumers who were fraudulently enrolled, protecting them from potential financial or tax liability. The agency has further blocked 850 agents and brokers from facilitating Marketplace enrollments. Consumers who believe they may have been fraudulently enrolled in a plan should call the Marketplace call center at 1-800-318-2596.
Maximum Appointment Wait Times
Beginning in 2025, insurers in the FFM will be required to meet new standards to ensure that their enrollees can obtain health care appointments within reasonable time frames. Specifically, insurers must demonstrate that they can meet the below wait time standards at least 90 percent of the time:
| Provider Specialty Type: | Appointment Must be Available Within: |
| Behavioral health | 10 business days |
| Primary care (routine) | 15 business days |
| Specialty care (non-urgent) | 30 business days |
New State-Based Marketplaces
The state of Georgia has transitioned from a state-based Marketplace (SBM) using the federal enrollment platform to a fully state-run Marketplace, Georgia Access. Consumers will no longer use HealthCare.gov to enroll, and instead can sign up through GeorgiaAccess.gov.
Illinois and Oregon are in the midst of their own transitions to state-based Marketplaces. For this open enrollment, Illinois will operate a state-based Marketplace on the federal platform (HealthCare.gov), shifting to a full SBM for plan year 2026. Oregon’s transition will follow one year later, for plan year 2027.
Limits on Non-Standardized Plans
Beginning in 2025, insurers in the FFM are limited to offering two non-standardized plans in each of the following four categories:
- product network type;
- metal level;
- inclusion of dental and/or vision benefits; and
- service area
However, insurers can obtain an exception to this limit if they can demonstrate that they’re offering plans with specific design features that benefit people with chronic and high-cost conditions. Specifically, insurers must show that their plans provide a 25 percent reduction in cost-sharing for benefits pertaining to the treatment of a chronic and high-cost condition.
Advance Notice of Failure to Reconcile
Beginning November 1, all Marketplaces are required to implement a policy that bars consumers from receiving future advance premium tax credits (APTCs) if they have failed to file taxes and reconcile (FTR) their APTCs for two years in a row. Beginning 2025, the Marketplaces must notify consumers after one year if they are at risk of losing APTCs due to their FTR status.
