CMS has made significant changes to ACA Marketplace rules that directly affect how agents and brokers operate. These changes come from the 2025 Marketplace Integrity and Affordability Final Rule, which took effect August 25, 2025. This article summarizes the key changes agents need to be aware of and what they mean in practice.

CMS identified widespread improper enrollments in the ACA Marketplace — in many cases, consumers were enrolled in plans without their knowledge, often by agents or brokers responding to misleading advertisements. These rule changes are designed to reduce fraud, protect consumers, and ensure subsidies go only to eligible individuals.

1. The 150% FPL Special Enrollment Period has been eliminated.

Effective August 25, 2025, the Special Enrollment Period (SEP) that allowed consumers with income at or below 150% of the Federal Poverty Level to enroll year-round has been removed. This SEP was identified as a major driver of unauthorized enrollments. After August 25, 2025, consumers who previously used this SEP must now have a qualifying life event to access a SEP outside of Open Enrollment. Note: This is a temporary measure scheduled to expire at the end of Plan Year 2026, after which the SEP is expected to resume in 2027.

2. Income verification requirements have been strengthened — and the 90-day DMI window is now a hard deadline.

Starting August 25, 2025, the Marketplace will no longer accept a consumer's self-attested income in two specific circumstances:

In either of these situations, a Data Matching Issue (DMI) is triggered and the consumer must submit documentation to verify their income.

What is the 90-day DMI window?

Under the ACA, consumers with an income DMI have 90 days from their eligibility decision to submit the required documentation. While the DMI is open, the consumer can enroll in a plan and continue receiving APTC — but if they do not resolve the DMI within 90 days, they will lose their APTC eligibility.

What changed with the 90-day DMI window?

Previously, consumers were given an automatic 60-day extension on top of the 90-day period, giving them up to 150 days total to resolve an income DMI. CMS permanently eliminated this automatic 60-day extension. The 90-day window is now a hard deadline — there are no automatic extensions. Consumers who do not submit acceptable documentation within 90 days will lose their APTC. CMS estimates this change alone will affect approximately 140,000 FFM enrollees and 86,000 state-based Marketplace enrollees per year.

What documentation is required to resolve an income DMI?

Consumers must upload or mail documentation to the Marketplace that substantiates their projected annual income. Acceptable documents include:

What should agents do when a client has a DMI?

After completing an enrollment, always review the eligibility determination notice for any DMI listed under the Next Steps section. If a DMI is present, inform the client immediately and set a clear expectation that they have 90 days to submit documentation — no extensions will be granted automatically. Track the deadline and follow up with the client well before it expires. If a client made a good faith effort to obtain documents but needs more time beyond 90 days, they may call the Marketplace Call Center to request additional time, though this is not guaranteed.

Note: Citizenship and immigration DMIs have a slightly longer window of 95 days.

Note: The income verification requirement is scheduled to sunset on December 31, 2026, unless extended by legislation or regulation.

3. Failure to file and reconcile APTC now results in faster subsidy removal.

Previously, consumers had to fail to file and reconcile APTC for two consecutive years before losing their subsidy. CMS has reinstated the one-year rule — consumers who fail to file their federal tax return and reconcile their APTC for a single year will be determined ineligible for APTC the following year. Agents should remind clients to file their taxes on time and reconcile any APTC received each year to avoid losing their subsidy.

4. Concurrent Medicaid and Marketplace enrollment is being actively enforced.

CMS reinstated twice-yearly Periodic Data Matching (PDM) checks to identify consumers enrolled in both Medicaid or CHIP and a Marketplace plan with APTC at the same time. Over 550,000 enrollees had their APTC ended in 2025 after CMS identified concurrent enrollments. Clients who gain Medicaid eligibility must be disenrolled from their APTC-subsidized Marketplace plan.

5. Unauthorized plan switching is being actively addressed.

CMS estimates approximately 200,000 consumers had their plan changed without their consent in 2025. Agents and brokers must never change a consumer's plan without their explicit consent. Unauthorized plan changes are a compliance violation and subject to enforcement action.

6. Agent and broker accountability standards have been raised.

CMS finalized a "preponderance of the evidence" standard for terminating an agent or broker's Marketplace Agreement. This means CMS can terminate an agent or broker's Exchange Agreement if the evidence shows it is more likely than not that a compliance violation occurred — a lower bar than before. CMS also has the authority to suspend an agent's or broker's ability to transact with the Exchange if their activity poses unacceptable risk to consumers or Exchange operations.

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