Eligibility Changes
DACA Recipients
Effective August 25, 2025, DACA recipients are no longer eligible to enroll in ACA Marketplace plans.
Low-Income Special Enrollment Period (at or below 150% FPL)
The monthly Special Enrollment Period (SEP) available to consumers at or below 150% of the Federal Poverty Level (FPL) ended as of August 25, 2025.
Until further notice, low-income clients who miss Open Enrollment will need a separate qualifying life event to enroll.
Carrier and Application Changes
NPN Overrides
Some carriers and states have removed the ability for agents to override the agent NPN on an application. Verify whether NPN overrides are permitted for each carrier and state before submitting an application.
Income Verification Timeline
CMS has strengthened income verification requirements. Consumers generally have a total of 90 days to verify their income after submitting an application.
Inform clients of this deadline at the time of enrollment and follow up proactively to avoid loss of coverage or financial assistance. In some cases, exceptions or extensions may be granted based on Marketplace determinations.
CMS Rule Highlights: What Is in Effect vs. Subject to Change
Some 2025–2026 CMS rules are fully in effect. Others are subject to implementation timing or legal and regulatory processes. Agents should be aware of both categories.
Currently in Effect
DACA eligibility removal — Fully in effect as of August 25, 2025.
Low-income SEP ending — In effect as of August 25, 2025.
Tax reconciliation (Failure to Reconcile — FTR) — For 2026, a one-year reconciliation requirement applies. Future enforcement may expand; agents should monitor CMS guidance for updates.
Subject to Change / Pending Implementation
Auto-renewals and subsidy rules — Certain processes may be updated based on future CMS guidance or rulemaking.
Data matching and income verification expansions — Additional verification requirements may be implemented; timing is subject to CMS updates.
Open Enrollment shortening — The shortened Open Enrollment window (November 1 – December 15) is not in effect for 2026 and remains subject to future implementation.
Agents should monitor CMS communications for updates, as changes may occur with limited notice.
Subsidy Changes
What Agents Need to Understand
Subsidies are changing for the 2026 plan year. The enhanced premium tax credits that were introduced and extended in recent years have expired, which may impact what clients pay.
Key impacts:
Clients with $0 premium plans — Many clients started paying premiums again.
Clients above 400% FPL — These clients lost subsidy eligibility under the expiration of enhanced credits.
Overall cost impact — Many consumers experience higher net premiums in 2026 compared to 2025, depending on income, age, and rating factors.
When reviewing clients for renewal, recalculate subsidy eligibility based on current income rather than assuming prior-year figures still apply.
Catastrophic Health Plans
General Eligibility
Catastrophic plans are available to two groups:
Under age 30 — Any consumer under 30 can purchase a catastrophic plan without needing an exemption.
Age 30 and older — Consumers must qualify for a hardship or affordability exemption to be eligible.
Expanded Hardship and Affordability Exemptions
Eligibility for hardship and affordability exemptions has been expanded. Consumers who are projected to be ineligible for Advance Premium Tax Credits (APTC) or Cost-Sharing Reductions (CSR) based on their annual household income may qualify. This includes:
Consumers with income below 100% of the Federal Poverty Level (FPL)
Consumers above 400% FPL who are ineligible for CSRs
The exemption application process is available through HealthCare.gov or through state-based exchanges.
Key Features of Catastrophic Plans
Premiums — Generally lower monthly premiums than metal-tier plans.
Deductible — Very high annual deductible that must be met before most coverage activates.
Essential health benefits — All ACA-required essential health benefits are covered.
Preventive care — 100% covered with no deductible requirement. Plans also cover at least three primary care visits per year before the deductible is met.
Income and Eligibility: What Agents Need to Know
What Counts as Income (MAGI)
The ACA uses Modified Adjusted Gross Income (MAGI) to determine eligibility for premium tax credits (APTC), cost-sharing reductions (CSR), Medicaid, and CHIP. MAGI is calculated as:
Adjusted Gross Income (AGI) + the following, if applicable:
Nontaxable foreign income
Nontaxable Social Security benefits
Tax-exempt interest
MAGI does not include Supplemental Security Income (SSI). MAGI does not appear as a line item on a tax return — agents and clients should not look for it there. For most consumers, MAGI is the same as or very close to their AGI.
Household Income on the Application
The Marketplace application requires income information for every person included in the client's federal tax household. In some cases, additional family members not on the tax return may also need to be entered. Guide clients carefully through this section to avoid eligibility errors.
Proof of Income Documents
When clients need to verify income, the following documents are commonly accepted:
Pay stubs — The two most recent pay stubs from each employer.
Federal tax return — Most recent Form 1040.
Wage and tax statements — W-2s and 1099s.
Self-employment records — Profit and loss statement, self-employment ledger, or Schedule C.
Social Security statement — Letter from the Social Security Administration.
Unemployment benefits letter — Official letter confirming unemployment benefits.
Reporting Expected Income Changes
If a client's income is expected to change during the coverage year, advise them to use documentation that reflects their current situation — not prior-year records. For example, a client who has started a new job should submit recent pay stubs from that job rather than tax returns from the previous year.
Self-employed clients with variable income may submit a written explanation that includes their name, address, application ID, and FFM ID number.
All documents must be legible, accurate, and clearly show the client's name, income amount, and the relevant tax year or pay period. Late or incomplete documentation can delay coverage or result in loss of financial assistance.
Compliance
Agent Compliance: Reporting Accurate Income
Agents must reinforce to clients that it is their responsibility to report accurate income — not the income estimate that maximizes their Premium Tax Credit (PTC). Inaccurate income reporting creates reconciliation liability for the client at tax time.
Agent Compliance: Consent and Account Access
The following rules apply to all agent-assisted ACA enrollments. These are CMS requirements, not internal guidelines.
Consumer accounts must use the consumer's email address only — or the email of their legally authorized representative. Do not enter your own professional, company, or agency email on a consumer's application.
Do not use or create dummy email addresses in place of the consumer's actual email.
Do not maintain ongoing access to a client's account or their associated email account after the enrollment is complete.
If a client may be eligible for Medicare, direct them to Medicare for an eligibility determination before assisting them with enrolling in a Qualified Health Plan (QHP).
Special Enrollment Periods (SEPs)
Changes in Household
Clients may qualify for a Special Enrollment Period if any of the following occurred in the past 60 days:
Marriage — Coverage can start the first day of the month following the last day of the enrollment month.
Birth, adoption, or foster placement — Coverage starts on the date of the event, even if the client enrolls up to 60 days afterward.
Divorce or legal separation with loss of coverage — Divorce or legal separation alone, without loss of health coverage, does not qualify.
Death of a household member — If the death causes the client to lose their current health plan, a SEP is triggered.
Changes in Residence
Clients may qualify for a SEP if they move to:
A new home in a new ZIP code or county
The United States from a foreign country or U.S. territory
Or move to or from: a place of school enrollment (students), a place of seasonal work, or a shelter or transitional housing
Moving solely for medical treatment or vacation does not qualify. For domestic moves, the client must provide proof of qualifying health coverage for at least one day during the 60 days prior to the move. Proof is not required for moves from a foreign country or U.S. territory.
Loss of Health Coverage
Clients who lost Medicaid or CHIP coverage within the past 90 days may qualify for a Special Enrollment Period. Document the loss of coverage carefully, as this SEP type requires verification.
Summary: Key Takeaways for Agents
Fewer consumers may qualify for Marketplace coverage due to recent eligibility and SEP changes.
Subsidies are changing.
Income verification rules are stricter and time-sensitive. Follow up with clients promptly after enrollment to ensure documentation is submitted within required timeframes.
Some CMS policies are subject to change or future implementation. Stay current on CMS guidance.
Agent compliance rules around consent, email addresses, and account access are CMS requirements and must be followed on every enrollment.