This week’s series covers:
- CMS Proposes New Marketplace Integrity and Affordability Rules
- CMS to End Medicare Advantage VBID Model by 2025 Due to Costs
Missed Last Week’s Healthcare.com Roundup? Here’s what happened:
- March 3, 2025
- February 25, 2025
- February 13, 2025
- February 5, 2025
- January 31, 2025
- January 22, 2025
- January 15, 2025
- January 8, 2025
CMS Proposes New Marketplace Integrity and Affordability Rules
The Centers for Medicare & Medicaid Services (CMS) has introduced the Marketplace Integrity and Affordability Proposed Rule, outlining new regulations for Health Insurance Marketplaces, insurers, agents, and brokers involved in Affordable Care Act (ACA) enrollments.
Key Proposed Changes
Consumer Eligibility & Verification
The proposal makes income verification stricter to prevent ineligible enrollments. It removes Deferred Action for Childhood Arrivals (DACA) recipients from ACA Marketplace eligibility; DACA is a program that protects certain undocumented immigrants who were brought to the U.S. as children from deportation.
Consumers using special enrollment periods (SEPs) must complete pre-enrollment verification. The way eligibility is checked and renewed will also change.
Marketplace Plan Regulations
Marketplace plans will no longer cover sex-trait modifications as an essential health benefit (EHB). (However, this is subject to state-mandated benefits and does not prohibit states from requiring the coverage of sex trait modification.) Sex-trait modifications refer to treatments like gender-affirming surgeries or hormone therapy for individuals transitioning between genders.
The Open Enrollment Period (OEP) will be shortened to Nov. 1- Dec. 15. The special enrollment period (SEP) for consumers with incomes below 150% of the federal poverty level (FPL) will be removed.
Tax Credit & Enrollment Oversight
Consumers who get advance premium tax credits (APTC), also known as ACA Subsidies, must now reconcile them every year to stay eligible. The process for automatically renewing health plans will change. There will be stricter rules for agents, brokers, and web brokers to make sure they follow Marketplace guidelines.
Why This Matters
For Consumers
The proposed rule introduces stricter eligibility criteria, which may help reduce fraudulent or improper enrollments, potentially leading to more stable insurance premiums. However, these changes could also create barriers to coverage, particularly for DACA recipients and low-income individuals who will no longer have access to a special enrollment period (SEP). Additionally, implementing enhanced income verification measures may help ensure that premium subsidies are allocated correctly, reducing the risk of tax discrepancies for consumers.
For Agents, Brokers, and Insurers
The increased compliance requirements outlined in the rule may affect agent and broker participation in the Marketplace, potentially altering how they assist consumers with enrollment. There will also be the implementation of a process for holding agents, brokers, and web-brokers accountable for noncompliance with applicable law. Changes to SEP verification could make it more challenging for agents and brokers to enroll consumers outside the Open Enrollment Period, which may impact commission-based sales. Furthermore, the exclusion of sex-trait modification coverage as an essential health benefit (EHB) could influence plan offerings and consumer demand, requiring insurers to reassess their coverage options.
Editor’s Note: This is a summary of the proposed rule and not a complete outline of all changes presented by HHS. There could be slight alterations from the published document if minor editorial changes are made during the review process. Healthcare.com will keep you apprised of updates as they are received.
CMS to End Medicare Advantage VBID Model by 2025 Due to High Costs
The VBID model will be phased out due to increased costs to the Medicare Trust Funds—here’s what it means for enrollees and industry stakeholders.
CMS is terminating the Medicare Advantage Value-Based Insurance Design (VBID) Model at the end of 2025 due to its considerable costs to the Medicare Trust Funds, totaling $2.3 billion in 2021 and $2.2 billion in 2022.
Evaluation findings revealed that these increased costs were driven by higher enrollee risk scores and increased Part D expenditures, with no viable policy modifications to address the financial impact.
CMS made adjustments for 2025 but determined that continuing the model would not align with its statutory requirement to control costs, leading to the decision to end it.
To support enrollees, CMS will coordinate with Medicare Advantage plans, advocacy groups, and State Health Insurance Assistance Programs to ensure a stable transition by 2026.
Why This Matters
For Consumers
The termination of the VBID model may impact Medicare Advantage enrollees who benefited from its specific benefits, such as cost-sharing reductions, wellness programs, and services addressing social determinants of health.
- Consumers enrolled in plans that participated in VBID may see changes in their coverage options for 2026, potentially affecting out-of-pocket costs and access to certain supplemental benefits.
- CMS plans to work with beneficiary advocacy groups and State Health Insurance Assistance Programs to help enrollees navigate these changes during the 2026 Open Enrollment Season.
- Seniors and individuals with chronic conditions who relied on VBID’s targeted benefits should review their options carefully when selecting a plan for 2026.
Why This Matters for Health Insurance Agents, Brokers, and Partners
Agents and brokers serving Medicare Advantage consumers will need to stay informed about the VBID model’s termination and how it affects plan offerings for 2026.
- Some plans that previously participated in VBID may adjust their benefits, impacting how agents guide clients in selecting the best coverage.
- Brokers should be prepared to explain these changes to beneficiaries, ensuring they understand any modifications in cost-sharing, supplemental benefits, or eligibility criteria.
- Industry partners working with MA plans may also need to adapt their strategies as plans shift their approach to benefit design in response to VBID’s discontinuation.
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