The following protections, finalized in the 2026 Final Rule, are at risk of being reversed if the recent Proposed Rule is implemented as written.

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Payment Thresholds

CMS is proposing to eliminate two of the three payment thresholds established in the 2026 Final Rule — the Permit Fixed option (fixed dollar threshold) and the gross-premium threshold under the Premium-Percent options. This would leave only the percentage-based net premium threshold in place.

This remaining threshold ensures that clients who pay at least 95% of their premium (or another percentage as defined by the carrier), after tax credits are applied, are not placed into a grace period. Without this safeguard, low-income clients could experience gaps in coverage.

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The intent behind the proposed change is to strengthen marketplace integrity by holding clients more accountable for premium payments. Given recent concerns about fraudulent enrollments, this could help reduce the risk of individuals being enrolled without their knowledge or consent.

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Reducing the Tax Reconciliation Requirement

Under current policy, individuals receiving premium tax credits have two years to reconcile their credits through tax filing before enrolling again. The new proposal would cut that period to just one year. By reverting to the 2015 policy, CMS aims to minimize improper enrollments and protect consumers from unexpected tax penalties.

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Reducing the Open Enrollment Period (OEP)

The proposed rule seeks to shorten the federal Open Enrollment Period to run from November 1 through December 15.

According to CMS, this change is intended to “reduce consumer confusion, streamline the enrollment process, better align with employer health plan enrollment dates, encourage continuous coverage, and reduce adverse selection.”

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However, this shift reduces the OEP by a full month. For agents working with both Medicare and ACA clients, this means only a one-week window where the OEP doesn’t overlap with Medicare’s Annual Enrollment Period (October 15–December 7). Note: This change only applies to the federal marketplace; state-based marketplaces may adopt similar timelines but are not required to.

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Eliminating the 150 Percent FPL SEP

To preserve program integrity and reduce taxpayer burden, CMS is proposing to eliminate the Special Enrollment Period (SEP) for individuals earning under 150% of the Federal Poverty Level.

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This SEP is especially important in states that haven’t expanded Medicaid. Without it, low-income individuals in non-expansion states could be left without coverage for months unless they qualify for another SEP or wait for the OEP. This change applies only to the federal exchange. We will continue to track how state-based marketplaces respond.

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Stricter Eligibility Verification

The Proposed Rule calls for marketplaces to end the practice of accepting self-attested income estimates when tax data is unavailable. Instead, income would need to be confirmed with documentation or reliable data sources. Limited extensions may still be granted for verification.

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Additionally, CMS wants all marketplaces to verify eligibility for at least 75% of new SEP enrollments. The agency believes this would lead to more consistent eligibility determinations and help maintain a stable risk pool, which could lower premiums for all consumers.

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Amending the Definition of Lawfully Present

The proposal includes a redefinition of “lawfully present” that would exclude Deferred Action for Childhood Arrivals (DACA) recipients. If finalized, this change would prevent Dreamers from enrolling in federal marketplace plans or qualifying for premium tax credits.

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Things to Watch

These proposed changes could significantly affect health insurance agents. So far, there’s no indication that state-based marketplaces will adopt policies similar to the federal proposals, such as terminating agents or changing automatic re-enrollment rules or OEP dates. Agents working in state marketplaces should stay informed about how these rules evolve.

For agents handling both ACA and Medicare enrollments, the overlapping OEP and AEP periods could create a highly compressed and demanding enrollment season. Non-compliant agents could also face termination under stricter CMS rules, which include a new definition of “preponderance of the evidence” to ensure accountability and transparency — aiming to protect consumers from unethical practices.

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These sweeping proposals mark the first major policy shift under President Trump’s second term, with a clear focus on increasing efficiency, cutting federal spending, and cracking down on fraudulent enrollments.