BLOCKED: 7 new ACA provisions might not affect your OEP

Just in the nick of time, federal courts have placed a stay on the Department of Health and Human Services’ newest armory of fraud weapons. The cities of Columbus, Ohio; Baltimore, Maryland; and Chicago, Illinois, along with two other nonprofits are challenging nine provisions of the final rule created by the Department of Health and Human Services for the Marketplace back in March of 2025. The court ruled seven of these provisions should be reviewed further before they are enforced, but two are likely to remain. If the temporary blocks are made permanent, about 1.8 million people will keep their coverage intact. Which rules were stayed, which were denied the stay, and how will that affect your OEP?

What is getting paused?

While nine elements are being challenged; seven are stayed. These provisions would have gone into effect August 25, 2025, so these stays will probably change some of your OEP strategy. Here is what is getting paused:

$5 Re-enrollment “fee”

The provision reducing someone’s advance premium tax credits (APTCs) by $5 in the first month of re-enrollment is paused. This action would have essentially made a plan’s premium $5 a month until the consumer verified their APTCs, and therefore their eligibility for that with the Marketplace. If the consumer didn’t pay that $5, they would not be re-enrolled until they did. So, for now, passive renewals for these clients may continue.

Past-due premiums

HHS had wanted to allow carriers to force consumers to pay past-due premiums along with the binder payments before effectuating new coverage with that carrier. That provision is also stayed, mostly owing to the ACA providing guaranteed-issue coverage to applicants. For now, your members will be able to re-enroll, even if they owe back premiums. The nixing of consumers’ protections to keep their coverage even if their premiums went unpaid will be on hold. So if one of your consumers is worried the plan will disappear on them if they are unable to pay at some point, they will still have a bit of a cushion.

Actuarial value

The changes regarding the configuring of actual value standards will not be implemented for now. Long story short, this probably would have reduced the amount of premium tax credits available for your clients as the estimated value of the second lowest silver plan would have been lower.

Special enrollment period (SEP) eligibility verification requirements

SEPs would have had to be verified previous to the enrollment. But instead, the rule will stay as it is now, where an SEP can be verified after an enrollment. Coverage can still be revoked though, if the SEP is found to be invalid. So you will still need to make sure your clients can prove at some point their SEP is valid, they just won’t need to right when they enroll.

Failure-to-reconcile provision

HHS had planned to revoke eligibility for premium tax credits and advanced premium tax credits if a consumer failed to file and reconcile. However, the court found it likely this language contradicts the actual text of the Affordable Care Act. And so, it may be possible that enrollees will be eligible to receive future tax credits, even if they do not reconcile their taxes each year. For now, your client’s two year grace period is still safe.

Income verification when data shows income below 100% of the federal poverty level

If clients’ reported income didn’t match current-year IRS data, and that discrepancy meant the difference between meeting or surpassing the federal poverty level, it will no longer cost them the opportunity to stay on Medicaid. Your clients will still have another chance to rectify income levels if they need to.

Income Verification When Tax Data is Unavailable

No tax data? No income verification. No income verification? No APTCs, no Medicaid. This would have been the lay of the land, but a stay has been placed on this rule, too. If your clients do not have tax data on record, it will not be an automatic reason for denial.

What is holding on?

But two rules provisions will be implemented as planned:

Eliminating the Automatic 60-Day Extension was found to likely be legal. Household income data must be provided within 90 days of an enrollment, and your clients will not be able to submit attestations.

The Premium Adjustment Percentage calculations will still be reverted back to 2020-2021 formulations. This will probably change the amount your clients will have to pay when it comes to cost sharing.

You didn’t mention any dates?

The Open Enrollment window’s dates went unmentioned. So for now, it will probably remain shortened to the November 1 to December 15 timeline, beginning with plan year 2027.

Will the stays remain for OEP?

It’s pretty feasible. The APA states that proposed rules with irreversible effects can be paused for more review. Someone permanently losing their health insurance because they failed to produce some paperwork was ruled reason enough to pause for further review. This case will probably take months, meaning the stay has the potential to hold across OEP. Keep in mind too, this is not the only challenge to these new rules: 20 states have stepped up to bat in the Massachusetts court as well, with the results still yet to be seen. So if this challenge fails, another is in the works.

But what if they don’t?

1.8 million people will likely lose coverage. 400,000 of them will likely have access to health insurance through their employer, but it may be considered unaffordable by IRS standards. There currently is a financial penalty for the employer if their employees pay more for health insurance than what is considered affordable, which is why so many choose to offer ICHRAs to pair with those probably-soon-to-be-defunct-expanded subsidies. But can those penalties still apply if there are no subsidies to be had for affordable coverage elsewhere? It’s unclear: The way these penalties will be handled has not been mentioned as of yet. So employer group agents might not be out of the line of fire yet if any groups wind up getting stuck with those fines later on.

A few months later…

While the ACA was designed to “increase the number of Americans covered by health insurance and decrease the cost of health care,” this lawsuit exemplifies the discourse on how to satisfy that last portion. The current administration is looking to cut costs by weeding out income fudgers or extension period abusers. And that’s not to say there aren’t crooks out there who are signing consumers up for plans without their consent to make a buck.

If these changes eventually are unpaused, it would alter your plan of attack for some clients. Assume, for example, the $5 unverified consumers might pay to keep their coverage is trivial to them. But, you as their agent would want to make sure they understand the consequence, both for the sake of their wallet and your commissions. For now, you can confidently know that you can use your previous knowledge on how these factors work to make great decisions for your clients. Hopefully for the sake of your renewals, these new hurdles to maintain coverage are kept at bay, and the stays remain. Stay tuned, we’ll keep you on top of what might happen in the courtroom that will make your book of business unstable.