HHS Issues Final Rule on Marketplace Integrity and Affordability Including Annual Maximum Out-of-Pocket Limits 

August 2025 

Diana Craig, Director, Benefits Compliance 

On June 20, 2025, the U.S. Department of Health and Human Services (“HHS”) issued a Final Rule on Marketplace Integrity and Affordability under the Affordable Care Act (“ACA”). Most importantly, the Final Rule establishes 2026 maximum annual limitations on cost sharing at $10,600 for self-only coverage and $21,200 for other than self-only coverage. Otherwise, the balance of the modifications detailed in the Final Rule restrict marketplace eligibility, enrollment, and the availability of subsidies. These changes will likely result in approximately 1.8 million current exchange enrollees either dropping coverage or losing access to coverage, which may result in increased enrollment in employer sponsored group health plans. Alternatively, limiting subsidy eligibility could reduce employer costs by decreasing potential penalty risks, consistent with the requirements of Internal Revenue Code Section 4980H(b) (that is, the “B” penalty under the Employer Shared Responsibility Provisions of the ACA).   

Employer Action Items 

• Plan to implement the revised 2026 maximum annual limitations respecting all plan-level cost sharing.  

• Assess whether a shift in enrollment from exchanges onto group health plans due to a reduction in eligibility or access to subsidies will potentially result in a net increase in employer enrollment and related employer benefit costs.  

• Review individual coverage Health Reimbursement Arrangements (“HRAs”), as these changes may result in lower overall participation rates associated with such account-based plans.  

Summary 

The Final Rule on Marketplace Integrity and Affordability (“Final Rule”) establishes the maximum annual limitation on cost-sharing for 2026 as $10,600 for self-only coverage and $21,200 for other than self-only coverage. The revised limitation supersedes the previously announced 2026 draft limits of $10,150 and $20,300, respectively.  

The Final Rule also includes several changes that will restrict marketplace eligibility and enrollment, as well as reduce the availability of certain enrollment subsidies. These changes are effective beginning in sixty (60) days; however, generally, they are effective for calendar year 2026 operations/enrollments. More than half of the changes in the Final Rule sunset (that is, become ineffective due to lapse) at the end of calendar year 2026, as they were designed as temporary measures to address fraud, waste, and abuse in the short term. The most significant changes in the Final Rule are detailed below. 

Permanent policy changes include: 

• Repealing the rule that prohibits issuers from denying coverage based on unpaid past-due premiums.  

• Changing the annual Open Enrollment Period (“OEP”) beginning with the OEP for plan year 2027 for both on- and off-Marketplace individual market coverage. Exchanges can set their own OEPs, but each OEP must start no later than November 1 and end no later than December 31, and the OEP may not exceed nine (9) calendar weeks. All OEP enrollments must begin on January 1.  

• Amending the definition of “lawfully present” to exclude Deferred Action for Childhood Arrivals (“DACA”) recipients, making them ineligible to enroll in a Qualified Health Plan (“QHP”) through the Marketplace, for premium tax credits, and cost-sharing reductions (“CSR”).  

• Removing the automatic sixty (60) day extension of the statutorily required ninety (90) day period for resolving income inconsistencies.  

• Repealing the regulation that allows Marketplaces to automatically re-enroll CSR-eligible bronze QHP enrollees in a silver QHP with the same provider network if it has a lower or equivalent net premium as the bronze plan into which the enrollee would have been re-enrolled. 

• Prohibiting issuers subject to Essential Health Benefit (“EHB”) requirements (non-grandfathered individual and small group market plans) from covering specified sex-trait modification procedures, as an EHB. The final rule notes that this policy will not prohibit issuers subject to EHB requirements from voluntarily covering specified sex-trait modification procedures, nor will it prohibit states from requiring coverage of such services, subject to the rules related to state-mandated benefits. 

• Widening the de minimis ranges allowed in determining the Actuarial Value (“AV”) of most exchange benefit options to +2/-4 percentage points for all individual and small group market plans and +5/-4 percentage points for Bronze plans.  

Policy changes that will sunset at the end of calendar year 2026 include: 

• Requiring exchanges to determine an individual ineligible for advance payments of the premium tax credit (“APTC”) if they failed to file their federal income taxes and reconcile APTC for one (1) year instead of for two (2) consecutive tax years. 

• Requiring that Marketplaces evaluate annual income inconsistencies in certain circumstances when a tax filer’s attested projected annual household income would qualify the taxpayer as subsidy eligible due to having an income between 100% and 400% of the federal poverty level (“FPL”), while the income data returned by the Internal Revenue Service report an income of less than 100% FPL. 

• Removing the requirement that exchanges accept an applicant’s self-attestation of projected annual household income when the exchange attempts to verify the attested projected annual household income with the IRS, but the IRS indicates there is no tax return data available. Exchanges will be required to verify income with other trusted data sources (if available) and to require applicants to submit documentary evidence or otherwise resolve the income inconsistency.  

• Requiring Marketplaces on the Federal platform to ensure that consumers who are automatically re-enrolled with no premium responsibility following the application of APTC and without affirming or updating their eligibility information, are automatically re-enrolled with a $5 monthly premium until they update their information and confirm $0 premium eligibility. 

• Repealing the monthly special enrollment period (“SEP”) for individuals with projected household incomes at or below 150% of the FPL, due to concerns over unauthorized enrollments and adverse selection risk. 

• Finalizing a requirement that Marketplaces conduct pre-enrollment verification for SEP eligibility on the Federal platform (this provision does not apply to State Marketplaces at this time). 

• Mandating pre-enrollment eligibility verification for at least 75% of new enrollments through SEPs beginning plan year 2026 for Marketplaces on the Federal platform.  

Additional Information and Resources 

• Federal Register: Patient Protection and Affordable Care Act: Marketplace Integrity and Affordability  

• 2025 Marketplace Integrity and Affordability Final Rule Fact Sheet| CMS 
• CMS Finalizes Major Rule to Lower Individual Health Insurance Premiums for Americans, Guidance Overview | CMS