The Centers for Medicare & Medicaid Services (CMS) on March 19 issued the Marketplace Integrity and Affordability proposed rule that would change several enrollment and eligibility policies for plan year (PY) 2026.
CMS proposes to close the annual open enrollment for the federal marketplace a month earlier, on Dec. 15 rather than Jan. 15. CMS also plans to remove monthly special enrollment periods (SEPs) for individuals with income below 150 percent of the federal policy level. These SEPs allow individuals with low income to enroll in marketplace coverage outside of open enrollment when they lose access to other types of coverage and do not qualify for Medicaid.
CMS also proposes to amend the definition of “lawfully present” to exclude Deferred Action for Childhood Arrivals recipients, making them ineligible to enroll in marketplace health plans and state basic health plans.
Further, CMS proposes to exclude gender-affirming care or “sex-trait modification” services from coverage as an essential health benefits beginning in PY 2026. This proposal does not prohibit health plans from voluntarily covering these services if permitted in the state, nor would it prohibit states from establishing state mandates to cover this service.
Comments are due April 11.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.
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