CMS' proposed ACA rules: 10 things to know

[Duaine]

CMS is proposing new regulations on the ACA marketplace in 2026, which include some aimed at cracking down on fraud.

The agency published its proposed rules for the marketplace Oct. 4.

Here are 10 things to know:

1. CMS proposed holding lead agents at insurance agencies accountable for violations of marketplace standards.
   
   
2. The agency also proposed using its authority to suspend an agent or broker's ability to operate on the exchange if the agency deems the agent "poses an unacceptable risk to marketplace operations." The policy would improve security on the exchange, CMS said, resulting in fewer unauthorized changes to coverage.
   
   
3. CMS has moved to crack down on brokers making changes to enrollees' coverage without their knowledge. In the first six months of 2024, CMS said it received nearly 74,000 complaints about a plan being changed without the enrollee's consent, and nearly 130,000 complaints about individuals being enrolled in plans without their knowledge.
   
   
4. CMS has suspended at least 200 marketplace agents for reasonable suspicion of fraud since June.
   
   
5. The proposed rules would also add a new model consent form designed to help agents and brokers better document a customer's consent to enroll in a plan or change their coverage.
   
   
6. The agency also proposed allowing insurers to implement fixed-dollar or percentage-based thresholds to allow individuals to maintain their coverage even if they have not paid their full monthly premium. The agency proposed capping this amount at $5 or less.
   
   
7. CMS proposed several updates to the risk adjustment program, which spreads out costs between insurers in state marketplaces. The agency proposed updating its models with data from 2020 to 2022.
   
   
8. In addition to updating the models, CMS proposed phasing out special adjustments for Hepatitis C drugs and adding new adjustments for pre-exposure prophylaxis drugs to treat HIV.
   
   
9. CMS is seeking comment on how to reduce the risk of insurer insolvencies in the ACA marketplace. In recent years, multiple marketplace plans have become insolvent, leaving enrollees without coverage and insurers without risk adjustment payments.
   
   
10. The proposed rules are open for comment until Nov. 12.

Read more here.