Proposed CMS Rule Could Lead to Coverage Loss for Up to 2 Million Americans
In a controversial move, the Centers for Medicare & Medicaid Services (CMS) has proposed a new rule — the 2025 Marketplace Integrity and Affordability Rule — that aims to tighten enrollment eligibility and reduce improper use of premium subsidies in the ACA Marketplaces. However, health policy experts and provider groups are warning that the changes could cause widespread coverage loss, particularly in low-income and underserved communities.
Up to 2 Million at Risk of Losing Coverage
CMS itself estimates that between 750,000 and 2 million consumers could lose their health insurance coverage if the rule is fully implemented — many of them concentrated in states with high Marketplace enrollment such as Florida, Texas, and Georgia.
While the agency says the intent is to improve program integrity and reduce improper payments, critics argue the impact on patient access to care could be severe.
Key Proposals in the Rule:
- Stricter Enrollment Checks: Income and eligibility verifications would be intensified, especially for Special Enrollment Periods (SEPs).
- Ending Monthly SEP for Low-Income Enrollees: A popular option for those earning under 150% of the federal poverty level would be eliminated.
- Premium Payment Restrictions: Insurers could deny coverage to individuals who owe back premiums.
- DACA Exclusion: The rule would classify Deferred Action for Childhood Arrivals (DACA) recipients as not lawfully present for the purposes of ACA and Basic Health Program (BHP) eligibility.
- Open Enrollment Cut: The standard open enrollment window would shrink from 3 months to 6 weeks.
Backlash From Providers and Advocates
Healthcare organizations, including the American Hospital Association, have raised red flags about the proposed rule, warning it could destabilize access to care and increase the number of uninsured Americans — reversing recent gains made under the ACA.
“We’re deeply concerned about the impact on coverage continuity and patient access,” said a statement from the AHA. “Many individuals may not even realize they’re at risk until it’s too late.”
Fiscal Savings, Human Cost?
CMS estimates the changes could reduce improper federal spending by $11–14 billion by 2027. But with millions potentially losing access to coverage, the human and systemic costs may outweigh the savings.