CMS will implement policies meant to crack down on fraud in the ACA marketplace.
The agency published the 2026 final rule for ACA plans Jan. 13, and the regulations take effect Jan. 15.
CMS will finalize a policy that allows it to take enforcement actions against lead agents at insurance agencies that it determines are violating marketplace rules. The tougher enforcement comes after thousands of individuals were enrolled in ACA plans, or switched to a new plan, without their knowledge. CMS said it received 40,000 complaints of unauthorized plan switches in the first three months of 2024.
Here are five other regulations to know:
- CMS will broaden the scope of offenses for which brokers can be suspended from the marketplace. The agency said the policy is intended to reduce unauthorized changes to individuals' coverage.
- The agency will also update its model consent form to improve documentation of authorized changes.
- CMS will finalize language clarifying that plans are permitted to use "CSR loading" to reduce cost sharing. CSR loading, according to CMS, is raising premium costs to lower the amount consumers pay for deductibles, copayments and coinsurance.
- Insurers can implement policies allowing members to maintain their coverage if they have not paid the full premium amount. Under the new rules, consumers who owe $10 or less in premiums, or a net percentage of their premium, can maintain their coverage.
- CMS will update risk adjustment models in 2025. The program will add considerations for PrEP drugs to prevent HIV, to help address the high costs of the drugs, and reduce incentives for insurers to restrict coverage of the drugs.
Read more here.