Big Shifts for Health Insurance in 2025: What You Need to Know

Justin Spiller
Sep 2
5 min read

Updated: Oct 6

If you’ve been riding the Affordable Care Act (ACA) rollercoaster, you’ll want to buckle up for 2025. The Centers for Medicare & Medicaid Services (CMS) has finalized its “Marketplace Integrity and Affordability Final Rule.” For just about everyone who gets their health coverage through the ACA marketplace, things are about to look and feel a lot different. Here at Spiller Insurance, we’re breaking it all down for you in plain English, so you know what to expect and how to plan.

Premiums Are Dropping (But There’s a Catch)

Let’s start with the good news: CMS estimates individual health insurance premiums across the marketplace will decrease by about 5% in 2025. That means most folks shopping for plans should see some relief, which is welcome after years of steady increases.

But there’s more to the story. This drop in premiums is tied directly to measures designed to crack down on ineligible signups—what CMS calls “widespread fraud.” In 2024, roughly 5 million people were believed to be improperly enrolled, costing the system nearly $20 billion. By tightening the eligibility requirements and verification processes, regulators say they’ll shave about $12 billion in taxpayer costs in 2026 alone.

What’s the trade-off? CMS is upfront that these changes mean 750,000 to 1.8 million fewer people will be covered through the ACA in 2026 compared to 2025.

Shorter Open Enrollment Season

For years, ACA open enrollment ran from November 1 to January 15, giving you two-and-a-half months to shop and enroll. Starting this fall, the window closes a full month earlier: December 15 is now the cutoff for 2026 coverage.

This shorter window applies on both the federal Marketplace (Healthcare.gov) and most state exchanges. So, if you tend to wait until after the New Year to make insurance decisions, set yourself a reminder now!

Key 2025 Open Enrollment Dates

If you miss this window, you’ll need a qualifying event (like losing job-based coverage, marriage, or the birth of a child) to get a plan for 2026.

Fewer and Stricter Special Enrollment Periods

Over the last few years, special enrollment periods (SEPs) have helped people with lower incomes get coverage year-round. That’s changing:

The year-round enrollment option for those earning up to 150% of the federal poverty level is going away.
Certain other SEPs—like those allowing quick sign-ups after moving—are being tightened.
Expect to provide more documentation if you do qualify for a special enrollment.

This is designed to prevent what CMS calls “enrollment gaming.” But it also means you’ll need to be diligent about enrolling on time or risk going uninsured.

New $5 Monthly Fee for Auto-Enrollees

A biggie, especially if your premiums are covered by subsidies:

If you’re auto-enrolled in a zero-premium plan and don’t confirm your eligibility each year, you’ll be charged a $5 monthly fee.
This continues until you take action to verify your eligibility for fully subsidized plans.

Why the change? CMS found many people stayed in plans they no longer qualified for, driving up system costs. This “nudge” is meant to get folks to actively confirm or update their info each year.

If you want to avoid the $5 monthly charge, make sure to log into your Marketplace account or talk to your Spiller Insurance agent to verify your details during open enrollment.

Stricter Income & Tax Filing Verification

Another effort to reduce improper enrollments:

Stricter income verification required: If you report an income for the year ahead but the IRS doesn’t have any tax return for you, or your last tax return’s income was below the poverty level, get ready to provide documentation—pay stubs, W-2s, or other proof.
Advance premium tax credit reconciliations: Previously, if you missed filing taxes to “reconcile” your premium tax credits for two years, you’d lose eligibility for subsidies. Now, one missed year is enough to get you locked out until you’ve filed.

This can feel pretty technical, but it boils down to: If you get subsidies, get your taxes straight each year and keep your income info current!

DACA Recipients: Marketplace Access Rolled Back

In 2024, the marketplace opened up to DACA (“Dreamer”) recipients for the first time. The new rule reverses that decision, excluding DACA recipients from the definition of “lawfully present.” That means, as of August 25, 2025:

DACA recipients are no longer eligible to buy ACA marketplace plans.
They can’t receive premium tax credits or cost-sharing reductions.

If this affects you or your loved ones, you’ll need to explore alternative health coverage options. Our advisors at Spiller Insurance can help review what’s available—just get in touch.

New Employer Mandate Threshold

Are you covered through your job or run a business with 50+ employees? Here’s what’s new:

The “affordability threshold” for employer-sponsored plans goes up to 9.02% of household income (up from 8.39%).
Employers must ensure their lowest-cost self-only coverage option isn’t more than 9.02% of total household income, or they could face ACA penalties.

Workers: If your job-based plan just barely met the “affordable” bar last year, check carefully for 2026.

Employers: Review your benefits strategy now, or reach out to Spiller Insurance for a compliance check-up before open enrollment.

The Timeline: When All This Kicks In

The CMS rule takes effect August 25, 2025.
First impacted open enrollment: November–December 2025 (for 2026 coverage).
New verification, enrollment, and eligibility rules will be in force for the 2026 plan year.

While the timeline is tight, Spiller Insurance clients get proactive updates and personalized reminders at each stage. You can always book a consultation to walk through these changes in detail.

What Should You Do Next? (And How We Can Help!)

Change can be overwhelming. Here’s how you can stay prepared:

Mark Your Calendar for Open Enrollment: November 1–December 15, 2025.
Review Your Account: Update your Marketplace info, especially income and family size.
Check Your Email: We’ll send tips, reminders, and deadline alerts.
Verify Your Subsidy Eligibility: Avoid the $5 fee—reconfirm if you have a $0 premium plan.
Consult an Expert: Our agents know these rules inside out and are happy to help you navigate every step.

Want more details or have a question about how these changes affect you? Visit our information center or schedule a free plan selection session.

Quick FAQ: 2025 ACA Rule Changes

Q: Is it true I have less time to buy a Marketplace plan this year?

A: Yes! Open Enrollment is now Nov. 1 – Dec. 15 only.

Q: What if I forget to verify my eligibility for my $0 premium plan?

A: You’ll be charged a $5/month fee until you do.

Q: Can DACA recipients still get marketplace insurance?

A: Not after August 25, 2025—they are no longer considered “lawfully present” for eligibility.

Q: Do I need to file my taxes every year to keep my ACA subsidies?

A: Absolutely. Missing one year now disqualifies you for advance premium tax credits.

If you’re unsure where you stand or want tailored guidance for yourself, your family, or your business, our Spiller Insurance team is here to help.

Ready to make sense of the new ACA health insurance rules? Reach out to us or start your journey by booking a free consultation at spillerinsurance.com.