September 2025 | By Josh Schultz, Head of Government Affairs, Softheon
Key takeaways for health plans:
- The CMS Marketplace Integrity Rule, finalized in June 2025, introduced new compliance requirements.
- A federal court stayed most of the rule in August 2025, pausing seven provisions nationwide.
- Filings and approvals are now tied to court outcomes, leaving issuers with weeks (not months) to adjust.
- Short notice makes it harder to forecast churn, margin, and member mix heading into Open Enrollment 2026.
How the Integrity Rule Evolved
Finalized in June 2025, the CMS Marketplace Integrity Rule introduced major changes to ACA Marketplace operations, including:
- A $5 surcharge for certain auto-reenrollees who did not update their information.
- Additional verification for individuals enrolling during special enrollment periods (SEPs).
- New documentation requirements for some low-income applicants seeking subsidies.
- A one-year cutoff of subsidies for members who failed to reconcile with the IRS.
- Expanded actuarial value (AV) ranges to give issuers more flexibility in plan design.
For health plans, these changes meant new compliance steps and system modifications on a short timeline.
A federal court paused seven provisions in August 2025, finding some exceeded ACA authority and others lacked sufficient justification. The Department of Justice has appealed, but it is focusing narrowly on the new actuarial value flexibility. Many issuers already filed 2026 plans using the expanded AV ranges and rolling them back could force last-minute redesigns and repricing. The appeals court will decide whether those plans can move forward or must be refiled.
Implications for Health Plans
The real challenge for issuers is timing. CMS has created a special September 30 – October 1 refiling window if plan revisions are needed, while final rate approvals have been pushed into late September. What normally takes months is now compressed into weeks, right as teams prepare for Open Enrollment (OE).
This timing crunch creates operational stress, as issuers may need to rework plan designs and rates if AV flexibility is rolled back. It also heightens compliance pressure, with staff already stretched across Marketplace, broker, and member-facing operations. Strategically, the uncertainty makes it harder for plans to forecast churn, margin, and member mix heading into OE2026.
What It Means for Members
For members, the paused provisions mean no new surcharges, no additional SEP documentation, and no subsidy cutoffs tied to tax filing. Open Enrollment 2026 should feel familiar, aside from pricing.
That said, premiums are still climbing due to broader market trends. Nationally, rates are projected to rise by 23.4% in 2026, and the potential expiration of enhanced APTCs looms at the end of 2025. This means affordability challenges remain top of mind for consumers.
How Plans Can Prepare for Open Enrollment 2027
The provisions of the Integrity Rule isn’t gone — it’s paused. That means health plans should prepare for the unknown, where rules shift with little lead time.
This reality underscores three needs:
- Automation: Manual compliance steps are too risky under compressed timelines. Technology partners can help plans manage eligibility checks, reconciliation, and member notifications with speed and accuracy. Softheon’s sister company CITIZ3N supports eligibility verification at scale, reducing error and risk.
- Clear member communications: Plans that explain changes, or continuity, in plain language will earn member trust. Updated CMS noticing requirements already demand more flexible formats, and additional adjustments may come quickly.
- Proactive operations: Health plans must align teams around rapid response to regulatory shifts while still protecting member experience. Softheon’s platform helps health plans consolidate enrollment, billing, reconciliation, and notice fulfillment into one ecosystem, allowing them to adapt to policy changes without disrupting members.
Health plans face pressure to adjust quickly. Consumers will not feel the full effects of the new rule and legal changes in OE2026. The courts will decide how much of these provisions will carry over.
At Softheon, we work with health plans every day to navigate these shifts — reducing administrative burden through automation while keeping members front and center. Subscribe to the Softheon Newsletter for regular updates on the ACA, ICHRA, and Medicare Advantage.
