Open enrollment for 2025 ACA (Affordable Care Act)-compliant health insurance is just around the corner. Let’s take a look at the various changes that consumers should be aware of this fall.
DACA recipients may be eligible to use the Marketplace
DACA recipients are expected to be eligible to use the Marketplace for the first time, and able to qualify for income-based subsidies under the same eligibility rules that apply to any other applicant. As a result of this change, the government expects an additional 100,000 people to enroll in coverage for 2025.
However, attorneys general in 19 states have filed a lawsuit in a federal district court, suing to have the DACA eligibility rule delayed and overturned. Oral arguments in that case were heard in mid-October, and it’s possible the court will issue a ruling shortly before the start of open enrollment. So there is still some uncertainty around the issue of DACA recipients’ ability to enroll in Marketplace coverage for 2025.
Georgia switches to state-run Marketplace platform
Georgia will be operating its own Marketplace (exchange) platform this fall. Starting Nov. 1, residents will use Georgia Access – or an approved enhanced direct enrollment entity – to enroll in or renew coverage for 2025. Georgia residents have used HealthCare.gov for enrollment since 2014 but will no longer be able to use that platform to shop for 2025 coverage and subsequent years.
State-funded health insurance subsidies change in several states
In addition to the ACA’s federal premium subsidies and cost-sharing reductions, several states offer additional state-funded subsidies that further offset enrollees’ premiums, out-of-pocket costs, or both.
For 2025, there are some changes to these subsidies:
- California: A state program that debuted in 2024 eliminated deductibles and other out-of-pocket costs for applicants with household incomes up to 250% of the federal poverty level (FPL). For 2025, the program is expanding. All Covered California applicants will be eligible for plans that have zero deductibles and reduced out-of-pocket costs.
- New Mexico: State out-of-pocket assistance (SOPA) benefits are being expanded so that plans with 90% actuarial value (equal to a Platinum plan) will be available to enrollees with household income up to 400% of FPL. In 2024, the income limit to qualify for these 90% actuarial value plans was 300% of the federal poverty level.
- Colorado: In 2024, Colorado’s state-funded cost-sharing reductions are available to enrollees with household income up to 250% of FPL. For 2025, the eligibility limit will be reduced to 200% of FPL, meaning fewer people will qualify. Applicants with household incomes up to 250% FPL will continue to be eligible for federal cost-sharing reductions, but applicants with income between 200% and 250% FPL will qualify for only the federal benefit, not the state-funded cost sharing reduction.
- New York: State-funded Marketplace subsidies are not currently available, but New York has received federal permission to offer state-funded subsidies starting in 2025. and Under the terms of the state’s approved waiver amendment, applicants with income up to 400% of FPL will be eligible for new cost-sharing reductions, as well as additional cost-sharing assistance for diabetes care and pregnancy/postpartum care.
Some Oregon enrollees may switch to Basic Health Program
Oregon debuted a Basic Health Program – Oregon Health Plan Bridge – in July 2024. Adults who earn more than 138% of FPL but not more than 200% of FPL are eligible to enroll.
Read our overview of Basic Health Programs.
Marketplace enrollees in that income range had the option of switching to Oregon Health Plan Bridge starting in July 2024, but were not required to do so.
If these enrollees make any updates to their application (including changes to contact information, projected income, address, family size, a plan change made during open enrollment, etc.), their eligibility for Oregon Health Plan Bridge will be determined at that point. If they’re eligible for Oregon Health Plan Bridge, they will no longer be eligible for Marketplace subsidies.
So a person who updates their Oregon Marketplace account during open enrollment with a projected income in the range that’s eligible for Oregon Health Plan Bridge will generally find that moving to that coverage is their best option for 2025, as they would otherwise have to pay full price to keep their private Marketplace plan.
A person who lets their plan auto-renew without making any changes to the application can potentially keep their Marketplace plan through 2026 (instead of switching to Oregon Health Plan Bridge) but the state notes that if an enrollee experiences any changes – such as a change in income – they are required to update their application.
Individual and family premium increases average 6-7%
The insurers that offer individual/family health coverage have proposed overall average rate increases in the range of 6% to 7% for 2025. (The semi-weighted average is about 6.1%, and the median is about 7%.)
Rates have been finalized already in some states, but are still under review in many states. You can see specific details for carriers in your state by selecting your state on this map.
But it’s important to understand that average rate changes are calculated based on full-price (unsubsidized) premiums, and most enrollees don’t pay full price. As of early 2024, 93% of Marketplace enrollees nationwide were receiving premium subsidies that offset some or all of the cost of their coverage.
If you’re receiving a subsidy, the net (after-subsidy) premium you pay in 2025 will depend on how much your own plan’s premium changes, but also on how much the benchmark (second-lowest-cost Silver) plan premium changes because the cost of the benchmark plan is the basis for the amount of the premium subsidy. You’ll want to carefully review the notifications you receive from your insurer and the Marketplace to understand how your net premium will change if you renew your current coverage.
At least 18 states will see carrier entries or exits
As is the case every year, there will be some changes for 2025 in terms of which insurers offer Marketplace coverage in some states. In most states, the list of participating Marketplace insurers is the same for 2025 as it was for 2024. But in some states, new insurers are joining the Marketplace, while other states will see insurers exiting the Marketplace or leaving the individual market altogether.
We have details about 2025 insurer participation and premium changes on the pages we maintain for each state’s Marketplace, but here’s a summary of what we’re seeing in terms of carriers entering and exiting the Marketplaces for 2025:
Entries:
- UnitedHealthcare – entering Indiana, Iowa, Nebraska, and Wyoming
- HAP CareSource – entering Michigan
- WellSense – entering New Hampshire
- WellPoint – entering Texas, Florida, and Maryland
- Simply Healthcare Plans, Inc. – entering Florida
- Ambetter/Iowa Total Care – entering Iowa
- Antidote Health – entering Arizona
Exits:
- Celtic – leaving Indiana Marketplace (will still offer plans outside the Marketplace)
- Ascension (US Health & Life) – exiting Indiana, Kansas, Tennessee, and Texas
- Cigna – exiting Pennsylvania, South Carolina, and Utah
- Ambetter/Western Sky – exiting New Mexico
- PacificSource – exiting Washington
- Medica – exiting Arizona and Illinois
- Aetna Life – exiting in Virginia (Aetna Health will continue to offer plans)
If your current insurer will be exiting your market at the end of 2024, you’ll need to select a new plan for 2025. You’ll have until Dec. 31 to pick a new plan with a Jan. 1 effective date. Depending on where you live, the Marketplace will likely automatically select a replacement plan for you if you don’t pick your own new plan. But it’s better to take an active role in picking your coverage.
Changes in insurer participation in the Marketplace obviously affect the plan options that are available to applicants, but they can also affect the benchmark plan premium – if the new or exiting insurer holds that position. Changes in the benchmark plan premium will affect premium subsidy amounts for everyone in that area who qualifies for subsidies, since subsidy amounts are calculated based on the cost of the benchmark plan.
New short-term health insurance rules affect access to coverage
As of Sept. 1, 2024, consumers can no longer buy short-term health insurance with total durations longer than four months, including renewals, and non-renewable plans are capped at total durations of three-months.
From late 2018 through August 2024, federal rules permitted the sale of short-term health policies with total durations of up to three years. For people who have been relying on these longer-term short-term health plans, it’s important to understand what’s available during the open enrollment period for 2025 health coverage, and the potential consequences of letting open enrollment go by without selecting a new plan.
If your current short-term policy is scheduled to terminate at some point in 2025, you will not be able to purchase another longer duration short-term policy at that point. All available policies will be capped at no more than four months in total duration, which might mean that you’ll be uninsured at some point in 2025. And the termination of a short-term policy is not a qualifying life event that would trigger a special enrollment period and allow you to enroll in an individual/family health plan at that point.
So if you’re currently enrolled in a short-term policy that will terminate in 2025, consider your Marketplace options during the upcoming open enrollment period. If you sign up for a Marketplace plan, it will provide coverage throughout 2025, and you may find that you’re eligible for federal or state financial assistance with the premiums.
Rules prevent unauthorized enrollments and plan changes
Over the last several months, CMS (the Centers for Medicare & Medicaid Services) has been taking steps to curb unauthorized enrollments and plan changes that were happening in states that use the federally run Marketplace (HealthCare.gov).
Starting in July, CMS implemented new rules that prevent brokers from adding themselves to a person’s HealthCare.gov account without the policyholder’s permission. (Unscrupulous brokers who did this in the past were able to get paid commissions for those accounts, and could make plan changes without the enrollee’s knowledge.)
If you want to assign a new broker to your account, you’ll either need to participate in a three-way call with the Marketplace call center and your new broker, or you’ll need to log into your HealthCare.gov account and add the new broker’s information. (Here’s how to do that.) This protocol is necessary if you want to switch from one broker to another, or if you were previously navigating the enrollment process on your own and you’ve decided you’d like a broker to help you.
Marketplace call center volume increases significantly once open enrollment is underway. So if you know that you’ll want to add a broker to your existing HealthCare.gov account or switch to a different broker – and you’re planning to utilize the three-way call to do so – you may want to address that issue before open enrollment begins.
If you’re in a state that runs its own Marketplace (meaning you don’t use HealthCare.gov), the Marketplace will have its own rules for adding a new broker to your account. The process varies from one state-run Marketplace to another, but your broker or the Marketplace will be able to explain what steps you’ll need to take if you want to add a new broker to your account.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
