"The finalized policies balance the urgent need to reduce the high level of improper and fraudulent enrollments with the desire to promote an efficient enrollment process over a longer term," officials say.

Although enrollment would be much lower in 2026 than in 2025, it would be about the same as in 2022.

The system would still support policies that generate $122 billion in annual premium revenue.

The number of customers who pay the premiums without help from government subsidies might fall just 7.5%, to 1.5 million, according to CMS analyst predictions.

By 2029, overall enrollment could rise to 18 million, and full-pay enrollment could rise to 2.4 million.

What it means: Benefits buyers and advisors who want to provide workers cash that the workers can use to buy their own individual health coverage can keep cash-for-coverage options on the menu.

ACA exchange basics: Congress put the framework for the exchange system — a web-based supermarket for health insurance — in the Affordable Care Act in 2010, and the system opened for business in 2014.

The ACA eliminated most of the underwriting and pricing strategies health insurers in the individual market once used to protect themselves from health risk.

Exchange designers tried to compensate by creating the ACA premium tax credit subsidy system. The tax credits are supposed to make the enrollee's share of the premium low enough to persuade young, healthy people to pay for coverage even when they feel healthy. Originally, the tax credits helped people with income from about 138% to 400% of the federal poverty level, or up to $128,600 per year for a family of four in most of the United States.

The exchange "open enrollment" calendar, or limits on when people can buy coverage without showing that they qualify for a "special enrollment period," is supposed to give people a chance to enroll voluntarily in coverage each year but scare them away from being uninsured, by raising the possibility that they could get pneumonia or break a leg at a time when they have no ability to sign up for health coverage.

CMS provides exchange services for 31 states through the HealthCare.gov public exchange program. For 2025 coverage, the HealthCare.gov open enrollment period ran from Nov. 1, 2024, through Jan. 15, 2025.

The District of Columbia and 19 states run their own ACA exchange programs. Most of the locally run exchange programs have open enrollment period periods that start around Nov. 1, but the ending dates vary widely.

During the peak years of the COVID-19 pandemic, exchange programs offered universal or nearly universal access to special enrollment periods.

Congress also provided a temporary increase in the generosity of the ACA premium tax credit program, to help pay for coverage if the premiums would eat up too much of their income even if their income was over 400% of the federal poverty level. The COVID emergency subsidy increase is set to expire Dec. 31.

New ACA exchange problems: The temporary increase in premium subsidies cuts the enrollee's share of the premiums to $0 for many exchange plan users. HealthCare.gov uses automated connections to entities such as the Internal Revenue Service to perform some application verification activities, but it has been letting applicants support much of the information on their applications by swearing that the information is correct, rather than providing tax forms, pay stubs or other documents to back up their assertions.

The number of people now getting "free" exchange plan coverage is now so high, and so much higher than the number of people in many states who are in that income range and lack coverage from Medicaid or employers, that about 6.4 exchange plan users may have "free" coverage as a result of providing fake income figures, according to analysts at Paragon Health Institute, a research center that's popular with Republicans.

Related: ACA exchange system faces enrollment fraud challenges

Some of the consumers may have lied about their income themselves, but, in other cases, agents seem to have "helped" the consumers by putting in fake income information themselves, according to CMS.

Agents have also used access to zero-premium policies and weak HealthCare.gov application substantiation requirements to sign consumers up for fake coverage and shift them into new plans without telling them, officials say.

The draft 2025 ACA exchange regulations: CMS posted the draft of the new final regulations March 19 and received 26,000 comments.

Related: ACA changes could impact employer plans, individual coverage reimbursements

CMS said in the draft that it would fight enrollment fraud and increase open enrollment period awareness by:

◆ Having all exchanges start their open enrollment period Nov. 1 and end it Dec. 15.
◆ Requiring enrollees to pay at least $5 per month for coverage, so that they know they have coverage.
◆ Eliminating a special enrollment period aimed at people without income that qualified them for "free coverage."
◆ Requiring exchanges to verify applications for at least 75% of the applicants who use special enrollment periods.
◆ Loosen the rules for deciding what level of information is needed to punish agents accused of wrongdoing, by letting decisions be based on a "preponderance of the evidence" rather than evidence showing that there is "clear and convincing evidence" that the agent is guilty.

The final exchange regulations: Here's how CMS handled the proposed changes in the final regulations.

Enrollment periods: CMS officials eased up, some. The big change is that officials will make the change effective starting with the open enrollment period for 2027 coverage, rather than trying to make the change for the open enrollment period for 2026 coverage.

HealthCare.gov will still have its open enrollment period run from Nov. 1 through Dec. 15.

A locally run exchange can have its open enrollment period run for any 90-day period between Nov. 1 and Dec. 31, but it must be prepared to have any coverage sold during its open enrollment period take effect Jan. 1, even if the coverage was sold Dec. 31, officials said.

Minimum payment and low-income enrollee SEP: CMS will require all enrollees to pay at least $5 per month, and it's also eliminating the special enrollment period for people who earn from 100% to 150% of the federal poverty level and in that way previously qualified for coverage with no monthly premium payment.

SEP eligibility verification: CMS will require both HealthCare.gov and locally run exchanges to verify at least 75% of new enrollments made through SEPs.

Agent evidence standard: CMS will move to the preponderance-of-evidence standard.

"These provisions are important consumer protections that address longstanding concerns with enforcement against noncompliant agents, brokers, and web brokers," officials said. "As these concerns exist regardless of the subsidy levels set by Congress, we are finalizing these provisions to be applicable as of the effective date of this rule and beyond."

ICHRAs and QSEHRAs: Interest in two main types of cash-for-coverage arrangements, individual coverage health reimbursement arrangements and qualified small employer HRAs, showed up in a CMS response to a commenter who asked about one of the new CMS anti-fraud rules.

The new rule will let exchange plan issuers collect past-due premiums from a consumer before selling the consumer new coverage.

States can regulate how demands for past-due premiums will work in their jurisdictions, officials said.

One commenter asked what would happen if an employer offers an ICHRA or QSEHRA plan to a worker who owes health insurer issuers money.

Employers satisfy their obligations by providing an ICHRA, whether or not the employee really enrolls in coverage, but workers who are offered an ICHRA and fail to get major medical coverage must forfeit the HRA, officials said.

Employers that offer QSEHRAs need not worry about their own coverage obligations, because, by definition, they are too small to be subject to ACA "share responsibility" penalties, officials said.

A worker who is offered a QSEHRA and fails to get health coverage may not receive HRA reimbursement, officials said.

CMS officials also talk about ICHRAs in an analysis of a decision to let the "second-lowest-cost silver plan in a market cover anywhere from 66% to 72% of the actuarial health value of the "essential health benefits" package, or standard benefits package.

Today, the actuarial value of that benchmark plan can range from 70% to 72% of the value of the essential health benefits package.

The benchmark plan is used to set premium tax credit amounts and to determine the minimum ICHRA contribution that can help an employer meet ACA coverage standards, officials said.

Because the richness, and the cost, of the benchmark silver plan could be a little lower, that means the minimum employer ICHRA contribution could be a little lower, officials said.