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Against AAFP objections, new CMS coverage rule will hinder care access
July 21, 2025, News Staff — A CMS final rule governing Patient Protection and Affordable Care Act health care coverage will limit care access for patients when it goes into effect August 25.
In conflict with AAFP policy and guidance the Academy submitted to CMS when the rule was proposed, the ACA Marketplace Integrity and Affordability final rule targets two vulnerable populations: enrollees in the Deferred Action for Childhood Arrivals program and patients seeking gender-affirming care. It also generally stiffens barriers against ACA Marketplace enrollment and eligibility.
Specifically, the final rule
- shortens the annual open enrollment period to close by December 31
- allows insurers to deny coverage based on unpaid past-due premiums
- requires payment of initial and past-due premium amounts to establish new coverage
- eliminates some automatic re-enrollments
- eliminates monthly special enrollment periods for individuals with household incomes at or below 150% of the federal poverty line (eligible low-income consumers had been able to enroll in Marketplace plans year-round)
- prohibits coverage of (and defines) specific sex-trait modification procedures as an essential health benefit (EHB)
- excludes DACA recipients from CMS’ definition of “lawfully present”
Additional provisions in the rule further restrict the eligibility and enrollment verification process; these are set to expire at the end of 2026.
The Academy has long advocated for DACA stability. The program’s beneficiaries include thousands of health care workers and hundreds of medical students, medical residents and physicians, many of them working in areas of high need.
The AAFP was among the medical societies that opposed CMS’ proposal to define “sex-trait modification” in the rule. The Academy cautioned in its comments to the agency that “attempting to codify a definition risks oversimplifying the range of medical treatments that could fall under this category.”
“The AAFP also believes that all decisions about patient care should be guided by the physician-patient relationship, which is central to ensuring individualized and appropriate care,” the Academy’s letter added. “We encourage CMS to defer to medical expertise and clinical guidelines rather than define terms that are not widely used in the medical community.”
The published rule nevertheless finalized that definition, establishing new limits to care access.
In line with the Academy’s advocacy, the rule increases accountability and oversight for ACA Marketplace brokers and agents and extends the federal exchange open enrollment period through December 31—beyond the originally proposed date of December 15. However, the latter change also applies to a feature of the final rule the AAFP opposed: allowing state and non-federal insurers, including those not participating in the ACA Marketplace, to set their own open enrollment periods with certain limitations, starting in fiscal year 2027.