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Federal Changes to Your Health Insurance

The 2025 Marketplace Integrity and Affordability Rule introduces changes to eligibility, enrollment, income verification, and plan design that affect Covered California enrollees. Some provisions are already in effect, while others are on hold due to court rulings.

Key Changes at a Glance

The 2025 Marketplace Integrity and Affordability Rule includes several changes to eligibility, enrollment, plan design, and income verification. Here's a quick summary of what's changing and when:

Already in Effect

  • DACA eligibility ended Aug 31, 2025
  • Low-income SEP eliminated Sep 1, 2025
  • 60-day income doc extension removed

On Hold (Court-Blocked)

  • Stricter income verification requirements
  • File-tax-return (FTR) eligibility checks

2026 Plan Changes

  • Updated out-of-pocket maximums
  • Catastrophic plan redesign
  • Minor premium adjustments for gender-affirming care

Future (2027+)

  • Shorter open enrollment period starting 2027
  • Subsidy repayment cap elimination (2027 taxes)

DACA Eligibility Changes

What This Means for You

If you or a family member had coverage through Covered California under DACA status, that coverage has ended. Here's what you should know:

  • DACA recipients can no longer enroll in or renew marketplace health plans
  • Other household members who are eligible (such as U.S. citizens or lawfully present family members) can still enroll
  • Visit our DACA health insurance options page for alternative coverage options

Low-Income Special Enrollment Period Eliminated

Who's Affected?

This change affects individuals and families with low incomes who previously could sign up for health insurance at any time during the year. For reference, 150% FPL in 2025 is approximately:

1 person
$22,590/yr
2 people
$30,660/yr
3 people
$38,730/yr
4 people
$46,800/yr

How to Enroll Now

Without this SEP, low-income individuals must now enroll through one of these paths:

  • Open Enrollment: Sign up during the annual open enrollment period (November 1 - January 31)
  • Qualifying Life Event: You may still qualify for a special enrollment period if you experience a major life change such as losing other coverage, getting married, having a baby, or moving to a new area

Income Documentation Changes

What Changed

When the income you report on your application doesn't match what the marketplace finds in federal data sources, you're asked to provide documents to verify your income. Previously, you had:

  • Before: 95 days + an automatic 60-day extension = up to 155 days total
  • Now: 95 days only — no automatic extension

If you receive a notice about an income inconsistency, respond promptly with the required documents. If you need more time, contact us for assistance.

Premium and Plan Design Updates

The 2026 plan year includes several updates to out-of-pocket limits and how catastrophic plans are designed.

2026 Out-of-Pocket Maximums

These are the most you'd pay for covered services in a year:

  • Individual: $9,200
  • Family: $18,400

These limits apply to all non-grandfathered plans.

Catastrophic Plan Redesign

Catastrophic plans (for people under 30 or with hardship exemptions) will now:

  • Cover 3 primary care visits before the deductible
  • Have the same out-of-pocket maximum as other plans ($9,200)

These are now HSA-eligible as high-deductible health plans.

Subsidy Repayment Changes (2027 Taxes)

If you received more financial help (premium tax credits) than you qualified for, you'll need to repay the difference when you file your federal taxes. Starting with 2026 tax returns filed in 2027, the caps on repayment amounts are being eliminated — meaning you could owe back the full excess amount.

Protect yourself: Keep your income updated on your application throughout the year. This is the best way to make sure you receive the right amount of financial help and avoid a surprise at tax time.

Gender-Affirming Care

California Still Requires Coverage

Regardless of the federal change, California state law requires all health plans to cover gender-affirming care. The state's anti-discrimination protections remain in full effect. All health plans through Covered California continue to include this coverage.

Minor Premium Impact

Because gender-affirming care is no longer a federal EHB, insurers may adjust premiums slightly to account for this state-mandated benefit. The estimated impact is less than $1 to less than $10 per month depending on the plan. This is a small technical adjustment — your coverage for gender-affirming care is unchanged.

Open Enrollment Changes

Missed Open Enrollment?

If you miss open enrollment, you may still be able to get coverage through a qualifying life event such as losing other coverage, getting married, having a baby, or moving. Contact our agents to check your options.

Provisions On Hold (Court-Blocked)

Stricter Income Verification

The rule proposed requiring consumers to verify their income before receiving financial help (premium tax credits), rather than the current system where credits are provided while documentation is resolved.

Stayed by Court

File-Tax-Return (FTR) Requirement

The rule proposed checking whether applicants filed their federal tax returns as a condition for receiving premium subsidies. People who didn't file could be denied financial help.

Stayed by Court

What this means for you: For now, income verification and tax filing requirements remain unchanged from previous years. We'll update this page if courts allow these provisions to move forward.

Steps to Take Now

With these federal changes, it's more important than ever to stay on top of your health insurance. Here's what you should do:

1

Keep Your Information Updated

Report any changes to your income, household size, or address as soon as they happen. This ensures you receive the correct amount of financial help and avoids repayment surprises at tax time.

2

Watch for Official Notices

Covered California may send you notices about eligibility, income verification, or plan changes. Open and read them carefully — missing a deadline could affect your coverage or financial help.

3

Respond to Requests Promptly

If you're asked to submit documents (like income verification), do it as soon as possible. The 60-day extension is gone — you now have only 95 days to respond.

4

Review Your Plan at Renewal

Don't just auto-renew. Compare your current plan with other options during open enrollment. Premiums, benefits, and your subsidy amount can change each year.

Need Help Understanding These Changes?

Our licensed agents can help you navigate these federal changes and find the right coverage for your needs — at no extra cost to you.

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