How to Prepare for Major ACA Changes & Open Enrollment

The Affordable Care Act (ACA) landscape is undergoing significant changes, and individuals, families, small business owners, and employers in Illinois need to prepare for what’s ahead. With open enrollment around the corner, understanding the new regulations, compliance updates, and market trends is essential for securing affordable and effective health insurance coverage.

This guide breaks down the most critical changes to the ACA, insights from industry leaders, and actionable strategies to ensure you’re ready for what’s coming.

A Transformative ACA Landscape in 2025

Over the past year, the ACA marketplace has experienced rapid shifts in regulation, technology, and market dynamics. Industry leaders have emphasized the importance of staying informed and proactive, especially as new rules and compliance measures reshape how insurance agents, agencies, and carriers operate.

Key Trends Shaping the ACA Market

Rising Premium Costs: Premiums are expected to increase significantly in 2025, with some states seeing hikes of 20-30%. This is driven by a combination of factors, including higher healthcare utilization, delayed care during the pandemic, changes in subsidies, and the removal of certain populations from the marketplace.
Enhanced Compliance Requirements: Stricter rules around income documentation, tax filings, and Special Enrollment Period (SEP) verification are coming into effect, aiming to reduce fraud and stabilize the market.
Carrier Consolidation and Adjustments: Major carriers like Am Better are refining their processes, introducing advanced technology, and adjusting compensation structures to better adapt to the evolving landscape.

Critical ACA Changes You Need to Know

To help you prepare for the upcoming open enrollment period, here’s a breakdown of the most impactful changes happening this year:

1. Elimination of the 150% Federal Poverty Level (FPL) SEP

Historically, individuals earning 150% or less of the federal poverty level could qualify for a Special Enrollment Period (SEP) year-round. However, this option has been permanently removed as of August 2025 due to widespread misuse. Moving forward, individuals must rely on other qualifying events to enroll outside of the annual open enrollment period.

2. Stricter Income Verification Rules

Income verification will now be mandatory, particularly for those whose reported income falls below 100% of the federal poverty level on their application. Consumers must provide documentation such as W-2s, pay stubs, or profit and loss statements during enrollment.

This change is aimed at reducing inaccuracies and ensuring consumers receive the correct amount of subsidies. Agents must educate clients about these new requirements upfront.

3. Tax Filing Compliance

Consumers who haven’t filed taxes for the previous year will lose their subsidies starting in 2025. This is a significant shift from previous rules, which allowed a two-year grace period. Agents and agencies need to prioritize outreach to ensure clients meet this requirement.

4. DACA Participants No Longer Eligible for ACA Coverage

Dreamers under the Deferred Action for Childhood Arrivals (DACA) program are no longer eligible for ACA coverage, including both subsidized and unsubsidized plans. Agencies serving immigrant populations must adjust their strategies accordingly.

5. Auto-Renewal Changes: From $0 to $5 Premiums

Consumers who previously paid $0 premiums may see a minimum premium of $5 in 2025 if they don’t actively renew their plans. Consumers who pay the $5 in January will receive a refund via their tax returns. However, failure to pay could result in coverage loss after 90 days. Encouraging clients to manually renew their policies is critical to avoiding lapses in coverage.

What to Expect During Open Enrollment 2025

Dates to Remember:

November 1, 2025 – January 15, 2026
- Enrollments completed by December 15, 2025, will have a January 1, 2026, effective date.
- Enrollments completed after December 15, 2025, will have a February 1, 2026, effective date.

Renewal Challenges:

This year, automatic renewals will require more active agent involvement. Policies must be re-enrolled manually, ensuring all income and household details are accurate. This creates a demand for human interaction on both ends of the transaction – agents and consumers.

Industry Insights and Innovations

Carrier Adjustments

As the ACA market matures, leading carriers like Am Better are introducing measures to enhance agent and consumer experiences. These include:

Direct Agent Payments: Am Better plans to allow agents to receive commissions directly, separating them from agency compensation. This could reduce friction caused by delayed or inaccurate payments.
Improved Book Visibility: Agencies will soon have better tools to monitor their books of business, including insights into client activity over the past 12 months.
Technology Upgrades: Enhanced agent portals and systems aim to streamline enrollment and provide clearer insights into client data.

Compliance and Fraud Prevention

New rules ban practices like National Producer Number (NPN) overrides in several states, including Florida, North Carolina, and Wisconsin. NPN overrides, which allow agencies to claim policies under one central number, have been linked to fraud and obscured accountability. The industry is shifting toward individual accountability, with more carriers expected to follow suit.

Preparing for the Future: 2026 and Beyond

While 2025 presents unique challenges, the ACA marketplace is expected to stabilize in the coming years. Key trends to watch include:

Expansion of ICHRA (Individual Coverage Health Reimbursement Arrangements): More states are adopting this model, allowing employers to give employees a stipend to purchase their own plans.
Regulatory Clarity: Recent lawsuits and regulatory changes may lead to more consistent standards across the marketplace.
Premium Adjustments: Subsidies are expected to evolve, potentially moderating premium hikes in 2027.

Heather, an expert in ACA operations, summed it up aptly: "Change always brings opportunity. While this year presents hurdles, it also paves the way for a more stable and sustainable ACA marketplace."

Key Takeaways

Be proactive: Start preparing now for open enrollment, focusing on manually renewing policies to avoid lapses in coverage.
Educate clients: Explain new income verification rules, tax filing requirements, and the transition from $0 to $5 premium plans.
Adapt to compliance changes: Stay ahead by avoiding outdated practices like NPN overrides and ensuring transparency in your operations.
Diversify portfolios: Consider expanding beyond ACA products to include ancillary services like short-term medical or supplemental plans.
Leverage technology: Embrace carrier-provided tools for better visibility and streamlined workflows.
Monitor policy changes: Keep an eye on the renewal of enhanced subsidies and potential regulatory shifts in 2026.

Conclusion

The ACA landscape in 2025 brings both challenges and opportunities for Illinois residents and businesses. By understanding the key changes, adapting to compliance measures, and staying proactive during open enrollment, agents and consumers alike can navigate this evolving market successfully. While the short-term outlook may be turbulent, the long-term prospects point to a more stable and sustainable ACA marketplace.

Source: "Episode 98: Upcoming ACA Changes & Updates" – Agent Boost Marketing, YouTube, Aug 19, 2025 – https://www.youtube.com/watch?v=J86FePE4Q9M

Use: Embedded for reference. Brief quotes used for commentary/review.