Marketplace shifts ahead: How they’ll impact therapy and your practice

The Centers for Medicare & Medicaid Services (CMS) recently shared updates to the Affordable Care Act (ACA) marketplaces through the 2025 Marketplace Integrity and Affordability Final Rule. These changes aim to reduce fraud, improve program integrity, and stabilize insurance markets. However, they may also create new challenges for folks trying to access care—and for the therapists dedicated to supporting them. 

You care deeply about your clients’ well-being, and these updates could impact their ability to afford coverage, maintain consistent insurance, and continue therapy. It’s important to understand how these rules might affect your practice and the lives of those you care for. Below is a simple explanation of the key changes, what they mean for your clients and practice, and strategies to help you navigate these shifts with confidence and compassion. 

A closer look at the policy changes 

Here’s a breakdown of the key elements in the CMS final rule and the ripple effects they may cause in terms of client care and access. 

Stricter eligibility verification for subsidies 

One of the most substantial changes involves tightened rules around eligibility for Advance Premium Tax Credits (APTC), which help lower the cost of health insurance for low- and moderate-income individuals. CMS has reinstated a policy that revokes subsidies for people who fail to file and reconcile their taxes for the previous year. 

What it means for clients: A single missed tax filing could mean the loss of financial assistance for insurance, leaving many without affordable coverage. This could particularly impact individuals with fluctuating incomes—for example, gig workers or those transitioning between jobs. 

Additionally, CMS is rolling back an automatic 60-day extension that was previously available for resolving income inconsistencies. People now have just 90 days (as required by statute) to verify their income, which could result in more clients losing subsidies due to missed deadlines. 

Changes to coverage rules could increase out-of-pocket costs 

A big change is being made to how much health insurance plans are required to cover. This is measured by something called the actuarial value (AV), which is just a fancy way of saying what percentage of your healthcare costs the plan will pay for. The rest is what you pay out-of-pocket, like deductibles or copays. 

Now, insurance companies have more flexibility. For example, Silver plans used to have to cover between 68% and 72% of your costs. With the new rules, they can cover as little as 66%. This means insurance companies might lower what they cover by increasing things like deductibles, copays, or coinsurance, which could make it more expensive for people to use insurance. 

What it means for clients: The wider range allows insurers to market plans as “silver” or “gold” even if they pay less of the average patient’s costs. This means people might unknowingly enroll in plans that look affordable but result in higher out-of-pocket expenses for services like therapy. A silver plan that used to have a $4,000 deductible, for instance, might now have a deductible closer to $5,750 under the new rules. 

Ending income-based enrollment flexibility 

Before, people earning up to 150% of the Federal Poverty Level (FPL) could sign up for health coverage anytime during the month through a Special Enrollment Period (SEP). This was helpful for low-income individuals dealing with financial instability. Now, this option has been removed, so it’s more important than ever to sign up for coverage on time. 

What it means for clients: People will now only be able to enroll during the standard Open Enrollment Period or under specific (and more restrictive) SEP criteria. This makes missing the enrollment window particularly risky for individuals whose financial situations prevent them from securing coverage. 

Exclusion of specific groups from coverage 

One important policy change affects people who are part of the Deferred Action for Childhood Arrivals (DACA) program, often called Dreamers. Under this policy, DACA recipients are no longer considered “lawfully present” when it comes to accessing healthcare coverage through the Affordable Care Act (ACA). What does this mean? Unfortunately, it means that Dreamers can’t buy health insurance through ACA marketplaces or qualify for subsidies to help make coverage more affordable. This can create significant challenges for many DACA recipients who are already navigating complex systems while striving for stability and opportunity in their lives. 

What it means for clients: Affected individuals lose access to both full-price and subsidized plans, further exacerbating existing barriers. This could disproportionately affect younger patients’ families who rely on therapy for mental health support. 

New rules for automatic re-enrollments 

Lastly, CMS has required a $5 minimum premium for individuals who are re-enrolled in $0-premium plans without updating their eligibility information. While this amount seems small, CMS expects it to improve consumer engagement with their coverage and prevent accidental or improper enrollments. 

What it means for clients: Even minor premiums could dissuade people from keeping their coverage, leading to increased drop-offs. 

What this all means for therapists  

These changes to subsidies and insurance coverage could have a significant impact on you and your clients. Without subsidies, some of your clients may feel forced to drop their insurance, leaving them with higher out-of-pocket costs that make therapy less accessible. This could lead to fewer appointments, canceled sessions, or even the heartbreaking decision to stop treatment altogether. 

You might see clients skipping sessions or facing added financial stress due to increased cost-sharing. Limited mid-year enrollment options could leave some of your clients unexpectedly uninsured, especially those in underserved communities. These disruptions make it even harder for you to provide consistent care and can leave you navigating the strain of trying to help in difficult circumstances. 

Marginalized groups are likely to feel these changes the most, and you may find yourself considering reduced fees to ease their burden—often at the expense of your own financial and emotional resources. Coverage lapses and billing complications could add to your challenges, leading to canceled sessions and uncertainty for both you and your clients.  

These issues highlight just how important it is to find compassionate, sustainable solutions that support you and the important work you do. Your care and dedication are invaluable, and it’s essential to ensure you have the resources and systems in place to continue making a difference. 

How therapists can respond and support their clients 

• Help them stay informed: Many of the changes in these rules require people to be more proactive about managing their insurance.  

• Educate your clients—not just about the importance of filing taxes but also about understanding their plan details and coverage options.  

• Provide resources or recommend local organizations that can help with tax preparation or insurance navigation during enrollment periods. 

• Advocate for mental health access: You can advocate for your clients in several ways, from writing appeals for coverage denials to joining professional associations that influence healthcare policy.  

• At a local level, collaborating with advocacy groups to expand Medicaid or simplify enrollment processes can have a broader impact on underserved patients. 

• Be flexible with payments: Consider adapting your practice model to minimize the financial strain on clients.  

• This might include offering sliding-scale fees, setting up payment plans for out-of-pocket costs, or adjusting cancellation policies for people navigating coverage gaps. 

• Prepare for administrative challenges: Expect to spend more time verifying clients’ eligibility or handling sudden insurance issues.  

• Automating parts of your administrative workflow (e.g., with billing software) can help save time while maintaining quality. 

Bravely facing change 

The 2025 Marketplace Integrity and Affordability Final Rule reflects a balance between fraud prevention and the need for affordable, accessible care. However, for you and your clients, the reality is more complicated. Shrinking subsidies, stricter paperwork rules, and rising out-of-pocket costs mean that people may face even greater challenges in maintaining therapy. 

By staying informed and proactive, you can help clients overcome these hurdles while protecting your practice. Whether through community advocacy, client education, or flexible payment options, you can play a vital role in ensuring that care remains accessible—even as the rules around insurance get tougher. 

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