Balancing Integrity with Access: What the 2024 Marketplace Final Rule Means for Compliance

It’s not every day that a regulatory rule both shores up protections and risks cutting off access—but the 2024 Marketplace Integrity and Affordability Final Rule does exactly that. As a compliance professional, I see this regulation as one of the most complex balancing acts HHS has attempted under the Affordable Care Act.

On one hand, it pushes Marketplaces toward fairness, transparency, and anti-fraud accountability. On the other, it could create real challenges for the very populations it’s meant to protect.

So what does the rule actually do—and what are the risks? Let’s unpack it.

What the Rule Actually Does: Three Key Focus Areas

1. Strengthening Marketplace Integrity

HHS is pushing back hard against misuse and inefficiencies in the enrollment process. Key reforms include:

• Stricter oversight of Direct Enrollment (DE) platforms and web brokers, ensuring they display all Qualified Health Plans fairly and don't steer consumers toward higher-commission options.
  

• Enhanced verification of eligibility for Special Enrollment Periods (SEPs)—a critical mechanism that allows consumers to enroll outside of the annual Open Enrollment Period due to life events like loss of coverage, marriage, birth of a child, or moving to a new coverage area. These SEPs are vital safety nets—but they’ve also become vulnerable to exploitation and inconsistent application.
  

To preserve the integrity of these special windows, HHS is demanding improved documentation, standardization of eligibility checks, and transparency from enrollment entities.

2. Expanding Affordability for More Americans

Affordability gets a boost through technical, but impactful changes:

• The "family glitch" fix is now formally codified. Previously, families were often ineligible for subsidies if an employer offered “affordable” coverage for the employee—even if family premiums were sky-high. Now, more family members will qualify for premium tax credits.
  

• Income verification processes are updated to align more closely with real-world employment fluctuations and reduce misclassifications that either incorrectly grant or deny subsidies.

3. Advancing Health Equity and Access

Equity isn’t just rhetoric in this rule—it’s operationalized through:

• Expanded outreach obligations for State-Based Marketplaces, including culturally and linguistically appropriate engagement.
  

• Improved transitions between Medicaid and Marketplace coverage, helping to prevent coverage gaps during the “unwinding” of pandemic-era Medicaid expansions.
  

• Clearer protections against coverage termination due to administrative errors or miscommunications.

Risks: Who Could Be Hurt and What Compliance Needs to Watch

As I reviewed this rule, it became clear: it solves some problems but introduces others. Here's where the friction lies:

1. Administrative Overload for Smaller Entities

Smaller health plans, brokers, and nonprofit enrollment assisters may not have the infrastructure to absorb the increased documentation and verification burdens. Training, new software, and revised SOPs take time and money—resources not all organizations have.

Compliance Risk: Delayed implementation, inconsistent eligibility checks, or documentation gaps that result in audits, sanctions, or consumer harm.

2. Risk of Reduced Access

More rigorous SEP verification could unintentionally block access to coverage. Imagine a single parent moving across state lines to escape domestic violence, unable to provide a utility bill or lease in time to verify their new address. Technically noncompliant, but very much in need.

Who Gets Hurt: Individuals in crisis, those with limited literacy or internet access, immigrants, and communities already facing systemic barriers to healthcare.

3. Data Privacy Concerns

More documentation means more personally identifiable information (PII) is collected, stored, and transmitted. Yet many DE platforms and brokers lack strong cybersecurity frameworks.

Compliance Risk: Breaches of HIPAA-adjacent data or OCR investigations under the FTC’s health breach notification rules.

4. Medicaid Churn and Coverage Gaps

While the rule supports continuity of care between Medicaid and the Marketplace, execution depends on state capacity. Many states are still struggling to staff Medicaid offices, leaving room for enrollment errors or lapses in coverage.

Disadvantage: Consumers may lose care access during transitions, impacting chronic disease management, prenatal care, and mental health services.

What Compliance Professionals Should Do Now

There’s no time to “wait and see.” The 2024 rule is final. Here’s your roadmap:

• Audit your SEP processes now. Are you collecting the right documentation? Are your teams trained to recognize valid life events? Do you have a consistent, documented workflow across platforms?

  
  

• Revisit your DE contracts. Do they include clear terms around plan neutrality, display requirements, and SEP handling? Do your partners have escalation paths for noncompliance?

  
  

• Bolster your privacy and security policies. Update your breach protocols and data handling training, especially for enrollment staff managing document uploads or screenshots of financial info.

  
  

• Prepare for CMS and HHS audits. The rule hints at more aggressive oversight. Create audit trails, establish internal checkpoints, and perform mock compliance drills.

  
  

• Invest in equity-forward design. This includes language access, plain-language forms, culturally appropriate FAQs, and user-friendly tech for consumers with disabilities.

Final Reflections: Compliance as a Balancing Act

This rule is not just about compliance—it’s about redefining the values we bring to our work. We’re being asked to stand for both precision and empathy. For both rules and access. For both system integrity and human dignity.

The challenge is big, but so is the opportunity. Let’s ensure our organizations aren't just compliant—but conscious of how these policies land in real lives.

Because the real success of this rule won’t be measured in checkboxes—it’ll be measured in people getting covered, staying covered, and getting the care they deserve.

— Jessica