CMS Proposes Pre-Eligibility Checks for ACA Exchange Subsidies Starting in 2028

The Centers for Medicare & Medicaid Services (CMS) has proposed changes to how consumers qualify for financial assistance through Affordable Care Act (ACA) Exchanges. Under the Exchange Pre-Eligibility Verification Notice of Proposed Rulemaking, consumers seeking advance payments of the premium tax credit or income-based cost-sharing reductions would generally need to pass eligibility verification before receiving subsidies. CMS presents the proposal as an effort to address vulnerabilities that can enable fraudulent or ineligible enrollments and to implement the Working Families Tax Cuts legislation. The requirements would begin with 2028 health plans, giving the agency and the organizations that support Exchange operations time to assess potential implementation needs if the proposal is finalized.

The proposed approach also affects annual re-enrollment. CMS says currently enrolled consumers would be automatically re-enrolled with ongoing financial assistance only if they return to the Exchange, confirm certain eligibility criteria annually, and have those criteria re-verified. Consumers who do not complete that process would still be automatically re-enrolled, but without financial assistance. CMS states that the changes would not affect consumers who do not apply for financial help or are not eligible for it. For eligible consumers, the distinction makes the verification process and the handling of missing or unconfirmed information operationally important.

CMS proposes a pre-Open Enrollment verification window beginning August 1 each year. Consumers could use that period to verify certain information before the next coverage year, and, when the Exchange requests supporting documentation, provide it for review ahead of Open Enrollment. The stated aim is to help avoid delays by giving consumers and Exchanges more time to resolve verification issues. For contractors, this points to potential impacts across eligibility-system workflows, data verification, consumer communications, document intake and review, and the systems that support annual renewals. The announcement, however, does not identify a specific acquisition, solicitation, award, contractor, or final technical requirement.

CMS Administrator Mehmet Oz said the proposal would “protect taxpayer dollars and restore trust in the Exchanges by verifying eligibility before that money leaves the building.” Treasury Secretary Scott Bessent similarly described the proposed rules as implementing reforms intended to close eligibility loopholes and reserve taxpayer-funded premium tax credits for eligible Americans. These statements explain the administration’s program-integrity rationale; they do not establish final policy or procurement specifications. CMS is accepting comments for 30 days after publication. Because the supplied announcement does not provide a publication date from which to calculate the deadline, interested organizations should consult the official rulemaking notice for the applicable calendar date and submission instructions.

• CMS proposes verification before consumers receive advance premium tax credit payments or income-based cost-sharing reductions.
• The requirements would generally begin with 2028 health plans, subject to the rulemaking process and final requirements.
• Enrollees seeking continued financial assistance would need to return to the Exchange, confirm certain eligibility criteria annually, and complete re-verification.
• Consumers who do not complete the proposed annual confirmation could be automatically re-enrolled without financial assistance.
• Consumers who do not apply for financial assistance or are not eligible for it would not be affected by these changes, according to CMS.
• The proposed annual pre-Open Enrollment verification window would begin August 1, with time to resolve information requests and submit supporting documents.
• Potentially relevant contractor capabilities include eligibility-system updates, data verification, document processing, workflow management, and consumer support; CMS has announced no related solicitation or award.
• Interested stakeholders may submit comments within 30 days after publication; the provided source does not state a date for calculating the deadline.
• The proposal implements the Working Families Tax Cuts legislation, according to CMS, and is framed as a measure to strengthen Exchange program integrity and protect taxpayer funds.