CMS Proposes Making ACA Enrollees Pass Eligibility Checks Before Subsidies Flow Starting In 2028
The proposed rule would also strip subsidies from automatic renewals unless consumers return each year to re-verify.
The Centers for Medicare & Medicaid Services (CMS) proposed a rule on Friday that would require Affordable Care Act Exchange consumers to pass eligibility verification before they receive premium subsidies, starting with 2028 health plans. CMS Administrator Dr. Mehmet Oz said the change would protect taxpayer dollars.
Verification before the money moves
The proposal covers consumers seeking advance payments of the premium tax credit or income-based cost-sharing reductions. Under the Exchange Pre-Eligibility Verification Notice of Proposed Rulemaking, they would generally have certain eligibility criteria verified before getting financial help.
CMS said the step ends a vulnerability that has been used for fraudulent or ineligible enrollments. The agency said the rule implements provisions of the Working Families Tax Cuts legislation.
"Federal subsidies should only go to eligible Americans, not to fraudsters gaming the system," Oz said. Treasury Secretary Scott Bessent said the proposed rules close eligibility loopholes so that Premium Tax Credits are reserved for eligible Americans.
Auto-renewal would lose its subsidy
Consumers already enrolled would keep ongoing financial assistance at automatic re-enrollment only if they return to the Exchange each year, confirm certain eligibility criteria and have them re-verified. Those who do not would be re-enrolled automatically without financial assistance.
CMS said the changes would not affect consumers who do not apply for, or are not eligible for, financial help.
A verification window opens August 1
Consumers would be able to verify certain information with the Exchange starting August 1 each year, before Open Enrollment. CMS said the window is meant to avoid delays and give people more time to supply documents if the Exchange needs them.
The first window would begin August 1, 2027, for 2028 coverage.
Stakeholders can submit comments for 30 days after the proposed rule is published.
Sources
- CMS Proposes New Verification Requirements to Implement Law that Combats Exchange Fraud and Protects Taxpayer Dollars — Centers for Medicare & Medicaid Services
- Shopping for an ACA plan this year? Here's what you need to know. - CBS News — CBS News
- Trump administration sued for second time over ACA broker freeze | Healthcare Dive — healthcaredive.com
- What We Know about Trump’s $500 ACA Checks and the User Fees Funding Them | KFF — kff.org
- Five major companies pledge faster, electronic prior authorizations | Healthcare Dive — healthcaredive.com
- Department of Health and Human Services and the Justice Department’s Civil Division Announce Anti-Fraud Healthcare Self-Disclosure Pilot Program | HHS.gov — hhs.gov
