Exchange Pre-Eligibility Verification Proposed Rule (CMS 9873-P)

Consistent with the President’s goal to prevent waste, fraud, and abuse, today the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued the Exchange Pre-Eligibility Verification Notice of Proposed Rulemaking. This rule would align Exchange eligibility and verification regulations with new requirements specified under the Working Families Tax Cuts (WFTC) legislation (P.L. 119-21).

The WFTC legislation amended the Internal Revenue Code to establish new eligibility requirements for the premium tax credit (PTC). The Exchange Pre-Eligibility Verification proposed rule would establish new Exchange requirements that align advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs) eligibility with PTC eligibility changes enacted under sec. 71303 of the WFTC legislation and proposed to be codified in regulations issued by the Department of the Treasury on October 15, 2026.

Currently, when consumers apply for coverage through Exchanges, they provide certain information that Exchanges may attempt to verify electronically. If an Exchange cannot verify the information electronically, the consumer enters an inconsistency period during which they need to submit documentation to verify their information. Under existing policy established by the Affordable Care Act (ACA), Exchanges provide APTC and CSRs (collectively, financial assistance) during the inconsistency period to consumers who otherwise appear eligible. If they do not submit documentation to verify their eligibility before the end of the inconsistency period, APTC and CSRs are generally reduced or ended.

The Exchange Pre-Eligibility Verification proposed rule would require Exchanges to verify the following criteria before providing financial assistance:

- household income and family size

- status as a citizen, U.S. national, or eligible noncitizen (including lawfully present)

- eligibility for or enrollment in other qualifying coverage

- place of residence

However, under the proposed rule, consumers could enroll in Exchange coverage without financial assistance during the inconsistency period while verifications are pending.

It would also establish a verification period beginning August 1 before Open Enrollment (OE) each year to ensure that consumers have ample opportunity to provide and confirm information impacting their eligibility before the following coverage year. This proposed rule also includes provisions on annual eligibility redeterminations and re-enrollment, eligibility redeterminations during the plan year, timeline requirements for states seeking to transition to a State-based Exchange, binder payments, a waiver of the proposed verification requirements for certain Special Enrollment Periods (SEPs), effective dates for eligibility determinations, annual OE notices, and plan selection requirements.