CMS Proposes New Verification Requirements to Implement Law that Combats Exchange Fraud and Protects Taxpayer Dollars

CMS Proposes New Verification Requirements to Implement Law that Combats Exchange Fraud and Protects Taxpayer Dollars

The Centers for Medicare & Medicaid Services (CMS) has taken another step to combat fraud and strengthen program integrity in the Affordable Care Act (ACA) Exchanges by improving the consumer eligibility verification process for premium subsidies. Under today's proposed rule, consumers seeking advance payments of the premium tax credit or income-based cost-sharing reductions must first pass eligibility verification before receiving subsidies, ending a vulnerability that has been used for fraudulent or ineligible enrollments.

"Federal subsidies should only go to eligible Americans, not to fraudsters gaming the system," saidCMS Administrator Dr. Mehmet Oz. "Implementing the Working Families Tax Cuts legislation will protect taxpayer dollars and restore trust in the Exchanges by verifying eligibility before that money leaves the building."

"Hardworking American taxpayers should not be forced to subsidize health care for people who are ineligible under federal law," said Treasury Secretary Scott Bessent. "Today's proposed rules implement the common-sense reforms enacted by the Working Families Tax Cuts to close eligibility loopholes and ensure taxpayer-funded Premium Tax Credits are reserved for eligible Americans. Under President Trump, this Administration is cracking down on fraud and corruption; holding bad actors accountable; lowering health care costs for Americans; and restoring integrity to our tax code and health care system."

The Exchange Pre-Eligibility Verification Notice of Proposed Rulemaking would generally require consumers seeking financial help through the Exchanges to have certain eligibility criteria verified before receiving financial assistance beginning with 2028 health plans. Additionally, CMS proposes that currently enrolled consumers would only be automatically re-enrolled in coverage with ongoing financial assistance if they return to the Exchange to confirm certain eligibility criteria annually and have it re-verified by the Exchange. Otherwise, they would be automatically re-enrolled without financial assistance. The new requirements would help ensure that only eligible consumers receive financial assistance during both initial enrollment and annual re-enrollment in qualified health plans (QHPs). These changes would not affect consumers who don't apply for or are not eligible for financial help.

Consumers would have the option to verify certain information with the Exchange starting on August 1 each year before Open Enrollment. This new pre-Open Enrollment window is designed to help consumers avoid potential delays by allowing the Exchange to verify certain information ahead of the next coverage year. It also gives consumers additional time to provide documents for review before Open Enrollment begins if the Exchange needs documents to confirm information on their application. The first pre-Open Enrollment window would start August 1, 2027, for 2028 coverage.

This proposed rule advances the Trump Administration's efforts to ensure that taxpayer-funded assistance goes only to eligible consumers by implementing relevant provisions of the Working Families Tax Cuts legislation and reflects CMS' commitment to Exchange integrity.

To view the CMS fact sheet, visit: https://www.cms.gov/newsroom/fact-sheets/exchange-pre-eligibility-verification-proposed-rule-cms-9873-p .

To view the proposed rule, visit: https://www.federalregister.gov/public-inspection/2026-21891/patient-protection-and-affordable-care-act-exchange-pre-eligibility-verification .

Stakeholders are invited to submit public comments for a 30-day period following publication of the proposed rule.

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