CMS proposes eligibility checks before marketplace enrollees get premium help from 2028

The Centers for Medicare & Medicaid Services (CMS) has proposed that people who buy health insurance through the Affordable Care Act marketplaces, called Exchanges in federal rules, pass eligibility checks before they receive federal help with their premiums, starting with 2028 health plans. The proposed rule was published in the Federal Register on October 27, four days after CMS announced it.

The rule would carry out section 71303 of Public Law 119-21, the law enacted on July 4, 2025, that is commonly known as the One, Big, Beautiful Bill Act and that CMS calls the Working Families Tax Cuts legislation. Under the new tax code language, a month generally does not count as a coverage month for the premium tax credit unless an Exchange has verified the enrollee's eligibility. The requirement applies to tax years beginning after December 31, 2027.

What would change

Before paying advance premium tax credits or cost-sharing reductions, Exchanges would have to verify four things:

• household income and family size
• citizenship, U.S. national status or eligible immigration status
• eligibility for, or enrollment in, other qualifying coverage
• place of residence

Today, when an application does not match government data, the applicant has 90 or 95 days to resolve the mismatch by sending documents (95 days for a citizenship or immigration issue). In the meantime the applicant is treated as eligible for coverage and, if applicable, for financial help. Under the proposal, CMS says, Exchanges "would no longer be permitted to provide financial assistance during inconsistency periods." People could still enroll without financial help while their documents are reviewed, and CMS proposes paying the help retroactively for those months once they are verified.

At renewal, Exchanges could not continue an enrollee's financial help for the next plan year unless the enrollee provides or confirms the required information and it goes through verification. Enrollees who do not re-verify, CMS says, "would be automatically re-enrolled without financial assistance." A new verification window would open on August 1 each year, before open enrollment; the first would start August 1, 2027, for 2028 coverage.

Some family-size changes would be exempt from verification, including those tied to a special enrollment period for a birth, adoption or marriage.

What the agency expects

The rule's regulatory impact analysis gives these annual estimates, starting with the 2028 plan year:

CMS expects those 332,500 people to opt out of enrollment "due to administrative barriers associated with the verification process," and says people who do not enroll because of such barriers "are likely to be younger and healthier than those remaining in the risk pool, leading to higher overall premiums." The analysis also says eligible consumers who cannot complete the verification process will not receive the tax credit in advance.

Federal subsidies should only go to eligible Americans, not to fraudsters gaming the system.

No statement opposing the proposal was found in official sources as of October 29, 2026. The rule's public docket showed no posted comments that day, and we found none in releases from state marketplaces, state insurance regulators or members of Congress.

A related Treasury proposal

On October 15, the Treasury Department and the IRS published proposed premium tax credit regulations to implement the same law's changes to the credit, including the verification requirement. The IRS said they would restrict the credit to U.S. citizens, U.S. nationals and certain lawfully present noncitizens beginning in 2027. The law also removed the limit on how much of an excess advance payment a household must repay at tax time, for tax years beginning after December 31, 2025.

Comments on the Treasury proposal are due November 30, 2026, and a telephone public hearing is scheduled for December 8, 2026, at 10 a.m. Eastern time.

How to comment

Comments on the CMS proposal must be received by November 27, 2026. They can be submitted at regulations.gov under docket CMS-2026-3367, using file code CMS-9873-P, or by mail. CMS says all comments received before the deadline are available for viewing by the public. Our explainer on how a federal rule is made describes the steps that follow.