The Centers for Medicare & Medicaid Services (CMS) have released a proposed rule that could significantly change how marketplace consumers qualify for financial assistance, starting with the 2028 plan year.
If finalized, these changes would require marketplace exchanges to verify key eligibility information before consumers receive advance premium tax credits (APTC) and cost-sharing reductions (CSRs).
For agents who sell Affordable Care Act (ACA) plans, the Exchange Pre-Eligibility Verification rule could mean more documentation, more client outreach, and fewer opportunities for clients to enroll with subsidies while eligibility issues are unresolved.
Why CMS Is Proposing Pre-Eligibility Verification Changes
The latest CMS ACA proposed rule implements requirements included in the Working Families Tax Cut legislation and aims to reduce improper enrollments, fraud, and subsidy payments made to consumers whose eligibility hasn’t been verified.
Today, consumers can generally receive financial assistance while they resolve data matching issues, such as income or citizenship verification problems. Under the new proposal, that would change for several key eligibility factors.
What Consumers May Have to Verify Before Receiving Subsidies
The biggest change for agents is that exchanges would have to verify several eligibility factors before providing clients with APTC or CSRs.
These include the client’s:
- Household income and family size
- Citizenship, U.S. national status, or lawful presence
- Eligibility for or enrollment in other qualifying coverage
- Place of residence
If the information can’t be verified electronically, clients could still enroll in a marketplace plan, but they would not receive financial assistance until the verification issue is resolved. Agents may need to spend more time gathering proof of income, residency, or other eligibility information before enrollment is completed.
Annual Subsidy Eligibility May No Longer Be Automatic
Additionally, CMS would require consumers to confirm certain eligibility information if they want to continue receiving financial assistance. Exchanges would need to re-verify that information before applying APTC and CSRs for the next plan year.
Consumers who don’t complete this process could still be automatically re-enrolled in coverage, but without financial assistance. If they are used to receiving immediate subsidies may see higher initial premiums if required documentation is missing. This could be a severe financial burden for some applicants who rely on subsidies or tax credits.
Retention efforts may become more important than ever. Proactively contacting existing clients each year to ensure they complete the verification process and avoid losing their subsidies could become key.
A New Pre-Open Enrollment Verification Period
CMS is also proposing a new annual verification window that would start August 1, before the Open Enrollment Period (OEP). This period would allow consumers to submit eligibility information early, so exchanges could verify it before the enrollment season begins.
If finalized, the first pre-Open Enrollment verification period would begin August 1, 2027, for 2028 coverage.
With these changes, the ACA selling season may effectively start months earlier. You could begin working with clients in August to resolve documentation issues ahead of the OEP, rather than scrambling to fix them after enrollment has already started.
New “Contingent” Plan Selections as Eligibility Verification Pends
To help consumers navigate verification delays, CMS is proposing a new plan selection option.
During the OEP or a Special Enrollment Period, consumers could choose a “contingent” marketplace plan based on estimated financial assistance while verification is pending. The plan would not become effective unless and until it’s determined that your client is eligible for subsidies.
CMS says this approach could help consumers avoid missing enrollment opportunities while waiting for eligibility verification. If they are only determined eligible for financial assistance after their enrollment window has closed, they could still enroll in the plan.
Flexibility for ‘Family Size’ Special Enrollment Periods
The proposal includes an exception for some Special Enrollment Periods (SEPs) that are related to family size.
Consumers experiencing the following events could continue receiving financial assistance during the verification process (if allowed by the exchanges):
-
Gaining a dependent
- Marriage
- Birth
- Adoption
- Foster care or court order
-
Certain dependent-loss situations
- Divorce
- Legal separation
- Death
Allowing these clients to receive flexibility in life situations like the above, while their applications are being verified, reduces coverage gaps but also reduces the possibility for improper enrollments. By vetting applications processed with an SEP, marketplaces have more visibility over enrollments that could have been taken advantage of previously by bad actor agents.
CMS Considering Stronger Residency Verification
While CMS is not currently proposing new residency verification standards, it is seeking public comment on ways to strengthen residency verification in the future. The proposal notes that unauthorized enrollments and inaccurate residency attestations could contribute to program integrity issues.
Additional residency documentation requirements could emerge in future rulemaking.
When Would CMS’ Pre-Eligibility Verification Changes Take Effect?
CMS proposes implementing these requirements beginning with eligibility determinations for the 2028 plan year. The new pre-OEP verification period would begin August 1, 2027, if the rule is finalized.
It’s important to remember that this is currently a proposed rule, not final policy. CMS is accepting public comments through November 27, 2026.
One Last Note
If finalized, this proposal would represent one of the most significant marketplace eligibility changes in recent years. ACA agents may want to prepare for a future where eligibility verification happens earlier, subsidy approvals require more documentation, and annual client outreach becomes even more important.
While the changes generally wouldn’t take effect until the 2028 plan year, now is a good time to start educating clients about the importance of keeping income, residency, citizenship, and other eligibility records up to date. Doing so could help prevent subsidy delays and create a smoother enrollment experience, especially if these requirements are made final.
We’re here to support you through updated regulations and changing requirements! Register with Ritter today to have access to IntegrityCONNECT, a top-of-the-line CRM for managing and enrolling ACA clients.
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