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Policy Proposed rule would hold back ACA subsidies until eligibility is verified

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Tuesday, November 3, 2026 From the publisher Free hospital price search Published bysoro
The Care Ledger

Policy

Proposed rule would hold back ACA subsidies until eligibility is verified

A federal proposal would stop paying marketplace subsidies while eligibility questions are resolved, starting with 2028 coverage, and officials expect fewer people to enroll as a result.

  • The Care Ledger
  • 3 min read
  • 5 sources
  • Reviewed by an editor
A tall sign reading Hubert H. Humphrey Building, U.S. Department of Health and Human Services
The sign outside the Department of Health and Human Services headquarters in Washington. Photo: G. Edward Johnson, via Wikimedia Commons (CC BY 4.0)

The Centers for Medicare & Medicaid Services (CMS) proposed on Oct. 23 that people buying coverage on the Affordable Care Act (ACA) marketplaces pass eligibility checks before they receive advance premium tax credits or income-based cost-sharing reductions. Today, applicants whose information does not match government records generally have 90 or 95 days to resolve the issue while that help continues. Under the proposed rule1, which would apply starting with the 2028 plan year, CMS estimates 332,500 fewer people would enroll each year.

Without the advance credit, an enrollee pays the plan's full premium. The rule puts the average advance payment at $655 a month per enrollee. CMS acknowledges in the proposal that many people who must wait for verification are unlikely to be able to afford a full-price plan in the meantime, and that more people could become uninsured as a result.

What would change

Marketplaces would have to verify household income and family size, citizenship or immigration status, place of residence, and eligibility for other coverage before paying financial help, according to a CMS fact sheet2. People could still enroll at full price while a check is pending, and enrollees would receive the credit retroactively for those months once verified. Applicants could also choose a plan that takes effect only if they are found eligible.

Returning enrollees would be automatically renewed with financial help only if they come back each year and have their information verified again. Otherwise, they would be renewed without it. Marketplaces would open a voluntary verification window on Aug. 1 each year, before open enrollment, with the first on Aug. 1, 2027. Verification would be waived for certain family-size changes, such as a birth, adoption or marriage, with help based on what the enrollee reports.

CMS estimates federal subsidy spending would fall $7.6 billion a year. About $2.6 billion would come from the people who do not enroll. The other $5 billion would come from paying subsidies about one and a half fewer months, on average, to roughly 5 million people who must verify their information and later enroll with help. The agency expects average premiums to rise about 0.4%, because younger and healthier people are more likely to drop out than finish the paperwork.

Why the administration says it is needed

CMS says the rule carries out section 71303 of the Working Families Tax Cut legislation, the 2025 budget law. In a press release3, CMS Administrator Mehmet Oz said subsidies should go to eligible Americans and "not to fraudsters gaming the system." Treasury Secretary Scott Bessent said taxpayers should not subsidize coverage for people the law makes ineligible. CMS also says checking eligibility first could spare enrollees from repaying excess tax credits when they file their taxes.

The rule itself lists costs beyond enrollment. It warns that care may shift to "under-prepared emergency departments" and that states and the federal government could pay more for emergency-only Medicaid.

A companion Internal Revenue Service (IRS) proposal published Oct. 154 would write other parts of the same law into tax regulations. It reflects the law's removal of the cap on how much excess advance credit people must repay at tax time, starting with the 2026 tax year, and the end of the credit for some lawfully present immigrants with incomes below the poverty line.

CMS's baseline projects about 16.9 million marketplace enrollees in 2028 before the rule. The Healthcare Financial Management Association (HFMA) reported5 that this baseline is already down from 19.2 million enrollees in February 2026.

What comes next

Both rules are proposals and could change. Comments on the CMS rule are due Nov. 27, 2026, according to the Federal Register. Comments on the IRS rule are due Nov. 30, with a telephone hearing scheduled for Dec. 8. The first verification window would open Aug. 1, 2027, for 2028 coverage.

Sources

Every figure in this story was checked against these sources on Friday, October 23, 2026.

  1. 01Federal Register (Centers for Medicare & Medicaid Services), "Patient Protection and Affordable Care Act, Exchange Pre-Eligibility Verification" (proposed rule CMS-9873-P, FR Doc. 2026-21891, 91 FR 67656), public inspection copy filed October 23, 2026, published October 27, 2026public-inspection.federalregister.gov
  2. 02Centers for Medicare & Medicaid Services, "Exchange Pre-Eligibility Verification Proposed Rule (CMS-9873-P)" (fact sheet), October 23, 2026cms.gov
  3. 03Centers for Medicare & Medicaid Services, "CMS Proposes New Verification Requirements to Implement Law that Combats Exchange Fraud and Protects Taxpayer Dollars" (press release), October 23, 2026cms.gov
  4. 04Federal Register (Internal Revenue Service, Department of the Treasury), "Premium Tax Credit" (proposed rule REG-101576-26, FR Doc. 2026-21056, 91 FR 65494), October 15, 2026govinfo.gov
  5. 05HFMA, "ACA marketplace subsidy verification rule would reduce enrollment starting in 2028" (Nick Hut), October 24, 2026hfma.org
  6. PhotoThe sign outside the Department of Health and Human Services headquarters in Washington. Photo: G. Edward Johnson, via Wikimedia Commons (CC BY 4.0).commons.wikimedia.org

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