Patient Protection and Affordable Care Act, Exchange Pre-Eligibility Verification

CMS published a proposed rule (CMS-9873-P, RIN 0938-AW03) in the Federal Register on October 27, 2026, implementing new Exchange eligibility and verification requirements mandated by section 71303 of the Working Families Tax Cut (WFTC) legislation, Public Law 119-21 (July 4, 2025). The rule proposes amendments to 45 CFR Part 155 governing Exchange establishment standards. The comment period closes November 27, 2026. The central change flows from section 71303(a) of the WFTC legislation, which amends section 36B of the Internal Revenue Code to add a pre-verification requirement before a month qualifies as a coverage month eligible for advance payments of the premium tax credit (APTC). Effective January 1, 2028, an Exchange must verify an enrollee's eligibility using applicable enrollment information provided or confirmed by the applicant, covering household income and family size, citizenship or eligible noncitizen status, health coverage status, and place of residence. Section 71305 of the WFTC legislation separately eliminated the repayment cap on excess APTC for tax years after December 31, 2025. The proposed rule would prohibit Exchanges from authorizing APTC and cost-sharing reductions (CSRs) for applicants with unresolved data matching issues (DMIs) related to citizenship and lawful presence (45 CFR 155.315(c)), residency (45 CFR 155.315(d)), non-employer-sponsored minimum essential coverage (45 CFR 155.320(b)), annual household income, family size, and eligible noncitizen status (45 CFR 155.320(c)(3)), and employer-sponsored plans (45 CFR 155.320(d)), until those DMIs are adjudicated. An exception applies where the applicant's tax household qualifies for a special enrollment period (SEP) under 45 CFR 155.420(d)(2)(i) or (ii). The rule proposes a mandatory annual pre-open enrollment (pre-OE) verification period beginning August 1 each year, during which consumers may provide and Exchanges must attempt to verify specified eligibility information for the subsequent plan year. Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs) would be required to offer pended plan selections, under which a plan selection is transmitted to the issuer and coverage becomes effective only after APTC and CSR eligibility is confirmed. New effective date rules govern when coverage takes effect based on when DMIs are resolved relative to the 15th of the applicable month. The annual redetermination provision under 45 CFR 155.335 is amended to prohibit redetermination of APTC and CSR eligibility for a subsequent plan year unless the enrollee provides or confirms income, family size, citizenship or noncitizen status, other coverage status, and residency on or after August 1 and no later than December 31 of the preceding year.