Health Exchanges Could Verify Eligibility Before Enrollment
Published Date: 10/27/2026
Proposed Rule
Summary
This new rule affects people using health insurance exchanges by making sure their eligibility is checked more carefully before they enroll. It updates how and when eligibility is verified, adds new ways to enroll during verification, and sets new start dates for coverage. These changes aim to keep the system fair and smooth, with comments open until November 27, 2026.
Analyzed Economic Effects
6 provisions identified: 2 benefits, 3 costs, 1 mixed.
APTC/CSR withheld for certain data mismatches
Exchanges would not be able to authorize advance payments of the premium tax credit (APTC) or cost‑sharing reductions (CSRs) for applicants who have data matching issues (DMIs) related to citizenship/lawful presence, residency, non‑employer minimum essential coverage, household income/family size/eligible noncitizen status, or employer‑sponsored coverage until the Exchange adjudicates those DMIs. This restriction would not apply if the applicant's tax household is eligible for the special enrollment periods described in Sec. 155.420(d)(2)(i) or (ii).
Must confirm key facts Aug 1–Dec 31 to keep subsidies
To be redetermined eligible for APTC and CSRs for the next plan year, an enrollee or application filer must provide or confirm household income and family size; U.S. citizenship or eligible noncitizen status; eligibility for or enrollment in other minimum essential coverage; and place of residence on or after August 1 and no later than December 31 of the year preceding the plan year. The Exchange would be required to attempt to verify that information using the verification processes in Secs. 155.315 and 155.320.
New pre‑open enrollment verification window
Exchanges would be required to provide a pre‑open enrollment verification period starting each year on August 1 (beginning August 1, 2027 for plan year 2028) and continuing until the Exchange's annual Open Enrollment Period begins. During that pre‑OE period you may choose to provide eligibility information for the upcoming plan year and the Exchange would be required to attempt to verify that information.
Pended plan selections and 15th‑of‑month cutoff
Exchanges would be required to allow applicants to "pend" a plan selection so that the plan is only sent to the issuer and coverage only becomes effective after the Exchange determines eligibility for APTC and CSRs. For pended selections, if all of a consumer's DMIs described in Sec. 155.315(f)(ii) are resolved by the 15th of the month following the consumer's otherwise prescribed effective date, the consumer can keep that coverage effective date; if DMIs are resolved between the 16th and the end of the month, the coverage effective date becomes the first day of the next month.
Retroactive enrollments allowed with binder rules
Exchanges may, and the Federally‑facilitated Exchange and State‑based Exchanges on the Federal platform would be required to, make retroactive enrollments under specified enrollment provisions, subject to existing binder payment rules for retroactive enrollments. This means an Exchange can enroll you retroactively under the rule's listed circumstances but binder payment rules still apply.
When plan‑year changes take effect
The proposed rule would set effective‑date rules for eligibility redeterminations during a plan year: redeterminations from enrollee‑reported changes would be effective on the first day of the month following the redetermination unless the enrollee qualifies for certain SEPs. The rule also proposes effective‑date rules that apply when Exchanges resolve DMIs or when a consumer's DMI expires because they did not submit sufficient documentation.
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Key Dates
Department and Agencies
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