联邦医保中心拟出新规：医保补贴先过四项核查才发放，2028年实施
美国卫生与公众服务部（HHS）下属的联邦医保与医疗服务中心（CMS）10月23日发布拟议规则（编号CMS-9873-P），提出自2028年计划年度起，消费者通过医保市集领取保费税收抵免预付（APTC）和分摊费用减免（CSR）之前，须先通过四项资格核查，补贴核查通过后才发放。拟议规则已在《联邦公报》预刊，刊登后有30天公众评论期。
按现行《平价医疗法案》的安排，消费者在市集申请医保时提交收入、身份等信息，市集先做电子核对；无法电子核实的，消费者进入「不一致期」，在此期间补交证明文件，补贴照常发放，只有到期仍未补交才会被调减或停发。
拟议新规把顺序倒过来：四项信息必须先核实，补贴才开始发放。四项核查是：家庭收入与家庭人数；公民、美国国民或合格非公民（含合法居留者）身份；是否符合或已参加其他合格保险；居住地。核查未完成期间，市集不得发放补贴，但消费者仍可按全价先行参保；核查通过后，已参保月份的补贴可追溯补发。
在保消费者也受影响：今后每年自动续保时，只有主动返回市集确认信息并重新通过核查的人，续保才继续带补贴；没有主动确认的，将按全价自动续保、不带补贴。为给消费者留出准备时间，CMS提出每年8月1日起开放「开放注册前核查期」，可提前提交资料核查；第一个窗口2027年8月1日开放，面向2028年度保障。因出生、领养、结婚或家庭成员去世等触发特殊注册期的家庭人数变化，可豁免新的核查要求；市集还须允许消费者选择「附条件计划」，资格确认后计划才生效。
CMS表示，新规是落实《工作家庭减税法》（P.L.119-21）第71303条对保费税收抵免资格的新要求，财政部已于10月15日发布配套拟议法规。新规只适用于2028年计划年度的资格认定，不影响11月1日开始的2027年度开放注册。
来源：GSM·美国
CMS Proposes Verify-First Rule for Health Insurance Subsidies: Four Checks Before Assistance, Starting in 2028
The Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services (HHS), issued a proposed rule (CMS-9873-P) on October 23 that would require consumers to pass four eligibility checks before receiving advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSRs) through the health insurance Exchanges, starting with the 2028 plan year. The proposal carries a 30-day public comment period following publication in the Federal Register.
Under current Affordable Care Act policy, applicants submit information such as income and immigration status, which Exchanges try to verify electronically. If the information cannot be verified, the consumer enters an "inconsistency period" to submit documents while financial assistance continues; assistance is reduced or ended only if documentation is not provided by the end of that period.
The proposed rule reverses that order. The four criteria that must be verified before assistance begins are: household income and family size; status as a citizen, U.S. national, or eligible noncitizen (including lawfully present immigrants); eligibility for or enrollment in other qualifying coverage; and place of residence. Consumers could still enroll in coverage without assistance while verification is pending, and once verified, assistance would be provided retroactively for the months they were enrolled.
Current enrollees are also affected: under the proposal, consumers would be automatically re-enrolled with financial assistance only if they return to the Exchange each year to confirm their information and have it re-verified; those who do not would be renewed without assistance, at full price. To give consumers time, CMS proposes a pre-open-enrollment verification period beginning August 1 each year, with the first window opening August 1, 2027, for 2028 coverage. Verification requirements would be waived for certain family-size changes tied to special enrollment periods, such as birth, adoption or marriage, and Exchanges would have to allow "contingent" plan selections that take effect only once eligibility is confirmed.
CMS says the rule implements new premium tax credit eligibility requirements under section 71303 of the Working Families Tax Cuts legislation (P.L. 119-21); the Treasury Department issued related proposed regulations on October 15, 2026. The proposal would apply only to eligibility determinations for plan year 2028 and does not affect the open enrollment for 2027 coverage that begins November 1.
Source: GSM · USA
来源：GSM·美国（原文链接）
图片来源：图：美国卫生与公众服务部总部 Humphrey 大楼（华盛顿），联邦医保与医疗服务中心（CMS）隶属该部。（图：Wikimedia Commons，CC BY 2.0）/ The Humphrey Building in Washington, headquarters of the U.S. Department of Health and Human Services, which oversees CMS. (Photo: Wikimedia Commons, CC BY 2.0)
GSM Global · 本篇英文版 English edition of this story
