CMS拟新规：医保交易所补贴先核资格再发放，四项信息付款前核实，2028年计划起实施
美国医疗保险和医疗补助服务中心（CMS）10月23日公布一项拟议规则：今后通过医保交易所（HealthCare.gov及各州交易所）申请保费税收抵免预付和分摊费用减免的人，要先通过资格核实，补贴才会发出。这项名为「交易所资格预核实」的规则（CMS-9873-P）只影响2028年及以后的健康计划，不改变11月1日开始的2027年度开放登记。
按现行做法，当交易所无法电子核实申请信息时，投保人会进入一段「不一致期」，期间补贴照常发放，事后补交材料，交不上再停发。新规将终结这一安排：家庭收入与家庭人数、公民或合法居留身份、是否有其他符合条件的医保（如Medicaid或雇主医保）、居住地这四项，必须在补贴发出前核实完毕。核实未完成期间，消费者仍可先按全价投保。
为了让消费者有时间备齐材料，新规要求各交易所每年8月1日起开放一个预核实窗口，第一个窗口是2027年8月1日，对应2028年计划。规则执行的是《工薪家庭减税法》（P.L. 119-21）第71303条；财政部已于10月15日提出配套的税收抵免拟议规则。新规10月27日刊登《联邦公报》，公众有30天时间提交评论。
CMS局长Mehmet Oz博士说：「联邦补贴只应发给符合资格的美国人，而不是钻空子的欺诈者。在钱离开大楼之前先核实资格，将保护纳税人的钱，并恢复人们对交易所的信任。」财政部长Scott Bessent表示，配套规则将「堵住资格漏洞」。2027年度开放登记照常进行：11月1日至2027年1月15日，12月15日前登记可保2027年1月1日起生效。
CMS Proposes Verify-First Rule for ACA Subsidies: Four Eligibility Checks Before Payments, Starting With 2028 Plans
The Centers for Medicare & Medicaid Services (CMS) proposed a rule on October 23 that would require Affordable Care Act marketplaces to verify a consumer's eligibility before any advance premium tax credits or cost-sharing reductions are paid. The proposal, called the Exchange Pre-Eligibility Verification rule (CMS-9873-P), would apply beginning with 2028 health plans and does not change the open enrollment for 2027 coverage that begins November 1.
Under current policy, when a marketplace cannot electronically confirm something on an application, the enrollee enters an "inconsistency period" and keeps receiving subsidies while documentation is sorted out, with assistance reduced or ended if the paperwork never arrives. The proposed rule ends that practice. Four items would have to be verified before financial help starts: household income and family size; status as a citizen, U.S. national or eligible noncitizen; eligibility for or enrollment in other qualifying coverage such as Medicaid or a job-based plan; and place of residence. Consumers could still enroll in coverage without financial assistance while verification is pending.
To give people time to gather documents, marketplaces would open a pre-verification window each year starting August 1. The first window opens August 1, 2027, ahead of 2028 coverage. The rule implements Section 71303 of the Working Families Tax Cuts legislation (P.L. 119-21); the Treasury Department proposed matching premium tax credit regulations on October 15. The proposal was scheduled for Federal Register publication on October 27, followed by a 30-day public comment period.
"Federal subsidies should only go to eligible Americans, not to fraudsters gaming the system," said CMS Administrator Dr. Mehmet Oz. "Implementing the Working Families Tax Cuts legislation will protect taxpayer dollars and restore trust in the Exchanges by verifying eligibility before that money leaves the building." Treasury Secretary Scott Bessent said the companion rules "close eligibility loopholes." Open enrollment for 2027 coverage runs as planned from November 1, 2026, to January 15, 2027, with a December 15 deadline for coverage starting January 1.
来源：GSM·美国（原文链接）
图片来源：美国卫生与公众服务部总部标识（资料图）。G. Edward Johnson 摄，CC BY 4.0，经 Wikimedia Commons。 / Signage at the U.S. Department of Health and Human Services headquarters (file photo). Photo by G. Edward Johnson, CC BY 4.0, via Wikimedia Commons.
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