Centers for Medicare & Medicaid Services Re-establishes Computer Matching Program for Affordable Care Act Eligibility Verification

The Department of Health and Human Services, through its Centers for Medicare & Medicaid Services (CMS), has announced the re-establishment of a significant computer matching program with State-Based Administering Entities. This program, titled "Determining Eligibility for Enrollment in Applicable State Health Subsidy Programs Under the Patient Protection and Affordable Care Act," is set to commence no sooner than 30 days after its publication in the Federal Register on October 29, 2026. Its primary function is to support accurate eligibility determinations for millions of Americans seeking coverage through the Affordable Care Act (ACA), Medicaid, and the Children's Health Insurance Program (CHIP), while also bolstering measures to prevent improper payments and dual enrollments.

Legal Framework and Program History

This re-established matching program operates under the authority of the Privacy Act of 1974, specifically subsection (e)(12), which mandates federal agencies to provide public notice of such data exchanges. The underlying legislative mandate for the program itself stems from the Patient Protection and Affordable Care Act (PPACA) of 2010, codified at 42 U.S.C. 18001, et seq. CMS notes that this is not a new initiative but a re-establishment of an ongoing program that has been in place since 2013 and was most recently renewed in 2025. The program aims to streamline the verification process for individuals applying for or renewing their enrollment in various state health subsidy programs.

Core Objectives of the Matching Program

The central purpose of this data matching initiative is multi-faceted. First, it enables CMS to provide State-Based Administering Entities (AEs) with verified information, often sourced from other federal agencies through related agreements, to ascertain applicants' eligibility for state health subsidy programs. These programs include Qualified Health Plans (QHPs) offered through exchanges, Medicaid, CHIP, and Basic Health Programs (BHPs). The program also helps determine eligibility for exemptions from the ACA's requirement to maintain minimum essential coverage (MEC) or from the associated individual responsibility payment.

Beyond initial eligibility, the matching program plays a critical role in program integrity. It facilitates the sharing of information between CMS and AEs, and among AEs themselves, to verify whether applicants and enrollees are currently eligible for or already enrolled in a Medicaid or CHIP program. This cross-referencing is crucial for preventing concurrent enrollment in more than one state's Medicaid program, a process supported by the Multi-State Enrollment Prevention (MSEP) system. Additionally, the program supports the implementation of statutory requirements related to Medicaid community engagement, ensuring compliance with evolving program rules.

Key Participating Entities and Data Flow

The matching program involves two primary categories of participants: the Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) as the federal agency, and State-Based Administering Entities (AEs). AEs encompass a broad range of state-level organizations responsible for administering insurance affordability programs. These include state Medicaid and CHIP agencies, state-based exchanges (SBEs), and Basic Health Programs (BHPs). Currently, AEs in all 50 states, the District of Columbia, and Puerto Rico participate, with potential for other U.S. territories to join. In states utilizing the federally-facilitated exchange (FFE), the AE primarily refers to the Medicaid/CHIP agency. For states operating their own SBEs, the AE would include both the SBE and the Medicaid/CHIP agency. Notably, Minnesota and New York operate AEs that function as both an SBE and a BHP.

All information exchange within this matching program is conducted through a centralized data services hub established by CMS. This hub serves as the secure conduit for data flow between CMS and the various state AEs, supporting both federally-facilitated and state-based health insurance exchanges.

Individuals and Records Involved

The program processes data for several categories of individuals. These include applicants who seek eligibility for enrollment in state health subsidy programs through an exchange or state agency. It also covers enrollees whose eligibility is undergoing redetermination, renewal, or periodic verification, which now includes checks for Medicaid community engagement and multi-state enrollment. Finally, the program includes non-applicant members of an applicant's household whose information is pertinent to the applicant's eligibility, such as tax filers, spouses, tax dependents, and other household members whose income contributes to the household total.

The categories of records exchanged are extensive and critical for comprehensive eligibility assessments. These include identifying records (Social Security Number, name, date of birth), minimum essential coverage period records, return information (household income and family size data), citizenship status, birth and death information, disability coverage and income details, postsecondary educational enrollment records, and imprisonment status records. Specific data elements CMS may receive from AEs include SSN, name, date of birth, and Medicaid/CHIP eligibility and enrollment details. In turn, AEs may receive from CMS SSN validation, citizenship or immigration status verification, incarceration status, MEC eligibility/enrollment, Federal Tax Information (FTI)-based income, Veteran's disability ratings, educational enrollment data, Social Security Title II benefits, quarters of coverage, and death indicators. These records are disclosed from the CMS Health Insurance Exchanges System (HIX), consistent with its System of Records Notices (SORNs).