Non-Financial Eligibility for Premium Tax Credit Programs and Services... · Non-Financial...
Transcript of Non-Financial Eligibility for Premium Tax Credit Programs and Services... · Non-Financial...
Throwback One:
Non-Financial Eligibility for
Premium Tax Credit
2016 TACHC OUTREACH & ENROLLMENT CONFERENCE
Shelby T. Gonzales
Center on Budget and Policy Priorities September 20, 2016
Non-Financial Eligibility Requirements for PTCs 2
Must be enrolled in a metal-level qualified health plan
→ (not a catastrophic plan)
Enrollment Residency Not Incarcerated No MEC Citizen or
Lawfully Present
Non-Financial Eligibility Requirements for PTCs
Must live in the marketplace service area and:
• Intend to reside, including without a fixed address; OR
• Entered service area with a job commitment or seeking
employment (whether or not currently employed)
→ The FFM uses self-attestation to verify residency
3
Enrollment Residency Not Incarcerated No MEC Citizen or
Lawfully Present
Non-Financial Eligibility Requirements for PTCs
Can’t be incarcerated to enroll in a QHP
• FFM considers individuals incarcerated if:
→ They have been convicted of a crime and sentenced to confinement
in an institution such as a correctional facility or inpatient mental
health facility
(This includes escapees from confinement)
4
Enrollment Residency Not Incarcerated No MEC Citizen or
Lawfully Present
People not considered incarcerated include those who:
• Have not been convicted of a crime
• Have been convicted of a crime but is not currently sentenced to
confinement
• Have been convicted of a crime and is sentenced to a partial,
limited, or alternative form of confinement, but no government entity
is required to provide the individual with medical care
Non-Financial Eligibility Requirements for PTCs 5
Enrollment Residency Not Incarcerated No MEC Citizen or
Lawfully Present
Must be ineligible for other MEC, such as:
GOVERNMENT-SPONSORED
COVERAGE
EMPLOYER-SPONSORED
INSURANCE (ESI)
SECRETARY OF HHS
CERTIFIED COVERAGE
Includes:
• Medicare (with some
exceptions)
• Medicaid (with some
exceptions)
• CHIP (with some exceptions)
• Other government-
sponsored coverage
Includes most offers of ESI
Exceptions—eligible for PTCs if:
• ESI is unaffordable or below
minimum value
• Eligible because of
relationship to employee
offered ESI but not included
on that person’s tax return
(e.g., non-dependent child
under 26)
Any health plan certified
as MEC by the Secretary
of HHS
Includes:
• Certain coverage
available outside U.S.
• Some student health
plans
→ Eligibility for MEC includes an offer of coverage, even if it is not taken
For more information, see the Health Reform: Beyond the Basics MEC Reference Chart ?
Government-Sponsored Coverage
Not Eligible for PTCs: Eligible for PTCs:
IF ELIGIBLE FOR THESE BENEFITS, WHETHER OR NOT ENROLLED DESPITE ELIGIBILITY FOR OR ENROLLMENT IN THESE BENEFITS
• Medicare Part A (premium free)
• Medicare Advantage
• Most Medicaid
• Most CHIP
• State high-risk insurance pools
beginning on or before 12/31/14
• Refugee Medical Assistance
• Most TRICARE
• DoD Continuation Coverage
(Nonappropriated Fund Health
Benefits Program)
• Peace Corps coverage
• Medicare (not premium free)
• Medicaid providing only:
- Family planning services
- Tuberculosis-related services
- Emergency treatment
- Pregnancy-related services (if HHS
does not consider coverage to be
equivalent to full Medicaid benefits)
• Medicaid coverage of the medically
needy
• 1115 Medicaid demonstration
• Space-available TRICARE
• Line-of-duty TRICARE
• AmeriCorps
• AfterCorps (for returning Peace Corps
members)
6
Employer-Sponsored Insurance
Not Eligible for PTCs if: Eligible for PTCs if:
• Eligible for ESI that is affordable and
minimum value
• Enrolled in ESI (regardless of whether
it is affordable or MV)
• Eligible for ESI that is not affordable
• Eligible for ESI that is not minimum
value
• In months of a waiting period for ESI
• Eligible for COBRA coverage
• Eligible for retiree coverage
7
For more information, see the Health Reform: Beyond the Basics MEC Reference Chart ?
Example: Option to Enroll in COBRA
Last month, Serena left a job where she had health
insurance. She has an offer of COBRA coverage
through her former employer, but she finds the cost is
too expensive.
She hasn’t enrolled in it.
8
Can Serena qualify for PTCs?
Answer:
• Yes. The option to enroll COBRA coverage does not bar a person from
eligibility for premium tax credits or cost-sharing reductions, including
after open enrollment ends.
• If open enrollment is over and Serena does not enroll in COBRA, she can
enroll in Marketplace coverage through the special enrollment period
triggered by her loss of employment-sponsored insurance.
Example: Enrolled in COBRA
She enrolled in COBRA because she didn’t know she
had a choice
9
Can Serena drop COBRA and qualify for PTCs?
Answer:
• Being enrolled in COBRA does not bar eligibility for PTCs or CSR, but
must drop coverage to enroll in QHP
• During open enrollment: can drop COBRA coverage and enroll in QHP
• Outside of open enrollment: dropping COBRA coverage will not trigger a
special enrollment period
– May have to wait until the next open enrollment period to enroll in QHP
ESI and Eligibility for PTCs
• An individual is not eligible for PTCs if eligible for ESI that is
affordable and adequate
10
WHEN IS AN OFFER OF ESI NOT COSIDERED MEC?
Not affordable OR Not adequate
Coverage is not affordable if the
employee contribution for self-only
coverage is more than 9.69% of
household income (in 2017)
Employee contribution for self-only
coverage is used to determine
affordability for both the employee and
other members of the family offered
ESI
Coverage is not adequate if it has a
minimum value (MV) less than 60%
actuarial value
Actuarial value = % the plan pays of the
cost of coverage for essential health
benefits for a typical population, after
accounting for cost-sharing charges
required under the plan
→ Eligibility for MEC includes an offer of coverage, even if it is not taken
ESI and Eligibility for PTCs: Family Coverage
• An employee’s family member is not eligible for PTCs if employee
contribution for self-only coverage is affordable
11
→ Exception: If the family member is not on the same tax return as the
employee, the offer of coverage does not bar eligibility for PTCs
Example: ESI and Eligibility for PTCs
• Household income: $48,500 (200% FPL)
• Monica’s employer offers coverage for both
Monica and her family
• The offer is considered affordable and meets
minimum value:
The family is ineligible for PTCs even if they
do not enroll
12
PLAN A
Cost Employee-only:
$198/month
(4.9% of income)
Employee + family:
$525/month
(13% of income)
AV 80%
Meets MV
Example: Coverage Choices for Young Adults
John, 24 years old
• Income: $23,540 (200% FPL), Employer offers ESI
• Tax Filing Status: Tax filer
• A 24-year-old child has the option of staying on his parent’s
ESI until he reaches age 26, even though he is no longer a
dependent.
If he chooses to be on his father’s ESI, it counts as MEC
If he chooses Marketplace coverage, he is still eligible for PTCs
13
CHOICE 1:
Employer Coverage
Cost $85/month
(4.3% of income)
AV 40%, does not
meet MV
Still eligible for PTCs
CHOICE 2:
Marketplace Coverage
Cost $123/month
after PTC
AV 87% after cost-
sharing reduction
CHOICE 3:
Coverage from Dad’s ESI
Cost $0/month
(Dad pays for
family coverage)
AV N/A
Still eligible for PTCs
Non-Financial Eligibility Requirements for PTCs 14
Enrollment Residency Not Incarcerated No MEC Citizen or
Lawfully Present
Must be a U.S. citizen or have a status considered “lawfully
present” under the ACA’s definition
For more information, see the Health Reform: Beyond the Basics: Key Facts: Immigrant Eligibility for Health Insurance Affordability Programs ?
Lawfully Present
Statuses Eligible for Medicaid: Other “Lawfully Present” Immigrants:
“Qualified” Immigrants:
• Lawful Permanent Resident (LPR/green
card holder)
• Refugee
• Asylee
• Cuban/Haitian Entrant
• Paroled into the U.S. for at least one year
• Conditional Entrant
• Granted Withholding of Deportation or
Withholding of Removal
• Battered Spouse, Child and Parent
• Trafficking Survivor and his/her Spouse,
Child, Sibling or Parent
Others:
• Member of a federally-recognized Indian
tribe or American Indian born in Canada
• Granted relief under the Convention
Against Torture (CAT)
• Temporary Protected Status (TPS)
• Deferred Enforced Departure (DED)
• Deferred Action (except DACA)*
• Paroled into the US for less than one year
• Individual with Nonimmigrant Status
(includes worker visas; student visas; U
visas; citizens of Micronesia, the Marshall
Islands, and Palau; and many others)
• Administrative order staying removal
issued by the Department of Homeland
Security
• Lawful Temporary Resident
• Family Unity
*EXCEPTION: Individuals granted deferred action under the 2012 Deferred Action for Childhood Arrivals
(DACA) program are not eligible to enroll in coverage in the Marketplace.
15
Lawfully Present
APPLICANT for Any of These Statuses: Must Also Have Employment Authorization:
• Lawful Permanent Resident (with an
approved visa petition)
• Asylum*
• Special Immigrant Juvenile Status
• Victim of Trafficking Visa
• Withholding of deportation or withholding
of removal, under the immigration laws or
under the Convention Against Torture
(CAT)*
• Applicant for Temporary Protected Status
• Registry Applicants
• Order of Supervision
• Applicant for Cancellation of Removal or
Suspension of Deportation
• Applicant for Legalization under IRCA
• Applicant for LPR under the LIFE Act
*Only those who have been granted employment authorization or are under the age of 14 and have had an
application pending for at least 180 days are eligible
16
PTCs for Certain Immigrants with Income < 100% FPL
• Lawfully present people with income below 100% FPL are eligible
for PTCs if they are not eligible for Medicaid due to their
immigration status
• In Texas this includes adults who are:
Not “qualified” immigrants
Qualified immigrants who are subject to and have not met the
five-year waiting period
Qualified immigrants who are subject to Texas restrictions:
→ Texas work credit requirement
→ Seven year limited eligibility for certain immigrants
Bottom line: Many lawfully present immigrants with incomes
below 100% FPL are eligible for PTCs in Texas
17
Lawfully Present But Not “Qualified” Immigrant
Other “Lawfully Present” Immigrants: APPLICANT for Any of These Statuses:
• Granted relief under the Convention
Against Torture (CAT)
• Temporary Protected Status (TPS)
• Deferred Enforced Departure (DED)
• Deferred Action
• Paroled into the US for less than one year
• Individual with Nonimmigrant Status
(includes worker visas; student visas; U
visas; citizens of Micronesia, the Marshall
Islands, and Palau; and many others)
• Administrative order staying removal
issued by the Department of Homeland
Security
• Lawful Temporary Resident
• Family Unity
• Lawful Permanent Resident (with an
approved visa petition)
• Asylum
• Special Immigrant Juvenile Status
• Victim of Trafficking Visa
• Withholding of deportation or withholding
of removal, under the immigration laws or
under the Convention Against Torture (CAT)
18
Five-Year Waiting Period
• “Qualified” immigrants are subject to a five-year waiting
period (also known as the “5-year bar”)
– The five years begin when an immigrant obtains a “qualified”
immigration status
! Does not affect eligibility for many immigrants in Texas because they
are barred by other Texas restrictions
19
Some people with a “qualified” immigration status are not subject to the 5-year bar:
Immigrants who physically entered the U.S. before 8/22/96 and remained in the U.S. continuously
until obtaining a qualified status
Refugees, asylees, persons granted withholding of deportation/removal (even if they later become
LPRs)
Cuban/Haitian entrants, certain Amerasian immigrants, individuals granted Iraqi or Afghan special
immigrant status, trafficking survivors (even if they later become LPRs)
Qualified immigrants who are U.S. veterans or on active military duty and their spouses or children
Children (at state option)
Pregnant women (at state option)
Texas Eligibility Restrictions for Qualified Immigrants
Texas work credits requirements for non-pregnant LPR adults in
Medicaid:
• Must have 40 qualifying quarters of work in the U.S.
• Can get credit from work completed by:
Self
Spouse if earned during marriage
Parent if earned before LPR turns 18 (including before birth)
• No credit for work quarters on/after 1997 if person with work
credits received Medicaid, SSI, food stamps, TANF or CHIP
! Work requirements do not apply to:
– Immigrants who physically entered the U.S. before 8/22/96 and remained
in the U.S. continuously until obtaining a qualified status
– Qualified immigrants who are U.S. veterans or on active military duty and
their spouses or children
20
Texas Eligibility Restrictions for Qualified Immigrants
Seven year eligibility limit for non-pregnant adults in Medicaid after
obtaining this status:
• Refugees
• Asylees
• Cuban/Haitian entrants
• Persons granted withholding of deportation/removal
• Amerasian immigrants
• Trafficking survivors
• Iraqi or Afghan special immigrants
! Seven year limit does not apply to:
– Immigrants who entered the U.S. before 8/22/96 and remained in the U.S.
continuously until obtaining a qualified status
– Qualified immigrants who are U.S. veterans or on active military duty and
their spouses or children
21
Ricky, Eva and Karina
• Ricky and Eva are married and have a
daughter, Karina
• Karina was born in Texas and is a U.S.
citizen
• Ricky became a LPR 6 years ago
• Eva came to the U.S. as a refugee ten
years ago
Income and tax filing
• Eva and Ricky are full-time college students and both work part-time jobs
• They project their income will be $20,000 for 2016
Who is applying for coverage?
• Ricky, Eva and Karina
22
Applying for coverage: YES Subject to work credits: YES MAY BE ELIGIBLE FOR:
QHP Enrollment Citizen: NO Satisfied work credits: NO
Immigration status: LPR Subject to 7-year limit: NO
Qualified immigrant: YES Reached 7-year limit: ----
Subject to 5-year bar: YES Lawfully present: YES
Satisfied 5-year bar: YES
Applying for coverage: YES Subject to work credits: N0 MAY BE ELIGIBLE FOR:
QHP Enrollment
Citizen: NO Satisfied work credits: ----
Immigration status: REFUGEE Subject to 7-year limit: Yes
Qualified immigrant: Yes Reached 7-year limit: Yes
Subject to 5-year bar: No Lawfully present: Yes
Satisfied 5-year bar: ----
Applying for coverage: YES Subject to work credits: ---- MAY BE ELIGIBLE FOR:
Medicaid/CHIP
QHP Enrollment Citizen: YES Satisfied work credits: ----
Immigration status: ---- Subject to 7-year limit: ----
Qualified immigrant: ---- Reached 7-year limit: ----
Subject to 5-year bar: ---- Lawfully present: ----
Satisfied 5-year bar: ----
Eligibility Based on Citizenship/Immigration Status Rules 23
Eligibility for PTC and Medicaid
Ricky is not eligible for Medicaid because he is subject
to immigration status-related work credit requirement
and does not have 40 attributable work credits . Ricky
is eligible for PTCs.
Eva is not eligible for Medicaid because she is subject
to a 7 year time limit for Medicaid eligibility and she
has been in the U.S. for 10 years. Eva is eligible for
PTCs.
Karina is eligible for Medicaid
Medicaid/CHIP Premium Tax Credits
Eligible? HH Income FPL Eligible? HH Income FPL
Ricky No 3 $20,000 99% Yes 3 $20,000 99%
Eva No 3 $20,000 99% Yes 3 $20,000 99%
Karina Yes 3 $20,000 99% No 3 $20,000 99%
24
Real-time Eligibility Verification
• Citizenship and immigration
status must be verified
• Applicants provide SSNs
and/or immigration
document numbers
• Those numbers and key
other factors are matched
against information in
government data files
26
Data Matching May Be Unsuccessful
• Errors in submission of SSN (or no number provided)
• Name, date of birth and SSN provided on the
application do not match what is in SSA or SAVE
records
!
• Data matching limitations:
→ SSA can’t verify citizenship for many citizens who were born outside
of the U.S.
→ SAVE can’t match certain immigrants in realtime
• Some consumers may not have document numbers readily
available (for example, derived citizens)
27
• “My Account Page” lets
consumers know when
they have a DMI
• DMI language appears
in red and says
“temporary eligibility.”
28 On-Screen Notice of a Data-Matching Issue
Notice of a DMI and Inconsistency Period 29
Source: Sample notice provided by CMS at https://marketplace.cms.gov/applications-and-forms/notices.html
Documents That Can Be Used to Prove U.S. Citizenship
Submit any one of the following documents to verify citizenship
U.S. Passport Certificate of Citizenship Certificate of Naturalization
State-issued enhanced driver’s
license (EDL)
— Currently available in Michigan,
New York, Vermont and
Washington
Document from a federally recognized Indian tribe that
includes the individual’s name, the name of the tribe, and
shows membership, enrollment, or affiliation with the tribe
— A tribal enrollment card
— A Certificate of Degree of Indian Blood
— A tribal census document
— Documents on tribal letterhead signed by a tribal
leader
NOTE: If a person does not have one of these documents, they will need two documents to prove citizenship.
30
If None of the Previous Documents Are Available:
Submit ONE document from EACH column (total of TWO documents)
One of the following documents: AND one of the following documents:
U.S. public birth certificate
Consular Report of Birth Abroad (FS-240, CRBA)
Certification of Report of Birth (DS-1350)
Certification of Birth Abroad (FS-545)
U.S. Citizen Identification Card (I-197 or the prior version I-179)
Northern Mariana Card (I-873)
Final adoption decree showing the person’s name and U.S.
place of birth
U.S. Civil Service Employment Record showing employment
before June 1, 1976
Military record showing a U.S. place of birth
U.S. medical record from a clinic, hospital, physician, midwife
or institution showing a U.S. place of birth
U.S. life, health or other insurance record showing U.S. place of
birth
Religious record showing U.S. place of birth recorded in the
U.S.
School record showing the child’s name and U.S. place of birth
Federal or State census record showing U.S. citizenship or U.S.
place of birth
Documentation of a foreign-born adopted child who received
automatic U.S. citizenship (IR3 or IH3)
Document must have a photograph or other information,
like name, age, race, height, weight, eye color, or address
Driver's license issued by a State or Territory or ID card
issued by the Federal, state, or local government
School identification card
U.S. military card or draft record or Military dependent’s
identification card
U.S. Coast Guard Merchant Mariner card
Voter Registration Card
A clinic, doctor, hospital, or school record, including
preschool or day care records (for children under 19 years
old)
2 documents containing consistent information that proves
your identity, like employer IDs, high school and college
diplomas, marriage certificates, divorce decrees, property
deeds, or titles
31
Immigration Document Types and Needed Numbers
Document Type: What to List for Document ID:
Permanent Resident Card (I-551) Alien registration number
Card number
Temporary I-551 stamp (on passport or I-94, I-94A) Alien registration number
Machine Readable Immigrant Visa (with temporary I-
551 language)
Alien registration number
Passport number
Country of issuance
Employment Authorization Card (I-766) Alien registration number
Card number
Expiration date
Category code
Arrival/Departure Record (I-94/I-94A) I-94 number
Arrival/Departure Record in foreign passport (I-94) I-94 number
Passport number
Expiration date
Country of issuance
Foreign passport Passport number
Expiration date
Country of issuance
32
Immigration Document Types and Needed Numbers
Document Type: What to List for Document ID:
Reentry Permit (I-327) Alien registration number
Refugee Travel Document (I-571) Alien registration number
Certificate of Eligibility for Nonimmigrant Student
Status (I-20)
Student and Exchange Visitor
Information System (SEVIS) ID
Certificate of Eligibility for Exchange Visitor Status (DS2019)
SEVIS ID
Notice of Action (I-797) Alien registration number or an I-
94 number
Description of the type or name of
the document
Other documents Alien registration number or an I-
94 number
Description of the type or name of
the document
33
Examples of Document Types
Permanent Resident Card (“Green card”, I-551)
Tips:
• 2010 revision
• Document/card number on the
back and contains 13 characters:
– Begins with three letters
– Followed by ten numbers
34
Alien Registration #
(may be referred to as USCIS #)
Card Number
Examples of Document Types
Permanent Resident Card (“Green card”, I-551)
Tips:
• 1997 and 2004 revision
• Document/card number on the
front
– Same letter/number scheme
35
Alien Registration #
(may be referred to as USCIS #)
Card Number
Examples of Document Types
Permanent Resident Card (“Green card”, I-551)
Tips:
• Older cards
• If the A# does not have 9 digits,
add one or two zeros before the
A# so that you can input nine
digits
• These cards do NOT have card
numbers
→ Enter “AAA0000000000” as
the card number
36
Alien Registration #
(may be referred to as USCIS #)
Immigrants with Incomes in the Medicaid Range
• For people with income that would potentially qualify them for Medicaid, the
Marketplace must verify that applicants are ineligible for Medicaid based on their
immigration status before determining their eligibility for subsidies.
• If Healthcare.gov can’t electronically verify an individual’s immigration status
through SAVE (i.e. if the individual has an immigration status DMI), immigration
status must be verified by the Marketplace through a manual document review
or by the Medicaid or CHIP agency
AS A RESULT:
If otherwise eligible for Medicaid based on
income and all other factors:
→ sent to Medicaid
37
If income is below 100% and not otherwise
eligible for Medicaid (appears to be in the
coverage gap):
→ given the opportunity to enroll in a
Marketplace plan with no advance
payments of the premium tax credits or
cost-sharing reductions
Process A: Appears Eligible for Medicaid
Appears Eligible for Medicaid Based on Income & Other Factors
Marketplace assesses consumer eligible for Medicaid and notifies consumer of eligibility
determination
Medicaid agency notifies consumer that proof is needed including but not limited to
immigration status
If consumer sends in proof, and is determined ineligible for Medicaid based on status, the
Medicaid agency sends consumer denial notice
Marketplace notifies consumer to come back to the Marketplace with instructions on how to
get correct eligibility determination
Consumer returns to Marketplace, indicates that has been denied Medicaid and provides
other needed information to establish eligibility
Correct eligibility determination for APTCs and CSR
Case sent to state Medicaid agency for further eligibility review including verification of immigration status
Case referred back to Marketplace
38
Process B: Treated As If in Medicaid Coverage Gap
Income is Below 100% FPL and Not Otherwise Eligible for Medicaid
Marketplace determines consumer can enroll in coverage without APTC and notifies consumer
that he may qualify for help paying for coverage but that proof of status is needed to make
that determination
If consumer sends in proof, case is sent to special unit to determine if eligible under Medicaid
rules
Consumer returns to Marketplace to select a plan with APTCs and CSR
If determined ineligible for Medicaid based on status, Marketplace notifies consumer about
eligibility for subsidies and SEP
39
Contact Info
• Shelby Gonzales, [email protected]
• For general inquiries, please email [email protected]
For more information and resources, please visit:
www.healthreformbeyondthebasics.org
This is a project of the Center on Budget and Policy Priorities, www.cbpp.org
40