Non-Financial Eligibility for Premium Tax Credit

2016 TACHC OUTREACH & ENROLLMENT CONFERENCE Throwback One: Non-Financial Eligibility for Premium Tax Credit Shelby T. Gonzales Center on Budget and Policy Priorities September 20, 2016

Non-Financial Eligibility Requirements for PTCs 2 Enrollment Residency Not Incarcerated No MEC Citizen or Lawfully Present Must be enrolled in a metal-level qualified health plan (not a catastrophic plan)

Non-Financial Eligibility Requirements for PTCs 3 Enrollment Residency Not Incarcerated No MEC Citizen or Lawfully Present 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

Non-Financial Eligibility Requirements for PTCs 4 Enrollment Residency Not Incarcerated No MEC Citizen or Lawfully Present 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) 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 Includes: Medicare (with some exceptions) Medicaid (with some exceptions) CHIP (with some exceptions) Other governmentsponsored coverage EMPLOYER-SPONSORED INSURANCE (ESI) 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) SECRETARY OF HHS CERTIFIED COVERAGE 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 6 Not Eligible for PTCs: IF ELIGIBLE FOR THESE BENEFITS, WHETHER OR NOT ENROLLED 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 Eligible for PTCs: DESPITE ELIGIBILITY FOR OR ENROLLMENT IN THESE BENEFITS 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)

Employer-Sponsored Insurance 7 Not 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 PTCs if: 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? For more information, see the Health Reform: Beyond the Basics MEC Reference Chart

Example: Option to Enroll in COBRA 8 Can Serena qualify for PTCs? 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. 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 9 Can Serena drop COBRA and qualify for PTCs? She enrolled in COBRA because she didn t know she had a choice 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 10 An individual is not eligible for PTCs if eligible for ESI that is affordable and adequate 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) Coverage is not adequate if it has a minimum value (MV) less than 60% actuarial value Employee contribution for self-only coverage is used to determine affordability for both the employee and other members of the family offered ESI 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 11 An employee s family member is not eligible for PTCs if employee contribution for self-only coverage is affordable 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 12 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 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 13 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 CHOICE 1: Employer Coverage CHOICE 2: Marketplace Coverage CHOICE 3: Coverage from Dad s ESI Cost AV $85/month (4.3% of income) 40%, does not meet MV Cost AV $123/month after PTC 87% after costsharing reduction Cost AV $0/month (Dad pays for family coverage) N/A Still eligible for PTCs 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 15 Statuses Eligible for Medicaid: 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 Other Lawfully Present Immigrants: 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.

Lawfully Present 16 APPLICANT for Any of These Statuses: 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)* Must Also Have Employment Authorization: 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

PTCs for Certain Immigrants with Income < 100% FPL 17 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

Lawfully Present But Not Qualified Immigrant 18 Other Lawfully Present Immigrants: 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 APPLICANT for Any of These Statuses: 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)

Five-Year Waiting Period 19 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 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 20 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

Texas Eligibility Restrictions for Qualified Immigrants 21 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

Ricky, Eva and Karina 22 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

Eligibility Based on Citizenship/Immigration Status Rules 23 Applying for coverage: YES Subject to work credits: YES MAY BE ELIGIBLE FOR: 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 QHP Enrollment Applying for coverage: YES Subject to work credits: N0 MAY BE ELIGIBLE FOR: 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: ---- QHP Enrollment Applying for coverage: YES Subject to work credits: ---- MAY BE ELIGIBLE FOR: Medicaid/CHIP Citizen: YES Satisfied work credits: ---- QHP Enrollment 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 for PTC and Medicaid 24 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%

Verification of Eligibility Based on Citizenship and Immigration Status

Real-time Eligibility Verification 26 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

Data Matching May Be Unsuccessful 27 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)

On-Screen Notice of a Data-Matching Issue 28 My Account Page lets consumers know when they have a DMI DMI language appears in red and says temporary eligibility.

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 30 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.

If None of the Previous Documents Are Available: 31 Submit ONE document from EACH column (total of TWO documents) 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) AND one of the following documents: 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

Immigration Document Types and Needed Numbers 32 Document Type: Permanent Resident Card (I-551) Temporary I-551 stamp (on passport or I-94, I-94A) Machine Readable Immigrant Visa (with temporary I- 551 language) Employment Authorization Card (I-766) Arrival/Departure Record (I-94/I-94A) Arrival/Departure Record in foreign passport (I-94) Foreign passport What to List for Document ID: Alien registration number Card number Alien registration number Alien registration number Passport number Country of issuance Alien registration number Card number Expiration date Category code I-94 number I-94 number Passport number Expiration date Country of issuance Passport number Expiration date Country of issuance

Immigration Document Types and Needed Numbers 33 Document Type: Reentry Permit (I-327) Refugee Travel Document (I-571) Certificate of Eligibility for Nonimmigrant Student Status (I-20) Certificate of Eligibility for Exchange Visitor Status (DS2019) What to List for Document ID: Alien registration number Alien registration number Student and Exchange Visitor Information System (SEVIS) ID 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

Examples of Document Types 34 Permanent Resident Card ( Green card, I-551) Alien Registration # (may be referred to as USCIS #) Card Number Tips: 2010 revision Document/card number on the back and contains 13 characters: Begins with three letters Followed by ten numbers

Examples of Document Types 35 Permanent Resident Card ( Green card, I-551) Alien Registration # (may be referred to as USCIS #) Card Number Tips: 1997 and 2004 revision Document/card number on the front Same letter/number scheme

Examples of Document Types 36 Permanent Resident Card ( Green card, I-551) Alien Registration # (may be referred to as USCIS #) 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

Immigrants with Incomes in the Medicaid Range 37 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 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 38 Appears Eligible for Medicaid Based on Income & Other Factors Marketplace assesses consumer eligible for Medicaid and notifies consumer of eligibility determination Case sent to state Medicaid agency for further eligibility review including verification of immigration status 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 Case referred back to Marketplace 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

Process B: Treated As If in Medicaid Coverage Gap 39 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 If determined ineligible for Medicaid based on status, Marketplace notifies consumer about eligibility for subsidies and SEP Consumer returns to Marketplace to select a plan with APTCs and CSR

Contact Info 40 Shelby Gonzales, gonzales@cbpp.org For general inquiries, please email beyondthebasics@cbpp.org 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