Marketplace Insurance: Eligibility, Mandates & Subsidies

BASIC PREMISE OF MARKETPLACE INSURANCE THE MARKETPLACE EXCHANGES ARE FOR PEOPLE WHO CANNOT AFFORD THE MARKETPLACE EXCHANGES ARE FOR PEOPLE WHO CANNOT AFFORD INSURANCE (MORE OR LESS)!!!!! INSURANCE (MORE OR LESS)!!!!!

KEY PROVISIONS INDIVIDUAL MANDATE INDIVIDUAL MANDATE UNLESS GRANTED AN EXEMPTION, EVERY U.S. CITIZEN MUST HAVE MINIMUM ESSENTIAL COVERAGE OF HEALTHCARE. IF PERSON DOES NOT OBTAIN HEALTHCARE S/HE WILL FACE A TAX PENALTY. MINIMUM ESSENTIAL COVERAGE MINIMUM ESSENTIAL COVERAGE PLAN THROUGH THE MARKETPLACE OR OTHER HEALTH INSURANCE THAT MEETS ACA REQUIREMENTS.

ELIGIBILITY IN GENERAL, AN APPLICABLE TAXPAYER APPLICABLE TAXPAYER ( PERSON WHOSE HOUSEHOLD INCOME IS AT LEAST 100%, BUT NO MORE THAN 400% OF THE FPL) IS ALLOWED PREMIUM ASSISTANCE FOR ANY MONTH THAT ONE OR MORE MEMBERS OF THE APPLICABLE TAXPAYER S FAMILY IS ENROLLED IN A QHP THROUGH THE EXCHANGE AND IS NOT ELIGIBLE FOR MINIMUM ESSENTIAL COVERAGE.

Granted by the Marketplace only Granted by the Marketplace or claimed on tax return Can only be claimed on tax return Exemption INDIVIDUAL MANDATE EXEMPTIONS CONSUMERS CLAIM MOST EXEMPTIONS WHEN FILING THEIR TAX RETURN CERTAIN EXEMPTIONS MUST BE GRANTED IN ADVANCE AND REPORTED WHEN FILING THE RETURN Coverage is unaffordable Coverage is unaffordable the minimum amount person has to pay is more than a certain % of household income Members of certain religious sects Members of certain religious sects a member of a sect recognized by the SSA as being opposed to accepting any insurance benefits General hardship General hardship homelessness, domestic violence, etc. Members Membersof Indian Tribes of Indian Tribes (used to be both, but transitioning)

SUBSIDIES PREMIUM TAX CREDITS A REFUNDABLE REFUNDABLECREDIT THAT LIMITS THE AMOUNT OF INCOME AN INDIVIDUAL MUST PAY TOWARD THE QHP PREMIUM. AVAILABLE FOR THOSE W/ INCOME OF 100% -400%. ARE NOT ARE NOTAVAILABLE FOR THOSE ELIGIBLE FOR COVERAGE THROUGH A GOVERNMENT PROGRAM. CAN TAKE IN ADVANCE OR PAY THE PREMIUM YOURSELF AND GET ALL OF THE CREDIT UPON FILING TAXES. MUST MUSTRECONCILE. CANNOT CANNOT FILE A MARRIED FILING SEPARATELY TAX RETURN. COST-SHARING REDUCTIONS REDUCES OUT-OF-POCKET COSTS AND PUTS AN ANNUAL CAP ON OUT-OF-POCKET COSTS. ONLY AVAILABLE TO THOSE W/ INCOME FROM 100% - 250%. ARE NOT RECONCILED, BUT STILL FILE TAXES.

A CLOSER LOOK AT THE PREMIUM TAX CREDIT THE LAW STATES THAT AN APPLICABLE TAXPAYER IS ALLOWED PREMIUM AS THE LAW STATES THAT AN APPLICABLE TAXPAYER IS ALLOWED PREMIUM ASSISTANCE ANY MONTH THAT ONE OR MORE MEMBERS ARE (1) ENROLLED IN A QHP; ANY MONTH THAT ONE OR MORE MEMBERS ARE (1) ENROLLED IN A QHP; AND FOR MINIMUM ESSENTIAL COVERAGE. FOR MINIMUM ESSENTIAL COVERAGE. SISTANCE ONLY AND (2) NOT ELIGIBLE (2) NOT ELIGIBLE ONLY FOR FOR

HOW DOES A PERSON GET THE PTC? STEP #1 FIRST, A CONSUMER APPLIES FOR COVERAGE IN THE MARKETPLACE, AND THE MARKETPLACE WILL ESTIMATETHE AMOUNT OF PREMIUM TAX CREDIT A PERSON MAY BE ABLE TO CLAIM FOR THE TAX YEAR, USING INFORMATION THAT THE CONSUMER PROVIDED. STEP #3 STEP #2 BASED ON THE ESTIMATE, THE CONSUMER CAN DECIDE TO HAVE SOME, NON, OR ALL OF THE PTC PAID IN ADVANCE DIRECTLY TO THE INSURANCE COMPANYTO BE APPLIED TO MONTHLY PREMIUMS. IF THE CONSUMER CHOOSES TO HAVE ALL OR SOME OF THE CREDIT PAID IN ADVANCE, SHE WILL BE REQUIRED TO RECONCILE RECONCILETHE AMOUNT OF ADVANCE PAYMENTS THAT THE GOVERNMENT SENT ON HER BEHALF WITH THE PREMIUM TAX CREDIT SHE CAN ACTUALLY CLAIM BASED ON HOUSEHOLD INCOME AND FAMILY SIZE.

WHAT DOES IT MEAN TO RECONCILE? WHY IS IT IMPORTANT TO RECONCILE? WHEN DO I RECONCILE? WHAT HAPPENS IF I DO NOT RECONCILE? DO I HAVE TO FILE MY TAXES? WHY? WHAT? HOW? WHO?

RECONCILIATION 101 GROUP ACTIVITY WHEN? WHEN? WHAT? WHAT? WHY? WHY? WHO? WHO? HOW? HOW?

REPORTING CHANGES TO THE MARKETPLACE

TERMINATING COVERAGE RULES FOR TERMINATING COVERAGE WHEN TO TERMINATE COVERAGE HOW TO TERMINATE COVERAGE

RULES HOW TO TERMINATE CONSUMERS MUST AND CANCEL VIA THEIR MARKETPLACE ACCOUNT OR CALL THE MARKETPLACE TO CANCEL. WHEN TO TERMINATE MARKETPLACE PLANS REQUIRE A 14-DAY MINIMUM WAITING PERIOD BEFORE TERMINATING. HOWEVER, AFTER THE TERMINATION IS REQUESTED, THE ENROLLEE MAY CONTACT THE ISSUER TO REQUEST THAT IT EFFECTUATE THE TERMINATION SOONER THAN 14 CALENDAR DAYS. PER 45 CFR SECTION 155.403(B)(1), THE EXCHANGE MUST PERMIT AN ENROLLEE TO TERMINATE HIS OR HER COVERAGE OR ENROLLMENT IN A QHP THROUGH THE EXCHANGE, INCLUDING AS A RESULT OF THE ENROLLEE OBTAINING OTHER MINIMUM ESSENTIAL COVERAGE. MUST GO ONLINE

OVERLAPPING COVERAGE MEDICARE & THE MARKETPLACE

Medicare Part A meets the requirement of having insurance for purposes of the tax penalty. Generally, Medicare and the Marketplace do not coordinate (for now). QHPs are not are not secondary insurance to Medicare. Cannot turn down Part A if receiving Social Security. Consumers are not entitled to subsidies if eligible for Medicare. Can have QHP before Medicare.

Hypothetical Hypothetical: Hannah is enrolled in a Marketplace plan and has been enrolled since 2015. She turned 65 on September 27, 2016 and is receiving Social Security benefits. Her Marketplace premium is $175 and has not increased since she turned 65. What are the key concerns? What are possible steps to take?

FAILURE TO FILE TAXES

APPEALS MARKETPLACE APPEALS DENIAL OF APTCS OR CSRS AMOUNT OF APTCS OR CSRS ADJUSTMENT IN APTCS OR CSRS AT END OF 90- DAY INCONSISTENCY PERIOD DENIAL OF ELIGIBILITY FOR THE MARKETPLACE DENIAL OF SEP TERMINATION OF MARKETPLACE COVERAGE DENIAL OF COVERAGE EXEMPTION DENIAL OF MEDICAID/CHIP ELIGIBILITY INSURER APPEALS INSURER DENIED CLAIM FOR LACK OF COVERAGE; INSURER WOULD NOT COVER A PRESCRIPTION; PROVIDER WAS LISTED AS IN-NETWORK, BUT WHEN ATTEMPTING TO USE COVERAGE, THE PROVIDER DOESN T ACCEPT THE CONSUMER S INSURANCE; ETC.