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

Verification of Eligibility Based on

Citizenship and Immigration Status

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, 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

40