Answers to Assister Questions from Overview of Periodic Data Matching (PDM) and Helping Newly Medicaid-eligible Consumers end coverage through the Marketplace with APTC and CSRs

The October 2, 2015 CMS webinar included an overview of Periodic Data Matching (PDM), which is a process the Marketplace uses to identify consumers in Federally-facilitated Marketplace states who are enrolled in Marketplace coverage with Advance Payments of the Premium Tax Credits (APTCs) or Cost Sharing Reductions (CSRs) and Minimum Essential Coverage (MEC) Medicaid or CHIP.

In September 2015, the Marketplace mailed paper notices to the household contacts of consumers who may be enrolled in a Marketplace plan with APTC or CSRs and Medicaid or CHIP that qualifies as MEC, with instructions on what to do next. If these “dually-enrolled” consumers do not end their Marketplace coverage with APTC or CSRs, the tax filer(s) will likely have to pay back all or some of the advance payments of the premium tax credit received for a Marketplace plan during the months the consumers were eligible for MEC Medicaid or CHIP. The October 2 webinar also included an update to a presentation originally made during December 2014, on how assisters can help consumers end their Marketplace coverage with APTC and CSRs.

Below are answers to questions that assisters asked during this presentation via the webinar chat feature. For more information, please see the September 30 and October 7, 2015 assister newsletter, and the following additional resources:

  • Click here to view the slide deck on Periodic Data Matching;click hereto view the slide deck on Helping Consumers End Coverage in a QHP through the Marketplace with APTC and CSRs; and click here to view both decks along with other resources on Marketplace eligibility and enrollment on Marketplace.CMS.gov.
  • Click here to view a sample PDM notice (also available in Spanish), and click here to view this notice along with other model notices on Marketplace.CMS.gov.

Q1: If a consumer who has Marketplace coverage with APTC/CSRs is determined eligible for minimum essential coverage Medicaid (with a retroactive Medicaid coverage start date that could be up to 3 months prior to the Medicaid application date), will the tax filer(s) be liable to pay back the premium tax credits received for the consumer’s Marketplace coverage during the time that the consumer was dually-enrolled in Marketplace coverage with APTC/CSRs and Medicaid?

A1: While tax liability is determined exclusively by IRS, according to IRS rules, the tax filer(s) may be liable to pay back APTC for months the consumer is enrolled in a Marketplace plan with APTC/CSRs and eligible for minimum essential coverage (MEC)* Medicaid or CHIP, beginning on the first day of the month following the Medicaid or CHIP eligibility determination. Thus, in the case of retroactive Medicaid coverage—back to the date of the application or up to three months prior, tax filer(s) are not liable to repay APTC received for the consumer’s Marketplace plan during the retroactive period; liability starts the first of the month following the Medicaid eligibility determination.

For example, if a consumer applied for coverage on May 20th and received a final determination of Medicaid eligibility on July 2nd, with a Medicaid coverage effective date back to April 20th, the tax filer’s liability to pay back APTC received for a Marketplace plan for that consumer would start August 1st. For consumer instructions on ending Marketplace coverage with APTC/CSRs when a consumer gets or has Medicaid or CHIP, click here. In addition, here is a presentation on the Process for Ending Coverage in a QHP through the Marketplace with APTC and CSRs. Note: These instructions include distinctions having to do with whether the consumer(s) are in an assessment or a determination state.

If interested, consumers determined eligible for MEC Medicaid or CHIP may maintain Marketplace coverage without financial assistance. After ending their Marketplace coverage with APTC/CSRs, they will need to submit a new application for Marketplace coverage without financial assistance, and enroll, if they are otherwise eligible.

*Most Medicaid or CHIP is considered MEC; some forms of Medicaid or CHIP coverage (e.g. emergency or coverage for pregnancy-related services only) are not considered MEC.

Q2: If a consumer is enrolled in Marketplace coverage with APTC/CSRs and is eligible for the Medicaid medically-needy program with a spend down (also known as share of cost Medicaid), does he or she need to end his or her Marketplace coverage with APTC/CSRs?

A2: Consumers who are enrolled in Marketplace coverage with APTC/CSRs and non-MEC Medicaid  do not need to end their Marketplace coverage with APTC/CSRs. Medicaid medically-needy coverage provided to consumers who must meet a spend down to be eligible (also known as share of cost Medicaid) is not recognized as MEC. Therefore, these consumers do not need to end their Marketplace coverage with APTC/CSRs, and tax filer(s) will not face a tax liability for dual-enrollment. Consumers who are enrolled in Marketplace coverage with APTC/CSRs and Medicaid medically-needy coverage with a spend down and who (for whatever reason) end their Marketplace coverage with APTC/CSRs could qualify for a hardship exemption from the MEC requirement if, in the discretion of the Marketplace, they have experienced a hardship with respect to the capability to obtain coverage.

Q3: Can a consumer stay enrolled in coverage through the Marketplace with APTC/CSRs if they are also eligible for MEC Medicaid/CHIP? What if the Medicaid/CHIP program is not considered MEC?

A3: Consumers determined eligible for MEC Medicaid or CHIP are not eligible for a Marketplace plan with APTC or CSRs. It is unlikely that a consumer who is enrolled in MEC Medicaid or CHIP will wish to maintain Marketplace coverage, but without financial assistance; however, if interested, these consumers may do so. In order to maintain Marketplace coverage without financial assistance, after ending their Marketplace coverage with APTC/CSRs, these consumers will need to submit a new application for Marketplace coverage without financial assistance, and enroll, if they are otherwise eligible.

Most Medicaid or CHIP is considered MEC; some forms of Medicaid or CHIP coverage (e.g., emergency Medicaid or coverage for pregnancy-related services only) are not considered MEC. If a consumer is enrolled in Medicaid or CHIP coverage that is not considered MEC, he or she may remain enrolled in Marketplace coverage with APTC/CSRs, if otherwise eligible; in such a case, the tax filer(s) will not face a tax liability at tax time to pay back APTC received for the Marketplace plan while the consumer was also enrolled in non-MEC Medicaid or CHIP.

Q4: Will consumers who may be dually-enrolled in Marketplace coverage with APTC/CSRs and Medicaid or CHIP who did not receive a notice (because they live in a state that had technical issues) still be liable to repay APTC for any months they were dually-enrolled?

A4: If dually-enrolled consumers do not end their Marketplace coverage with APTC/CSRs, the tax filer(s) will likely have to pay back all or some of the APTC received during the months* the consumers are also eligible for Medicaid or CHIP. Paper notices were sent to the household contact for consumers who were identified (through Periodic Data Matching) as enrolled in both a Marketplace plan with APTC or CSRs and Medicaid or CHIP; however, the Marketplace cannot identify all consumers in all Federally-facilitated Marketplace states who were dually-enrolled because not all states were able to fully participate in periodic data matching. Consumers in the following states will not receive notices in this round of PDM: AK, DE, GA, ME, MI, NJ, OR, SC, TN, and WY. Also, among participating states, sometimes states aren’t able to conduct the matching process for any consumers who were enrolled in a Marketplace plan with APTC, so some consumers who are dually-enrolled may not receive a notice. However, tax filer(s) will still be liable to repay all or some of the APTC received during the months* the affected consumers are also eligible for Medicaid or CHIP. To help address issues related to dual-enrollment in a Marketplace plan with APTC/CSRs and Medicaid or CHIP and the potential for increased tax liability, CMS has already published content in a number of venues, including on HealthCare.gov, other consumer notices, and within the online application.

*Note: liability starts the first of the month following the Medicaid or CHIP eligibility determination.

Q5: Will a dually-enrolled consumer who is ending his or her Marketplace coverage with APTC/CSRs at the Marketplace also need to contact his or her insurance company to end his or her Marketplace coverage?

A5: No. Consumers who are ending their Marketplace coverage with APTC or CSRs should take action to do so through the Marketplace (either at HealthCare.gov or through the Call Center). The process for ending Marketplace coverage with APTC/CSRs is outlined here. Instructions for consumers on cancelling a Marketplace plan when they get Medicaid or CHIP are available here. Important: For consumers ending Marketplace coverage with APTC/CSRs for some but not all people on their Marketplace application, they must continue through their “Enroll To-Do List” including selecting and confirming a plan for people staying in Marketplace coverage in order to complete the process and for coverage to be ended for those people being removed from Marketplace coverage (e.g. people who are ending Marketplace coverage with APTC/CSRs because they’re enrolled in Medicaid or CHIP).

Q6: Can consumers get back the premiums they paid to their insurance company for coverage through the Marketplace if they are enrolled in Medicaid/CHIP with a retroactive effective date, and they end their Marketplace coverage with APTC/CSRs?

A6: No. Consumers in this scenario generally will not be retroactively terminated from their Marketplace coverage with APTC/CSRs; therefore, issuers generally will not be required to refund premiums paid by consumers for the time in which the consumer(s) were enrolled in Marketplace coverage and were also enrolled in Medicaid/CHIP. This is true even if consumers did not use their Marketplace coverage while they were also enrolled in Medicaid or CHIP. For this reason, and also to help avoid potential tax liability, it’s important that consumers end their Marketplace coverage with APTC/CSRs when they are determined eligible for Medicaid or CHIP.

Q7: Can a consumer who is dually-enrolled in Marketplace coverage with APTC/CSRs and Medicaid/CHIP coverage retroactively end their Marketplace coverage when they realize they are enrolled in Medicaid/CHIP?

A7: No, generally, consumers can only end their Marketplace coverage prospectively. Retroactive termination of Marketplace coverage may be available only in limited cases, such as technical error of the Marketplace or an appeal decision holding that the eligibility determination was incorrect when made; in the event that prospective termination from Marketplace coverage was not possible due to technical error, retroactive termination must be requested through the Marketplace Call Center.

Q8: If some, but not all consumers on an application had a period of dual-enrollment in Marketplace coverage with APTC or CSRs and Medicaid or CHIP, will the tax filer(s) owe back APTC received for all consumers on the Marketplace application during reconciliation at tax time?

A8: No. Tax filer(s) for dually-enrolled consumers will likely have to pay back all or some of the APTC received for just the dually-enrolled consumers on the application, during the months those consumers were enrolled in a Marketplace plan with APTC/CSRs and eligible for Medicaid or CHIP (note: liability starts the first of the month following the Medicaid or CHIP eligibility determination).

 

 

 

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