Q: Are there certain situations where a consumer with an expired income data matching issue would have their APTC reverted to $0?

A: Yes, a consumer with an income data matching issue could have his or her APTC and cost sharing reductions revert to $0 if he or she did not provide a Social Security Number (SSN) for every member of the household, or if the IRS does not have data on file for everyone in the enrollment group. Additionally, if the income information the Marketplace collected from trusted data sources at the time of the consumer’s determination is high enough, the consumer may not receive any APTCs if they fail to resolve their data matching issue by the indicated deadline.

What assisters can help consumers do in this situation?

  • Encourage consumers with unresolved income data matching issue to report any change in expected annual household income by returning to the Marketplace application and entering a “change in circumstance.”
  • Consumers can go back to the application and include an SSN, when available, which will increase the likelihood that application information can be verified electronically.

Note: If an applicant who has an SSN doesn’t enter it, they may need to provide more information later. Although many of the fields in the immigration section of the application are labeled as optional, we highly recommend that consumers input all information they have and fill out as many of the fields as possible. This increases the likelihood of a smooth and swift verification of immigration status, and increases the likelihood of a successful application submission. As such, we recommend that consumers seeking coverage provide their SSN if they have one, though it is optional. Non-applicants are not required to provide their SSNs unless all of the following are true:

  • They have a spouse or tax dependent seeking APTC/CSR;
  • The non-applicant is a tax filer;
  • The non-applicant has an SSN; and,
  • They filed a Federal tax return in the previous tax year.


Q: If a consumer includes the barcode when they submit their documents do they also need to include their name and app ID on each document?

A: If a consumer chooses to mail in documents, we have previously shared that he or she should be sure to include the page from the eligibility notice or the warning notice from the Marketplace which includes a barcode unique to his or her application OR if the consumer does not have the barcode, he or she can include the consumer’s state, full legal name, and application ID (found at the top of the eligibility and reminder notice) with the documents. The barcode page lets us easily match up the mailed documents with the Marketplace application.

NEW: We recommend that consumers write their name, state, and application ID on documents they mail in, even when they also include their barcode. Including the consumer’s name, state and application ID is not required if the consumer is also mailing in the barcode, but it will be useful for processing purposes. Note: If a consumer has a data matching issue, sends in the barcode, but neglects to include his or her name, state, and application ID, this omission will NOT result in any change in their eligibility for coverage or adjustment to the APTC or cost-sharing.


KEY TAKEAWAY: As CMS shared in the March 28 and April 28, 2015 Assister newsletters, consumers who did not receive advanced payments of the premium tax credit (APTC) due to the systems issue affecting immigrants with incomes below 100% of the Federal Poverty Level (FPL) can now change their applications to receive an updated APTC determination and qualify for a prospective or retroactive special enrollment period (SEP). This clarification is to inform assisters that consumers eligible for this SEP have 60 days from the date they call the Marketplace Call Center about this SEP, OR until July 31, whichever is earlier, to select a plan.  

BACKGROUND: Consumers who have incomes below 100% of the FPL and have been denied Medicaid and CHIP by the state because of their immigration status may qualify for APTCs and Cost Sharing Reductions (CSRs) through the Marketplace. The Marketplace application includes a question to help identify these consumers. The question asks:

“Was this person found not eligible [for Medicaid or CHIP] by their state because of their immigration status”? 

The question appears when: (1) an applicant attests to being denied eligibility for Medicaid or CHIP, and (2) the applicant attested earlier in the same application to having a QHP-eligible immigration status. Answering this question allows the Marketplace to properly evaluate individuals for APTC and CSRs when they have an income under 100% FPL and an immigration status that makes them ineligible for Medicaid or CHIP.

SYSTEM ISSUE: As shared in the March 28 and April 28, 2015 Assister newsletters,the FFM has resolved a system issue that was affecting certain immigrants with incomes below 100% of FPL who applied for coverage with financial assistance between 11/15/14 and 3/13/15. Previously, when a household applied for Marketplace coverage and more than one applicant selected “yes” to the question above regarding their Medicaid or CHIP eligibility, the system would only allow the first person on the list of applicants to receive an APTC. This issue has been resolved so that all applicants who select “yes” can receive an APTC, if otherwise eligible.

A consumer can confirm if they have been impacted by this system issue by looking at their Eligibility Determination Notice (EDN) which will display the following:

  1. The EDN will show that the first applicant was found eligible for APTC and CSRs, while the other applicants were not.
  2. Under the EDN section titled “Why Don’t I Qualify for Other Programs?” the applicants who are affected by this system issue and found not eligible for APTC or CSRs will have the message:  “Your household’s yearly income is too low for a tax credit. Generally, individuals and families whose household income for the year is between 100 percent and 400 percent of the federal poverty line for their family size may be eligible for the tax credit.”

Consumers can also contact the Marketplace Call Center to see if they were impacted by this system issue.

NEXT STEPS FOR IMPACTED CONSUMERS: Assisters can help impacted consumers change their Marketplace applications to receive an updated APTC determination and qualify for a SEP for coverage that can be prospective or retroactive with a coverage effective date beginning as early as January 1, 2015. Consumers eligible for this SEP have 60 days from the date they call the Marketplace Call Center about this SEP, or until July 31, whichever is earlier, to select a plan. For example, if a consumer calls the Marketplace Call Center about this SEP on May 10th, the consumer will have until July 9 (60 days) to select a plan. If a consumer calls the Call Center about this SEP on July 30th, he or she will only have until July 31 to select a plan. For consumers that want to utilize the SEP, assisters should help them using the following instructions:

Option 1: Visit Healthcare.gov to determine if consumer is eligible for a SEP (prospective coverage only). Visit Healthcare.gov, log into account, and select “Report a Life Change” to update application. Consumers affected by the system issue described above should attest to the following question which grants a SEP:  “Did any of these people apply for coverage between November 15, 2014 and February 15, 2015? (Select their names if they applied through their state or the Marketplace).”  If a consumer is eligible for this SEP and does not want retroactive coverage, he or she can enroll prospectively with no further action needed.  If a consumer would like to enroll retroactively, he or she can do so by calling the Marketplace Call Center as outlined below.

Option 2: Contact Marketplace Call Center for a SEP (prospective and/or retroactive coverage). Consumers affected by the system issue described above can call the Marketplace Call Center at 1-800-318-2596 / TTY: 1-855-889-4325. Consumers should explain that they were affected by the “immigration block system issue” and that only some people in their household received APTC when they applied earlier. A Call Center Representative will help the consumer complete an application and grant a prospective or retroactive SEP.

Under this SEP, a consumer’s enrollment and APTC can be made retroactive with a coverage effective date as early as January 1, 2015. It is important to make sure that consumers understand that if they request retroactive coverage, they will be responsible for premiums due back to the coverage start date and will be responsible for any deductibles, co-pays, and co-insurance for services received during those months.



Congresspeople are in recess during the month of August, but usually use that time to connect with people and events in their districts.  Since they plan their travels during recess several weeks ahead of time, be sure to plan your event, contact Robbie Adams, HCAN Communications Manager about it at radams@hcanebraska.org and add it to the calendar of national events at http://www.healthcenterweek.com/submit-your-event.cfm .

The Federal Office of Rural Health Policy (FORHP) is pleased to announce the 60 new awardees for the 2015 Rural Health Care Services Outreach (Outreach) grant program. Each grantee will receive up to $200,000 a year to implement three-year projects, which will help create innovative solutions to benefit the community and address its needs. These grantees will be working with a consortium of local health care providers to expand and enhance the rural health care service delivery system so that it is more coordinated and integrated. Because these grantees have adopted or adapted an evidence-based or promising practice model, they will maximize their time providing services to help improve population health and demonstrate outcomes, as well as implementing strategies to sustain their projects.  These funded organizations are helping to change how health care is being delivered in rural communities. Please watch this short video that will provide a glimpse into the new 2015 cohort.

The 2012 cohort of Outreach grantees, which closed out April 30th, 2015, was the first group to adopt or tailor an evidence-base or promising practice model to address their community need.  As a result of FORHP’s funding, grantees have been able to implement results driven programs.  For example, Irwin County Board of Health in Ocilla, GA, adapted the National Diabetes Education Program “Power to Prevent: A Family Lifestyle Approach to Diabetes Prevention” curriculum and found at the end of their second year of their operation, 89% of their diabetic adult patients had a HgA1c <8.0%.  Another grantee, Nevada County Behavioral Health in Grass Valley, CA, served the seriously mentally ill (SMI) diabetics using the IMPACT and Quadrant IV Clinical Integration models to integrate behavioral and physical healthcare. By the second project year, this grantee observed a 25% increase in the percentage of SMI diabetic adults maintaining a HbA1c <8.0%.  FORHP looks forward to analyzing program data for this cohort and share more results with grantees and stakeholders in the future.

For more information about the Outreach program, please contact Linda Kwon (lkwon@hrsa.gov).


When: Wednesday, May 20, 2015, 12:00pm ET

Register at: http://bit.ly/1GKKbiS

Presented by: Zalika Shani, Vatsala Ramprasad MD, Crozer-Keystone Health System; Rachael Greenberg, National Nursing Centers Consortium

Content: May is National Asthma Awareness Month and the National Nursing Centers Consortium, Community Health Partners for Sustainability, and their partners are holding a webinar to support primary care providers concerning: Pediatric asthma control and education; Increasing awareness about asthma; Improving the lives of all people with asthma.     Participants will receive up-to-date asthma data about prevalence, ER/hospital visits, and cost, as well as learn about different ways to control asthma. By the end of the webinar, participants will be able to: Identify tools that can be used for an environmental history for pediatric asthma patients; Identify key patient education messages and free patient resources, including NNCC’s Lead and Healthy Homes Program; Recognize clinical care challenges and identify possible solutions using guidelines-driven clinical care of pediatric asthma.

KEY TAKEAWAY: Consumers who bought coverage through the Marketplace are just as satisfied as those with other types of insurance, according to a new national survey. Additionally, consumers’ satisfaction with the enrollment process has increased since the first year of Open Enrollment!

A new survey of more than 3,000 healthcare consumers conducted by consumer research firm J.D. Power offers the first comprehensive look at efforts to improve the consumer experience in the second year of Open Enrollment. The study measures satisfaction with Marketplace health plans obtained for the 2014 plan year, and it measures the enrollment experience of both new Marketplace enrollees and re-enrollees by examining seven attributes: amount of time to complete the renewal/enrollment process; clarity of instructions for completing enrollment application; courtesy of the representative; ease of navigating the Marketplace website; ease of renewing/enrolling; ease of understanding benefits and coverage; and variety of information available about health insurance plan choices.

Enrollment satisfaction among new enrollees increased by 55 points to 670 (on a 1,000-point scale) from 615 in 2014, when all enrollees were new to the Marketplace. Among members who re-enrolled, satisfaction with the enrollment process was rated 731 points, higher than new enrollees. Finally, enrollment satisfaction among re-enrollees is highest among those who enrolled through the Federally-facilitated Marketplace at 739 on a 1,000 point scale, followed by State-Partnership Marketplaces/Federally Supported State-Based Partnerships.

In terms of satisfaction with the health plans they obtained, in 2015 Marketplace customers’ ratings were identical to those of consumers with plans not purchased on the Marketplace, including employer-based plans.

  • To view a summary of these survey results from JD Power, click here.
  • To view a longer summary of the JD Power survey results, click here.

Key Takeaway: As of April 29, 2015, an SEP is once again available to eligible consumers who are survivors or victims of domestic violence or spousal abandonment so that they may enroll in a QHP through the Marketplace with advanced payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs), if eligible. This SEP is now available through the Marketplace Call Center.

As an assister, you may be in a position to help a survivor of domestic violence or spousal abandonment qualify for a special enrollment period (SEP) and apply for coverage through the Marketplace separately from their spouse.

CMS had previously established a time limited SEP to enable consumers who are survivors of domestic violence to enroll in a qualified health plan (QHP) through the Marketplace. This SEP was previously available to consumers through June 1, 2014. NEW: As of April 29, 2015, this SEP is once again available to eligible consumers who are survivors of domestic violence/abuse or spousal abandonment so that they may enroll in a QHP through the Marketplace with advanced payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs), if eligible. This SEP is available to survivors of domestic violence, survivors of domestic abuse or spousal abandonment. Spousal abandonment, sometimes referred to as desertion, refers to when an individual cannot locate his or her spouse after making a reasonable attempt to find the spouse. To access this SEP, eligible consumers should call the Marketplace Call Center at 1-800-318-2596 to explain that they are a survivor of domestic violence, victim of domestic abuse, or survivor or victim of spousal abandonment.

When completing their Marketplace application, consumers should indicate that they are not married on the application. Upon qualifying for the SEP, consumers will have 60 days to select and enroll in a QHP. They will receive regular, prospective coverage effective date following the 15th of the month rule.

Eligible consumers may tell you that they assumed or were informed that they were ineligible for APTC because they are married and not filing a joint tax return with their spouse. While this is generally true, there is relief for consumers in specific situations, including for survivors of domestic violence and spousal abandonment, as specified in IRS Publication 971: Innocent Spouse Relief. More details about filing taxes separately for individuals who meet these criteria are available on page three of the 2014 Instructions for Form 8962 Premium Tax Credit (PTC). In addition, consumers who were not able to get coverage earlier in the year due to their domestic situation may be eligible for an exemption from the individual shared responsibility requirement or “fee” for not having coverage. More information about exemptions is here.



Language on HealthCare.gov has been updated to address assister questions about what triggers the “permanent move” special enrollment period (SEP).  This SEP is triggered when consumers gain access to a new qualified health plan (QHP) as a result of a permanent move, even if they remain in their current plan service area. Therefore, even if the consumer is still in his or her current plan coverage area after his or her permanent move, he or she can still qualify for this SEP, as long as one or more new QHPs are available in his or her new location.

The move question on the SEP screener tool has been clarified to reflect this distinction. To view this updated content on the SEP screener tool, click here; to view it on the “Getting 2015 coverage with a Special Enrollment Period” page of HealthCare.gov, click here.