Reform Alert - News from the Blues' Office of National Health Reform

Determining eligibility to participate on the Exchange

Update: July 1, 2013 — Marketplace eligibility provisions amended in new proposed rule

August 16, 2012

The recently upheld Patient Protection and Affordable Care Act requires the development and operation of a health insurance Exchange in each state to let individuals purchase insurance coverage through qualified health plans. In order to purchase on the Exchange, individuals must be deemed eligible, and the Exchange will determine eligibility through a combination of applicant attestations and data sharing with federal and state agencies.

The following are specific criteria that will determine if an individual is qualified:

  • Citizenship, status as a national, or lawful presence in the U.S. for the entire period for which enrollment is sought. 
  • Residency, which is defined (as in Medicaid) as being physically present in the state with either 1) an intent to reside or 2) a job commitment or be seeking employment in the state. 
  • Incarceration disqualifies an individual from Exchange eligibility. 

If an individual asks for financial assistance in obtaining health care coverage, the Exchange is responsible for determining or assessing:

  • Medicaid eligibility 
  • CHIP eligibility, as well as eligibility for the Basic Health Program if one operates in the Exchange service area. 
  • Primary tax payers’ eligibility for an advance payment of premium tax credits. 
  • Eligibility for cost-share subsidy. 

Are there different eligibility standards for Indians?

The Exchange is required to determine whether an Indian applicant is eligible for special cost-sharing reductions. 

If an Indian meets the criteria below, all services must be provided to the individual with no cost sharing.

  • Has household income that does not exceed 300 percent FPL, and 
  • Enrolls in a QHP. 

Further, the Exchange must verify attestation of Indian status using federally permissible documentation, supplemented by additional documentation approved by HHS, as well as information supplied by the individual.

How will the premium tax credit be administered?

When the Exchange determines an individual’s eligibility for advanced payment of premium tax credits, HHS notifies Treasury, and Treasury makes advance payments directly to the issuer of the QHP selected by the individual. The Exchange simultaneously provides information to the QHP issuer, HHS and employer (if applicable, the Exchange notifies the applicant’s employer that the applicant is receiving a premium tax credit for individual market coverage on an Exchange). 

Exchanges can choose to have HHS make eligibility determinations for the premium tax credit and cost-sharing reductions. 

Enrollees must generally report changes affecting eligibility within 30 days.

If actual eligibility for premium tax credits varies from advanced payment of premium tax credits, the individual will reconcile with the IRS through the individual’s tax return filing. Exchanges, HHS and QHP issuers are not involved in this reconciliation process. 

What is the employer’s role for participating on the SHOP Exchange?

An employer participating in a SHOP Exchange must provide its employees with information about selecting and enrolling in a QHP. The SHOP Exchange will provide a uniform application and enrollment timeline for qualified employers and qualified employees to make benefit selections and provide required information to determine eligibility. Since the enrollment effective date for the SHOP may vary by employer, the uniform timeline will apply working backward from the coverage effective date. 

Employers are also responsible for providing information to the Exchange about changes to an employee’s eligibility to purchase coverage through the employer.

How will the Exchange handle information discrepancies?

The Exchange must verify information through electronic data sources. In cases of inconsistencies with information the individual attests to and information available to the Exchange, the individual will generally have 90 days to resolve the inconsistency.

Where can I find more information? 

For more information please see the Final Rule in the Federal Register at 45 CFR 155, Subpart D and 45 CFR 157.

The information in this document is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.

©1996-2014 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. We provide health insurance in Michigan.

State and Federal Privacy laws prohibit unauthorized access to Member's private information. Individuals attempting unauthorized access will be prosecuted.

Site Map  |  Feedback  |  Important Legal and Privacy Information

Explanation of Level A Conformance
Better Business Bureau Online Seal of Reliability