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Marketplace Exemptions and Appeals Assistance

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

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Marketplace Exemptions and Appeals Assistance This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

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Table of Contents

Course Introduction ......................................................................................................... 3

Minimum Essential Coverage Requirement ..................................................................... 8Exemption Types .......................................................................................................... 15Applying for an Exemption............................................................................................. 36Assisting Consumers with Eligibility Appeals ................................................................. 70Conclusion .................................................................................................................... 85Resources ..................................................................................................................... 86

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Course Introduction

Welcome

You need to be aware of this training disclaimer.

The information provided in this training course is not intended to take the place of the statutes, regulations, and formal policy guidance that it is based upon. This course summarizes current policy and operations as of the date it was uploaded to the Marketplace Learning Management System. Links to certain source documents have been provided for your reference. We encourage persons taking the course to refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

In this course, there are some references and links to nongovernmental third-party websites. The Centers for Medicare and Medicaid Services (CMS) offers these links for informational purposes only and inclusion of these websites should not be construed as an endorsement of any third-party organization's programs or activities.

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Course Introduction

Disclaimer

In this lesson, the terms "you" and “assister” refer to the following types of assisters:

Navigators in Federally-facilitated Marketplaces

Non-Navigator assistance personnel in Federally-facilitated Marketplaces, including federal In-Person Assisters (IPAs)

Certified Application Counselors in Federally-facilitated Marketplaces

Note: In some cases, "you" is also used to refer to a consumer but it should be clear when this is the intended meaning.

The terms “Federally-facilitated Marketplace” and “FFM,” as used in these training courses, include FFMs where the state performs plan management functions and State Partnership Marketplaces.

Generally, unless otherwise indicated, the term “Marketplace” is used in this course to refer to the individual market FFMs.

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Course Introduction

Welcome

Hi, I’m Jennifer. I don’t know if the Marketplace in my state will grant me an exemption or if I’ll be able to claim an exemption on my tax return. I didn’t enroll in health coverage because my faith is opposed to conventional health insurance.

Does Jennifer qualify for an exemption?

Can Jennifer claim an exemption even if she qualifies for health coverage?

How can she claim an exemption?

Hello, my name is Neha. Welcome to the Marketplace Exemptions and Appeals Assistance Course! Don’t worry if you can’t answer all of these questions. I will be here to help you learn the answers to these questions and more in the course.

Ready? Let’s go!

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Course Introduction

Course Goal

Under the Affordable Care Act, everyone who can afford to have health coverage but who chooses not to buy it may have to pay a fee. However, consumers who can't afford coverage or meet other conditions may qualify for an exemption. It is important for consumers to know that exemptions are available and to understand the steps they need to take to request an exemption.

This course addresses consumer responsibilities for maintaining minimum essential coverage as well as consumer rights to apply for an exemption or to appeal Marketplace decisions. It emphasizes both the capabilities and constraints of assisters in working with consumers in these situations.

Topics: This course includes information on:

• Minimum Essential Coverage (MEC)

• Tax implications of not having MEC

• Calculating the individual shared responsibility payment

• Exemptions from the individual shared responsibility payment

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• Tools to apply for an exemption

• Applying for an exemption

• Exemption Certification Number (ECN)

• Eligibility for Catastrophic coverage

• Notice of Eligibility Determination

• Starting an appeal

• Appeal resolution

• Appeals process

This course describes policies and procedures that are in place in all states for which FFMs are performing exemption determinations. As of April 2017, the FFMs are making exemption determinations in all states except Connecticut.

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Minimum Essential Coverage Requirement

Introduction

As you know, the Affordable Care Act requires individuals to have MEC, obtain an exemption, or pay a fee. MEC generally includes plans in the individual market, including Marketplace plans, job-based plans, most Medicaid plans, the Children’s Health Insurance Program (CHIP), Medicare, and student health plans that have been recognized as MEC.

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If consumers don't maintain MEC, they may have to pay a fee when they file their annual federal income tax return. This fee is called the individual shared responsibility payment. Some consumers may not have to pay this fee if they qualify for an exemption.

Tax Implications Describe the tax implications of not maintaining minimum essential coverage.

Calculate the Fee State how to calculate the individual shared responsibility payment.


Individual Shared Responsibility Payment: Tax Implications

Sometimes consumers ask me if they should get health coverage. I explain that when they file their federal income tax returns for the previous year, they may need to pay a fee for each month that each household member didn't have MEC or qualify for an exemption.

For example, consider a consumer and her child who didn't have MEC and didn't qualify for an exemption for 2017. The consumer’s husband was enrolled in Medicare for the entire year. In this case, the consumer would have to pay a fee only for herself and her child, but not for her husband, when she and her husband file their 2017 tax return.

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Knowledge Check

A consumer and his spouse didn't have MEC and don’t qualify for an exemption for 2017. Their two children were enrolled in CHIP for the whole year. Which family members will be assessed a fee for not having coverage?

Select the appropriate family members to determine who will be assessed a fee for not having coverage.

Answer The consumer would have to pay a fee for himself and his spouse but not for their children when filing their 2017 tax return.

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Individual Shared Responsibility Payment: Fee Calculation

The requirement to have MEC is also called the “individual mandate.” The fee for consumers who fail to maintain MEC increases every year. It is calculated in two different ways:

1) As a percentage of consumers’ household income, or

2) A per person amount.

Consumers must pay whichever amount is higher when filing their federal tax return for the year they didn’t have coverage.

For 2016 and beyond, the amounts are as follows:

Percentage amount: 2.5 percent of household income

Note: Only count the amount of income that’s above the yearly tax filing threshold ($10,300 for individuals, $20,600 for couples filing jointly in 2015, the most recent year available).

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The maximum fee is equal to the total yearly premium for the national average price of a Bronze plan sold through the Marketplaces.

Per person amount: $695 per adult in household who doesn’t have health coverage and $347.50 per child under 18 in household who doesn’t have health coverage.

The maximum fee for year 2017 is $2,085.

Some consumers only have MEC for a portion of a year. The fee for not having MEC will be one-twelfth of the annual amount for each full month the consumer and each of their household members didn't have MEC. The fee is calculated on a monthly basis and the monthly amounts are added up to determine the total annual payment. It is also important to note that consumers are considered to have MEC for an entire calendar month as long as they have MEC for at least one day during that month.

Additional Information Remember, if consumers are uncovered for no more than three consecutive months, they don’t have to pay the fee at all and they should request a "short gap" exemption when filing their tax returns. We will talk more about this, as well as the other available exemption types, later in the course.

Remember, consumers in a non-Medicaid expansion state who apply for coverage through its Marketplace and fall below 100 percent of the Federal Poverty Level (FPL) will get an exemption automatically

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Individual Shared Responsibility Payment: Fee Calculation (cont’d).

Review the table to see how the fee has increased every year for those who don’t maintain MEC.Year 2014

Year 2014

Amount Per Each Adult and Child (under 18) in household without health insurance $95.00 per adult/$47.50 per child

Percent of income over tax filing threshold (i.e., $10,300 per individual and $20,600 per couple filing jointly) 1% of income above threshold

Year 2015

Amount Per Each Adult and Child (under 18) in household without health insurance $325/162.50

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Percent of income over tax filing threshold (i.e., $10,300 per individual and $20,600 per couple filing jointly) 2%

Year 2016 and Beyond

Amount Per Each Adult and Child (under 18) in household without health insurance $695/$347.50 Percent of income over tax filing threshold (i.e., $10,300 per individual and $20,600 per couple filing jointly) 2.5%


Key Points

• If consumers don't maintain MEC, they may have to pay a fee when they file their annual federal income tax return.

• The fee is called the individual shared responsibility payment.

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• Consumers are considered to have MEC for an entire calendar month as long as they have coverage for at least one day during that month.

Exemption Types

Introduction

The Affordable Care Act includes different categories of exemptions from the individual shared responsibility payment. These include income-related, health coverage-related, hardship, and group membership exemptions.

Purpose & Categories of Exemptions State the purpose of exemptions and the exemption categories for the individual shared responsibility payment.

Affordability Exemptions Identify the two types of affordability exemptions and the criteria for each.

Hardship Exemptions Identify the types of hardship exemptions and the documentation required for each.

Role of Assister Describe the role of an assister in helping consumers apply for an exemption from the individual shared responsibility payment.

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Exemption Types

Purpose of Exemptions

If consumers qualify for and obtain an exemption, it means they won't have to pay the fee for not having MEC. Consumers must submit supporting documentation to apply for certain exemptions.

Consumers may apply for more than one type of exemption; however, they only need to receive one exemption for any one period of time to avoid paying a fee on their annual tax return for that period.

Remember, if a consumer's exemption is approved, they will receive an Exemption Certificate Number (ECN) for each household member who qualified for the exemption. When it's time for consumers to file their federal income taxes, they will write each person's ECN on Internal Revenue Service (IRS) Form 8965, Part 1, Column "C." Consumers must be sure to include Form 8965 when they file their federal tax return. Remember, you should not help consumers fill out IRS Form 8965 in your role as an assister but you may refer consumers to a licensed tax adviser or tax preparer if they want help with this form. When making such referrals, FFM assisters should be sure to follow CMS guidance at https://marketplace.cms.gov/technical-assistance-resources/assister-guidance-on-referrals-to-outside-organizations.pdf.

See Healthcare.gov for more information on exemptions.

https://marketplace.cms.gov/technical-assistance-resources/assister-guidance-on-referrals-to-outside-organizations.pdf


https://www.healthcare.gov/

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Exemption Types

Exemption Categories

There are various reasons why consumers can be exempt from the fee for failing to maintain MEC. You can find additional information and application links in the Resources section.

Short coverage gap This exemption applies to each consumer in a household who fails to have MEC for a period less than three consecutive months. Consumers are considered covered for any month they had MEC for even one day. Consumers who have two or more coverage gaps during the year can claim this exemption only for the months of their first coverage gap. Consumers claim this exemption when filing their federal income tax returns. You can find instructions here.

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/short-gap

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/short-gap

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Marketplace affordability Marketplace coverage is considered unaffordable if the lowest cost Bronze plan available to a consumer through a Marketplace for the 2018 benefit year is more than 8.13 percent (This amount is calculated each year and is subject to change from year to year. 8.13 percent reflects the affordability threshold for plan year 2018.) of household income.

• The total cost to a consumer must be more than 8.13 percent, including any premium tax credit the consumer would qualify for if they enrolled in that plan.

• If a consumer qualifies for this exemption, the exemption may apply to everybody on their tax return who doesn't have coverage for the 2018 benefit year.

Consumers may apply for this exemption to the FFMs or the IRS when filing their taxes if the exemption is needed for future months through the end of the tax year (based on projected income) or through the IRS when filing their taxes for prior months or the entire tax year (based on actual income).

Note: Consumers who qualify for an affordability exemption based on projected income may be eligible to purchase Catastrophic coverage. You can find affordability exemption application information here.

Job-based affordability Job-based health insurance is considered unaffordable in different ways depending on how the coverage is offered:

• For an employee: If the annual premium for the lowest cost self-only plan (a plan that covers only the employee and not members of the employee's family) is more than 8.13 percent of household income.

• For the employee's family: If the annual premium for the lowest cost family plan is more than 8.13 percent of household income.

If a consumer can claim this exemption, it may apply to everybody on the consumer's tax return who doesn't have coverage in 2018. This will depend on the cost of the coverage and who it's offered to.

Note: It's possible that an employee won't be eligible for the exemption because the self-only plan available to them is affordable. But other members of the household could be eligible for the exemption if family coverage offered to them is unaffordable.

Consumers may apply to the FFMs or the IRS when filing their taxes for this exemption if it is needed for future months (based on projected income) or to the IRS when filing their taxes for prior months or the entire tax year (based on actual income). You can find job-based Marketplace exemption application information here.

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/marketplace-affordability

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/employer-affordability

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/employer-affordability

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Consumers whose income is too low to file taxes This exemption applies to consumers who don't file tax returns because their household incomes are below the tax filing threshold. Consumers who don't file federal income tax returns are automatically exempt. However, the only way for consumers to know if they will qualify for this exemption is to file a federal tax return. If the consumer qualifies, his or her family members who did not have health coverage will also likely qualify for this exemption. You can find instructions here.

Consumers who are members of

• A federally recognized Indian tribe or are Indians eligible for services through the Indian Health Service, tribes or tribal organizations, or urban Indian organizations

• A recognized health care sharing ministry; or,

• A recognized religious sect with religious objections to insurance, including Social Security and Medicare.

This exemption applies to each consumer in a household.

Consumers who can obtain exemptions because they are members of (1) a federally recognized Indian tribe or are Indians eligible for services through the Indian Health Service, tribes or tribal organizations, or urban Indian organizations or (2) a recognized health care sharing ministry may receive exemptions only from the IRS when filing their annual federal income tax returns.

Consumers must apply to the FFMs for an exemption if they are a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare. You can find more information here.

Consumers who are United States (U.S.) citizens or residents living abroad or consumers who aren't lawfully present in the U.S.

Consumers who are United States (U.S.) citizens or residents living abroad or consumers who aren't lawfully present in the U.S.

This exemption is available for U.S. citizens who lived outside the U.S. for 330 days in the past 12 months or were bona fide residents of a foreign country for a full tax year, resident aliens meeting certain requirements, and "Dreamers." Consumers may apply to the IRS for this exemption when filing their federal income tax returns. You can find instructions here.

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/income-below-threshold

https://www.healthcare.gov/health-coverage-exemptions/forms-how-to-apply/

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/resident-alien

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/resident-alien

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Hardship This exemption applies to consumers facing life situations that keep them from obtaining health insurance such as: homelessness, receiving a utility shut-off notice, fire, flood or other disaster, bankruptcy, being a victim of domestic violence, death of a family member, or not being eligible for Medicaid because their state did not expand Medicaid. To claim most hardship exemptions, consumers must fill out a paper application and mail it to the FFMs. Instructions are here.

To claim the non-Medicaid expansion exemption, consumers must apply to the IRS when filing their federal income taxes. Instructions are here.

Incarceration This exemption is for consumers who were in prison, jail, or a similar institution or correctional facility during 2017. Incarceration doesn't include probation, parole, home confinement, or being held but not convicted of a crime. Consumers can apply for this exemption to the IRS when filing their tax return for any month they were incarcerated for at least 1 day. Instructions are here.

Refer to the Types of Coverage Exemptions of the Form 8965 Instructions in the Resources tab for a complete listing of every exemption from the individual shared responsibility payment.

https://www.healthcare.gov/health-coverage-exemptions/hardship-exemptions/

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/secretary-hardship

https://www.healthcare.gov/exemptions-tool/#/results/2016/details/incarceration

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Exemption Types

Exemption Categories (cont’d)

Remember that some exemptions are available:

• Only from the FFMs (most hardship and religious exemption)

• Only from the IRS when consumers file their federal income taxes (short coverage gap, federal tribe/Indian health coverage, health care sharing ministry, incarceration, non-citizen, U.S. citizen, or resident living abroad)

• From either the FFMs or the IRS when consumers file their federal income taxes, though each may be based on different information (Marketplace and job-based affordability exemptions)

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Exemption Types

Types of Affordability Exemptions

When you assist consumers with affordability exemptions, you need to know that:

Consumers can qualify for two different types of affordability exemptions: job-based coverage and Marketplace coverage.

Consumers who qualify for affordability exemptions can apply based on their projected annual household income or based on their actual annual household income.

Remember: Affordability for job-based coverage exemptions is determined by looking at the lowest-cost self-only or family plan (depending on who is applying for the exemption) offered by the consumer’s employer and comparing that to the consumer’s total projected or actual household income. If the job-based coverage is more than 8.13 percent of household income (or the cost of family coverage is more than 8.13 percent of household income), then the coverage is not affordable.

Affordability for Marketplace coverage exemptions is determined by looking at the lowest cost Bronze plan (depending on individual circumstances) and is granted if Marketplace coverage would cost more than 8.13 percent (2018) of the consumer’s income. To apply for an affordability exemption based on projected income, consumers can only apply through the FFMs.

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Job based Coverage To apply for an affordability exemption based on actual income, consumers can only apply through the IRS when filing their federal income taxes.

Marketplace Coverage To apply for an affordability exemption based on projected income, consumers can only apply through the FFMs

Exemption Types

Projected Affordability Exemption

How can you help consumers evaluate if they might qualify for an affordability exemption?

First, you should find out if consumers have access to job-based coverage and, if so, help them evaluate whether that coverage is considered affordable. If it is not, you should help them evaluate whether Marketplace coverage is affordable.

If a consumer’s share of their premium for a job-based plan that covers themselves and their family is less than 8.13 percent of their household income (2018), the plan is considered affordable.

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To summarize, consumers will qualify for an affordability exemption if:

• If a consumer doesn't have access to job-based coverage .

• The lowest cost Bronze plan in a Marketplace is still more than 8.13 percent of their projected household income (2018) after applying any premium tax credits for which they are eligible, the consumer will qualify for an affordability exemption.

Exemption Types

Tips for Completing Employer-Sponsored Coverage Questions on an Exemption Application

Let’s stop and review some important tips about discussing job-based coverage:

Affordability of job-based coverage is determined by looking at the lowest-cost self-only or family plan (depending on who is applying for the exemption) offered by the consumer’s employer and comparing that to the total projected household income. Employer insurance is considered affordable under the Affordable Care Act if the employee’s share of the premium for the lowest-priced plan available that would cover the employee only — not the employee’s family — is 8.13 percent or less of the employee’s household income (2018).

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Basically, if the consumer’s share of the premium for health care is 8.13 percent or less of household income (2018), the consumer can afford job-based coverage.

For 2018, if the premium is greater than or equal to 8.13 percent of a consumer's total household income, then the consumer may be eligible for a job-based coverage exemption.

Affordability isn't based on the cost of the coverage in which the consumer is currently enrolled or the cost of coverage the consumer may prefer.

The application for Marketplace coverage asks for the premium amount the consumer, as the employee, would pay for the coverage for self-only coverage, as well as for the premium amount the consumer would pay for family coverage (if available). Since the consumer is only applying for the exemption for himself, he doesn't need to include information about family coverage.

The consumer doesn't have to include information about the premium amount his employer pays or any deductibles or cost-sharing reductions (CSRs) (these aren't part of the calculation for cost of coverage).

OK, hope you are getting the hang of things now. Let’s go back to Eda and see where she tells us to enter the employer-sponsored coverage exemption.

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Exemption Types

Scenario Introduction

Now, let’s put what we discussed to a test. Meet Jeffrey, a consumer who needs assistance with applying for an exemption from the individual shared responsibility payment. After receiving consent to assist him, Eda, our assister, and Jeffrey begin to discuss his specific situation.

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Exemption Types

Scenario Introduction, cont’d

Jeffrey I would like to apply for an affordability exemption but I'm not sure what to do.

Eda I’d be happy to help you. I can help you identify the correct exemption application to use, guide you through the information that you need to fill out on the application if it is an exemption granted through the FFMs, help you identify the documents that you need to provide, and tell you where to submit the application. I can also help you answer some of the questions on the application if it is an exemption granted through the FFMs.

Jeffrey Great, thank you! I brought some information with me but I'm not sure if I have the right documents.

Eda Don't worry. Even if you don't have all of the required documents with you today, I can assist you in beginning the application for exemptions granted through the FFMs. However, you will want to include copies of all of the documents the application asks for before mailing it so the FFM can quickly process your application.

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Exemption Types

Employer-Sponsored Coverage Exemption

Eda The job-based coverage questions on the exemption application are similar to those on the health coverage application except that there’s space to put in information about the cost of family coverage.

For the lowest-cost plan that meets the minimum value standard offered to the employee and family members requesting an exemption (only include family plans for family members that do not already have an exemption). If the employer has wellness programs, provide the premium that the employee would pay if they don't get a discount for wellness programs, including smoking cessation programs.

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Exemption Types

Exemption Type: Hardship Exemption

Here are important details you need to know about assisting consumers with hardship exemptions:

The Affordable Care Act gives the Secretary of the Department of Health and Human Services (HHS) the authority to determine circumstances under which consumers can qualify for an exemption if they “have suffered a hardship with respect to the capability to get coverage under a qualified health plan.”

Consumers may qualify for a hardship exemption under several different circumstances. It's important to remember that for some of these circumstances, consumers must submit exemption applications with supporting documentation. It'll be used to determine if a consumer qualifies for the exemption.

The length of hardship exemptions varies depending on the type of hardship. At a minimum, the FFMs grant this type of exemption for one month before, during, and after a hardship event. Depending on the circumstances, this type of exemption can be granted for an entire year. Consumers who are granted hardship exemptions will get information about the length of their exemption from the FFMs.

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Exemption Types

Hardship Exemption Events Table

Earlier you saw chart describing all of the different types of exemptions. This chart explains the documents consumers must submit with their applications for each type of hardship exemption.

The last page of the hardship exemption application contains examples of hardships that may affect a consumer’s ability to receive health coverage.

Hardship Exemption Homelessness

Required Documentation Consumers don't have to provide any documentation.

Hardship Exemption Eviction or currently facing eviction or foreclosure

Required Documentation Consumers must provide a copy of their eviction or foreclosure notice

Hardship Exemption Received a shut-off notice from a utility company

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Required Documentation Consumers must provide the shut-off notice from the utility company.

Hardship Exemption Victim of domestic violence

Required Documentation Consumers don't have to provide any documentation.

Hardship Exemption Experience the death of a close family member

Required Documentation Consumers must provide the death certificate, a copy of the death notice from the newspaper, or a copy of the official notice of death.

Hardship Exemption Experienced a natural or human-caused disaster that resulted in substantial property damage

Required Documentation Consumers must provide the police or fire report, insurance claim, or other document from a government agency, private entity, or news source documenting the event.

Hardship Exemption Filed for bankruptcy

Required Documentation Consumers must provide a copy of the bankruptcy filing.

Additional Info Some consumers may apply for a hardship exemption because their individual insurance plan was cancelled after June 30, 2013 and they believe other Marketplace plans are unaffordable. They must provide a copy of a cancellation notice from their insurance company stating that their health plan was cancelled because it didn't meet the Affordable Care Act requirements for MEC. This notice must have been sent to the consumer after June 30, 2013.

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Exemption Types

Knowledge Check

A. Based on the information below, which of the following consumers may qualify for an exemption?

B. Claire is interested in applying for an exemption because she's an Indian and gets medical care through an Indian Health Service provider.

C. Bobby is interested in applying for an exemption because he doesn't have any chronic medical conditions and prefers to pay for his medical expenses out of pocket. He has several affordable MEC options.

D. Eric is interested in applying for an exemption because he can't afford the coverage provided through his employer or the available Marketplace plans in his area.

The correct answers are A and C. Claire and Eric may be eligible for exemptions since eligibility for care through an Indian Health Service provider and inability to afford coverage during the coverage year are reasons consumers may qualify for an exemption. You can offer to help these consumers understand the exemption process. On the other hand, you should advise Bobby that, even though he believes that he’s healthy and doesn’t need coverage, he doesn’t meet any exemption requirements based on health status. He may still be assessed a fee for failing to maintain MEC.

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Exemption Types

Applying for an Exemption

Please remember that while assisters may explain how to claim an exemption through the tax filing process, they may not help consumers fill out IRS forms or claim exemptions on tax returns. Answer the following question about consumers with low household incomes who don’t file federal income taxes.

Consumers whose household incomes are low enough that they won't be required to file taxes also don't need to apply for an exemption.

True or False?

This is true. However, if they do choose to file tax returns to receive a refund, they can claim the exemption based on having household incomes below the filing threshold. Also, filing an income tax return is the only way consumers will know if they qualify for this exemption.

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Exemption Types

Knowledge Check

Jennifer requests help because she doesn't know if she should apply through her state's Marketplace or through the IRS for an exemption when she files her taxes. Jennifer explains that she didn't enroll in health coverage because she's a member of a religious sect and is opposed to acceptance of the benefits of any private or public insurance that pays for medical care. Which of the following would be appropriate advice to give Jennifer?

A. Jennifer must apply for an exemption through the Marketplace and must claim the exemption on Form 8965.

B. Jennifer may apply for an exemption through the Marketplace or through the IRS when she files her taxes, whichever she prefers.

C. Jennifer should apply for an exemption through the IRS.

D. Jennifer will be granted an exemption automatically and doesn't need to take any actions.

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The correct answer is A. Only the Marketplaces grant exemptions for members of certain religious groups. Jennifer should apply for an exemption through the Marketplace. If her exemption is approved, Jennifer will receive an Exemption Certificate Number (ECN) for each member of her household. She will write the ECNs on IRS Form 8965 to claim this exemption on her tax return and include this form with her tax return. This exemption won’t be granted automatically.

Exemption Types

Key Points

• Consumers may be required to pay the individual shared responsibility payment or fee if they don't have MEC. Under certain circumstances, consumers may be exempt from this fee.

• You should be able to explain which types of exemptions require application to the FFMs, which exemptions require application to the IRS when consumers file their tax returns, and the general purpose of IRS Form 8965.

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Introduction

Consumers who may qualify for exemptions from the individual shared responsibility payment need to submit exemption applications to the FFMs or the IRS. Remember, there are different applications for different types of exemptions.

Exemption Tools Describe the purpose of and how to use the Health Care Exemptions Tool and the Tax Tool.

ECN State the purpose of the ECN.

Applying for an Affordability Exemption Describe how to apply for an affordability exemption.

Techniques for Assisters Describe techniques an assister can use to help consumers apply for an exemption from the individual shared responsibility payment through the FFMs.

Tax Filing Requirements State the tax filing requirements of an exemption.

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Eligibility for Catastrophic Coverage State the eligibility requirements for Catastrophic health plan coverage as an option for a consumer with an exemption.


Exemption Tool on HealthCare.gov

Now that you’ve learned about the types of exemptions and where consumers can apply for them, let’s review a couple of great Marketplace tools you can use to help consumers get started with applying for exemptions.

The Health Coverage Exemptions Tool helps consumers learn if they may qualify for an exemption and how to apply.

Enter “exemptions” in the Search field and then select the Health Coverage Exemptions Tool.

This tool asks consumers questions about their health coverage, income, and tax filing status. Then the tool asks questions related to the different exemptions to determine which exemptions they may be eligible for. At the end, consumers can select next steps to view instructions on how to apply for the appropriate exemption.

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Tax Tool on HealthCare.gov

Another tool helps consumers who may qualify for an affordability exemption get the information they need to claim it. The Health Coverage Tax Tool (https://www.healthcare.gov/tax-tool/) provides the price of the lowest cost Bronze plan in their area and other information consumers need to fill out IRS Form 8965 to file with their federal income tax return.

Remember, consumers may be eligible for the affordability exemption if the lowest cost Bronze plan is more than 8.13 percent (Remember, this amount is calculated each year and is subject to change from year to year. 8.13 percent reflects the affordability threshold for plan year 2018) of their projected income.

If an exemption is available through the tax filing process, consumers should follow the directions for filing Form 8965 located at IRS.gov. Remember, you should not help consumers fill out IRS Form 8965 because assisters should not provide tax advice in their role as assisters.

Beginning with FFM Navigator grants awarded in 2018, FFM Navigators are required to provide referrals to licensed tax advisers, tax preparers, or other resources for assistance with tax preparation and tax advice related to consumer questions about exemptions. Until FFM Navigator grants are awarded in 2018, FFM Navigators are permitted but not required to provide these kinds of referrals. Additionally, as long as they have sufficient

https://www.healthcare.gov/tax-tool/

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knowledge to make these types of referrals, non-Navigator assistance personnel and CACs in FFMs may choose to provide them. See the Resources section for a list of possible referral sources for tax questions. If you provide referrals, you should be sure to follow CMS guidance for FFM assisters at: https://marketplace.cms.gov/technical-assistance-resources/assister-guidance-on-referrals-to-outside-organizations.pdf.

The Health Coverage Tax Tool also helps consumers figure out if they are eligible to receive a premium tax credit. More information about premium tax credit eligibility can be found in other courses in this training.

Additional Information More Marketplace exemption resources can be downloaded at IRS.gov, including the current Form 8965, Health Coverage Exemptions, and instructions on how to fill them out. Consumers can claim most exemptions when they file their tax return using Form 8965. Consumers can use the IRS Interactive Tax Assistant to find out if they qualify for an exemption.

Consumers can also visit IRS.gov for a chart that displays which exemptions they must apply for through the IRS during tax season and which exemptions they must apply for by using a separate application available through the Marketplaces. More information about IRS forms and resources can be found in the Assister Standard Operating Procedures course.

https://marketplace.cms.gov/technical-assistance-resources/assister-guidance-on-referrals-to-outside-organizations.pdf.

https://marketplace.cms.gov/technical-assistance-resources/assister-guidance-on-referrals-to-outside-organizations.pdf.

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How and When to Apply for Different Types of Exemptions

Consumers have different timeframes to apply for each type of exemption. The timeframe depends on a few different factors. Here are some handy charts you can print to help consumers apply at the right time—but first, let’s review them. Select each of the exemptions below to learn how to apply and the timeframe for applying.

Select here to view a pdf version of this information. Type of Exemption:

Short coverage gap How to Apply Consumers can claim this exemption when filing their federal income taxes.

Consumers with 2 or more gaps in coverage during the year can claim this exemption only for the months of the first coverage gap. This is true even if both gaps are less than 3 months.

https://reviewlink.trivantis.com/content/115373/C13M3_How%20and%20When%20to%20Apply%20for%20Different%20Types%20of%20Exemptions.pdf

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Timeframe for Applying Apply after the 1, 2, or 3 consecutive month period that consumers did not have coverage. If the coverage gap period crosses over calendar years, the months without coverage of the second tax year aren’t counted for the exemption for the first tax year but the uncovered months from the first year are counted for the exemption for the second tax year

Marketplace Affordability How to Apply Consumers can claim this exemption when filing their federal income taxes if they need the exemption for months during the tax year the consumer is filing.

Consumers can claim this exemption either when filing their federal income taxes or they can download, fill out, and mail a Marketplace exemption application if they need the exemption for the current tax year. If the Marketplace exemption is approved, consumers will receive an ECN for each household member. When it’s time to file their federal income taxes, consumers will write each person’s ECN on IRS Form 8965, Part 1, Column “C.” Consumers must be sure to include Form 8965 when they file their federal tax return.

Timeframe for Applying Consumers can apply for the entire tax year, for prior months they could not afford Marketplace coverage, or for future months through the end of the tax year that they will not be able to afford Marketplace coverage.

Job-Based Affordability How to Apply Consumers can claim this exemption when filing their federal income taxes if they need the exemption for months during the tax year covered by the tax filing.

Consumers must be sure to include Form 8965 when they file their federal tax return.

Timeframe for Applying Consumers can apply for the entire tax year or for months during the tax year they could not afford job-based coverage.

Consumers Whose Household Income is Too Low to File Taxes How to Apply Consumers can claim this exemption when filing their federal income taxes.

Note: The consumer must file a federal tax return to determine eligibility but will be considered automatically exempt from the individual shared responsibility payment for that year if the consumer does not choose to file taxes.

Timeframe for Applying Consumers apply for this exemption after the coverage year where their income was too low to file taxes.

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Consumers who are members of a federally-recognized Indian tribe, Indians eligible for services through the Indian Health Service, tribes or tribal organizations, or urban Indian organizations How to Apply Consumers can claim this exemption when filing their federal income taxes.

Timeframe for Applying Consumers apply after the coverage year

Consumers who are members of a recognized health care sharing ministry (HCSM) or a recognized religious sect with religious objections to insurance, including Social Security and Medicare How to Apply Consumers can claim this exemption when filing their federal income taxes.

Timeframe for Applying Consumers apply after the coverage year.

Consumers who are members of a recognized religious sect with religious objections to insurance, including Social Security and Medicare How to Apply

Consumers can download, fill out, and mail a Marketplace religious exemption application to the address shown on the form. The consumer should include on the application everybody on the consumer’s tax return, even if the other individuals don’t need this exemption. If necessary, the consumer can make copies of Step 2 (page 4) for each person. The FFMs can’t process the application without the entire tax household’s information. This also helps the IRS match the consumer’s information.

If they have one, consumers should send a copy of an approved IRS Form 4029 (“Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits”) with the required signatures.

If the Marketplace exemption is approved, consumers will get an ECN for each household member. When it’s time to file their federal income taxes, consumers will write each person’s ECN on IRS Form 8965, Part 1, Column “C.” Consumers must be sure to include Form 8965 when they file their federal tax return.

Timeframe for Applying Consumers should apply during the relevant coverage year.

If consumers already have an ECN from the prior year for membership in a religious sect, they can use the same ECN to complete Form 8965 of their federal tax return. They will need to provide that ECN on their Form 8965 every year when filing their federal taxes as long as their membership status doesn’t change.

If consumers get this exemption, they won’t have to reapply for an exemption unless they turn 21 or leave the religious sect. If consumers received an ECN from a Marketplace before turning 21, they will need to complete a new exemption application with the Marketplace in order to get a new ECN when they turn 21.

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U.S. Citizen living abroad or consumers not lawfully present in U.S. How to Apply Consumers can claim this exemption when filing their federal income taxes.


Hardship How to Apply For most hardships, consumers can download, fill out, and mail a Marketplace hardship exemption application to the address shown on the form. If the Marketplace exemption is approved, consumers will get an ECN for each household member. When it’s time to file their federal income taxes, consumers will write each person’s ECN on IRS Form 8965, Part 1, Column “C.” Consumers must be sure to include Form 8965 when they file their federal tax return.

EXCEPT,

Consumers who would have qualified for Medicaid if their state had expanded Medicaid can claim this exemption when filing their federal income taxes. Timeframe for Applying

Timeframe for Applying Consumers should apply during the coverage year for hardship exemptions if they experience: homelessness, eviction or foreclosure, utility shut-off notice, domestic violence, death of a family member, caring for an ill family member, disaster, bankruptcy, unpaid medical expenses, child denied Medicaid/CHIP, waiting for a successful eligibility appeal, or an individual plan cancelled after June 30, 2013.

Consumers apply after the coverage year if they would have qualified for Medicaid if their state had expanded Medicaid.

Incarceration How to Apply Consumers can claim this exemption when filing their federal income taxes.


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Knowledge Check

Brian believes he's eligible for a hardship exemption and comes to you for help with his application. Brian explains that he recently received a shut-off notification from his electric company. He also tells you that he doesn't have a car; therefore, he doesn't visit a doctor on a regular basis.

Based on this information, what could you tell Brian about this exemption?

A. Brian can apply for a hardship exemption because he received a shut-off notice from the electric company. You also explain that he'll need to include a copy of the shut-off notice with his application.

B. Brian can apply for a hardship exemption because he doesn't have reliable transportation to visit his doctor.

C. Brian can apply for a hardship exemption because he cannot afford to purchase a car.

D. Brian doesn't meet any of the criteria for a hardship exemption.

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The correct answer is A. Brian can file for a hardship exemption because he received a shut-off notice from his electric company. Remind Brian that he needs to include a copy of the notice with his application. Brian's lack of reliable transportation doesn't qualify him for a hardship exemption.


How to Apply for a Marketplace Affordability Exemption

Jeffrey Hi, again. I would like to apply for an affordability exemption through the Marketplace. What do I need to know?

Eda You mentioned that you want to apply for an affordability exemption. You can apply to have this exemption granted by an FFM. If you choose to apply now, the exemption will be based on your projected household income for this year. If you're eligible, you'll lock in this exemption for the whole year and won't have to make any changes, even if your household income changes. You may want to know that if your income does change you may also come back to the FFM to buy coverage that is considered affordable. However, this affordability exemption, which is based on projected household income, is only available when you apply before the last date you could have enrolled in a qualified health plan (QHP) through an FFM. You also have the option of claiming the affordability exemption when you file your 2018 tax return. If you choose to claim it when filing your tax return, the exemption will be based on your actual annual household income. So, with that

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in mind, let’s get started.


Affordability Exemption Application: Step 1

Eda Let’s access the appropriate application for the state where you live. As you can see, your state is listed at the top of the form so we have the right one.

The first step of the application asks you to fill out your personal information, including your name, address, phone number, and whether you want to get information by email. If you have a preferred spoken or written language other than English, you'll want to fill that part in as well.

Jeffrey This information won't be hard for me to fill out. I can complete all of this now.

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Eda Step 2 of the application is a little more complicated. The first part of this section asks you for information about which of your household members you want to include on the application and their demographic information.

Jeffrey Why do I need to fill out all of this personal information?

Eda The application asks for your Social Security Number and income information to make sure your exemption is matched up with your tax return when you file it. Don't forget that all the information you submit is kept private and secure by the Marketplace. It can’t be shared with anyone else except as authorized by law.

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Knowledge Check

Let's pause for a second to make sure we understand what's going on before we continue with this scenario. Jessica comes to you for help completing an application for an exemption based on affordability. When reading the application, she noticed her state's name wasn't listed at the top. She's also worried about providing the details of her personal information and isn't sure if she's supposed to put her husband's income information on the application as well, even though they file taxes jointly. Finally, she realizes she didn't bring copies of any documents that would prove how much she makes in a year.

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Which of the following would be appropriate guidance to provide to Jessica?

A. You send Jessica away because she does not have all the required documents.

B. You tell Jessica that she has the wrong exemption application and you help her locate the correct one at HealthCare.gov/exemptions.

C. You assure Jessica that the information she submits on her application is kept private and secure by the Marketplace and won't be shared with anyone else as authorized and required by law.

D. You tell Jessica that she needs to include the information about her husband's income because they file taxes jointly.

The correct answers are B, C, and D. All exemption applications are located at HealthCare.gov/exemptions but there are different exemption applications based on the exemption type and the states in which consumers live. Reassure Jessica that the information she includes on her application is private and secure. The Marketplace will not share it with anyone unless authorized and required by law. You should also tell her that she’ll need to include the job and income information for each member of her household. Even though Jessica doesn’t have all the required documents with her today, you can help her start filling out the exemption application and identify the documents that she’ll need to gather and submit with it.

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Hopefully you were able to correctly answer the Knowledge Check and understand why answer choices B, C, and D were correct.

For now, let's go back to Eda, our assister, and Jeffrey, our consumer. They are about to discuss "proof of income." Eda has explained to Jeffrey that he needs to submit information to prove income. Jeffrey is able to submit a recent pay stub and a letter from his employer verifying his income.

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Eda Great. Both of those documents provide proof of income so you can submit copies of either one with your application. I just have a few additional questions for you. Does your employer offer job-based coverage?

Jeffrey Yes, but I don't think it's affordable so I haven't enrolled in it.

Eda That's OK. This just means that you need to answer a few questions about it before submitting your application.

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Knowledge Check

Jeffrey needs help filling out his exemption application. Jeffrey's job offers coverage but he believes that it won't be affordable. Jeffrey is married and his wife doesn't currently work. He wants to apply for an exemption based on affordability. What information does Jeffrey need to submit to complete this application?

A. Proof of household income

B. Estimated medical expenses

C. Information about the premium amount he'd have to pay for coverage for himself (self-only) as well as the premium he'd have to pay for family coverage

D. Cost sharing and deductible information that he'd have to pay for his job-based coverage

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The correct answers are A and C. You should explain to Jeffrey that he’s required to provide proof of his household income because he’s applying for an exemption based on affordability. In addition, tell Jeffrey that, since his employer offers coverage, he’ll need to include the premium that he’d have to pay for the coverage for himself (self-only) as well as the premium amount he’d have to pay for family coverage, if it’s available. You can also inform Jeffrey that he doesn’t need to include his estimated medical expenses or information about the premium amount his employer pays or any of the deductibles or cost sharing amounts for his coverage on the exemption application.



Eda We're getting close to completing your application. In the next step, you'll need to sign the application and confirm that all the information you provided is accurate. You will also see where to mail the application.

Jeffrey Great. I'm happy you're able to guide me through this entire application.

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Process for Submitting an Exemption Application

After Jeffrey completes and signs his application and collects copies of his supporting documentation, the application is ready to be sent to the Marketplace.

How should Jeffrey submit his information? Through the computer, by telephone, or through the mail?

Correct answer is through the mail.

The FFMs don't accept online or telephone exemption applications at this time. All exemption applications must be mailed with copies of consumers’ supporting documentation to the FFMs.

Mail your exemption applications with copies of your supporting documentation to the following Marketplace address:

Health Insurance Marketplace – Exemption Processing 465 Industrial Boulevard London, KY 40741

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Process for Submitting an Exemption Application

We are almost finished. Let’s go back to Eda and see how she ends her encounter with Jeffrey.

Eda After you submit your application, the FFM will review it and determine your eligibility. The time it takes to get a response will depend on:

• How complicated your request is,

• How complete your application is, and

• Whether you need to submit more supporting documentation after you apply.

If you're granted an exemption, the FFM will send you an ECN. You'll need the ECN when you fill out IRS Form 8965 and your federal income tax return and if you decide to enroll in Catastrophic coverage. Make sure you keep the certificate number and approval notice in a safe place. I'd also recommend that you keep a copy of your submitted exemption application and supporting documents in case follow-up is needed.

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Jeffrey Thank you for your help today.

Eda You're welcome!


Knowledge Check

Let's pause for a second to make sure we understand what's going on before we continue with this scenario.

On November 30, 2017, Megan, a member of a federally-recognized Indian tribe, comes to you because she is concerned that she may not have submitted an exemption application in time to avoid paying the fee on her 2017 tax return.

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Which of the following would be appropriate guidance to provide to Megan?

A. Megan, as a member of a federally-recognized Indian tribe, can submit her exemption application through the Health Insurance Marketplace now or submit the exemption application when she files her taxes.

B. Megan can claim the exemption on her tax return or may amend her tax return to claim the exemption.

C. Megan must request an exemption application from her specific tribe.

D. Megan is too late for 2017 but offer to help her with applying for an exemption for 2018.

The correct answer is B. Remind Megan that as a member of a federally-recognized tribe or a shareholder in an Alaska Native corporation, she may claim the exemption on her 2017 tax return or may amend her return to claim it. Further, an assister should not offer to assist a consumer in applying for an exemption that is claimed through the tax filing process.

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Tips for Assisting Consumers With Exemption Applications

We talked about various exemption applications over the last several slides. We watched Eda and Jeffrey discuss his options. Now, I want to provide you with some pointers to follow when helping consumers with exemptions.

• Be familiar with the different exemption types so you can help consumers determine which exemptions best fit their situations. If consumers choose the wrong exemption type or submit the wrong exemption applications, they'll have to submit new applications.

• Confirm that consumers who seek exemptions on behalf of other people are designated authorized representatives or are otherwise qualified to seek exemptions on behalf of others.

• Help consumers determine who's in their tax household.

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• Except for exemptions based on incarceration, consumers can use single applications per exemption type for multiple members of their tax households. Remind consumers to complete all of the questions on the application for every adult in the tax household and any dependent child who also needs the exemption. If consumers skip questions, the FFMs will contact them for the missing information. This will slow the exemption application process down. Encourage consumers to submit all supporting documents requested on the application because applications can't be processed until documentation is received.

• Remind consumers that they shouldn't send original documents to the FFMs (other than the application itself).

• Also, remind them to keep a copy of their completed applications and all documents sent to the FFMs along with proof of mailing.

• Make sure that any hard copies of consumers' records are returned. If information is left with you by accident, take immediate measures to have consumers pick up the information. Follow the procedures of your state's FFM and your organization for this issue.

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Knowledge Check

Brian is applying for a hardship exemption because his utilities were recently shut off. Which of the following should Brian include in his exemption application?

A. His original completed exemption application

B. A photocopy of the shut-off notice he received from the utility company

C. A photocopy of his completed exemption application

D. His original shut-off notice from the utility company

The correct answers are A and B. You should tell Brian that other than his completed exemption application, he shouldn’t send original documents to the FFM. Every consumer that you help, including Brian, should keep copies of their completed exemption applications and all documents sent to the FFMs along with proof of mailing.

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Exemption Certificate Number

I hope you feel more prepared to help consumers who are interested in exemptions from the individual shared responsibility payment. It might be a good idea to create your own chart of the different exemption types and application instructions that you can use when helping consumers.

Before we end this module, I want to share one last step about helping consumers with exemptions.

We talked about the ECN earlier in this module. The FFMs will process consumers’ exemption applications and issue exemption determinations. If an exemption is granted, consumers will receive a notification in their Marketplace accounts at HealthCare.gov or through their email and will be assigned an ECN. This ECN can be found in the Eligibility Results column of the notice. It is either six or seven digits long.

In situations where multiple household members qualify for exemptions, each consumer in the household will receive a separate ECN. When they file their federal income taxes, consumers will input their ECNs into IRS Form 8965, which they will file with their federal income tax return.

For more information, reference the “Consolidated Exemptions Table” fact sheet, which can be found in the Resources section.

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Additional Information If consumers qualify for a hardship exemption and plan to enroll in a Catastrophic health plan through the FFMs, they'll need their ECNs. If consumers plan to file a federal income tax return, they'll need their ECNs so the IRS knows that they have an exemption from an FFM. The federal income tax return includes instructions for when consumers should write down their ECNs. However, if consumers claim an exemption on their tax returns, they will not receive an ECN and do not need one.


Understanding IRS Form 8965

If consumers file their tax returns and want to claim an IRS or Marketplace exemption, they will need to complete and attach IRS Form 8965, Health Coverage Exemptions, to their tax returns. This form can be used to apply for an IRS exemption at tax filing time or to report an approved Marketplace exemption to the IRS at tax filing time. Only one Form 8965 should be filed for each tax household. If a consumer or another household member will be claimed as a dependent by another taxpayer, that household member does not need to file Form 8965 and does not have to pay the fee for not having coverage. Consumers may need to claim all members of their tax households on their exemption applications for their households to be considered for an exemption. If consumers receive an exemption from an FFM, they will need to enter their ECNs in the appropriate section of Form 8965.

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Catastrophic Coverage

Finally, let’s discuss Catastrophic coverage. The following consumers can purchase a Catastrophic health plan:

• Consumers under 30

• Consumers who receive a cancellation notice from their insurance company and believe other plans are unaffordable

• Consumers with a hardship exemption or an exemption based on inability to afford coverage

It's important to remember that consumers who enroll in a Catastrophic plan aren't eligible for premium tax credits.

Once consumers log in to their Marketplace accounts, they should select Exemption on the left side of Application Status. Here, they'll be prompted to enter the ECN for each person in their household who has qualified for an exemption.

Then, they'll be able to proceed with their applications and enroll in a Catastrophic health plan.

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For more information about applying for Catastrophic coverage, reference the frequently asked questions (FAQs) document on “Enrolling in Catastrophic Coverage,” which can be found in the Resources section.


Exemptions Simulation

OK! Now that we've talked about eligibility for Catastrophic plans, let's see what you have learned. In this scenario, David, the Gomez family's nephew, is applying for health coverage. I have his information listed on the board. I will guide you through helping David find the ECN in his eligibility results and then helping him enter it at HealthCare.gov to enroll in a Catastrophic plan. Please complete the actions discussed in the text and you will be on your way!

Age: 30

Salary: He makes $10,000 a year, which does not qualify him for financial assistance to help purchase a QHP through the Marketplace.

Medicaid: He does not qualify for Medicaid since he lives in Texas (a state that has not expanded Medicaid).

ECN: He will receive an ECN with his eligibility results.

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Exemptions Simulation

David is interested in seeing what type of assistance he is able to receive by filling out a Marketplace application. You have helped him fill out the application and he has submitted it. Now, let’s take a look at David’s eligibility results.

Selecting the View Eligibility Results button will open a PDF with information about the coverage he is qualified to receive.

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Knowledge Check

Now let’s examine the document and answer a couple of questions.

Text from sample document.

Eligible for an exemption for 2017. Save this notice for your records. If you file a federal income tax return for 2017, you'll need to provide this exemption certificate number (ECN) on your return: GZNUNXN. It's important that you provide this number when you file your tax return so the Internal Revenue Service (IRS) knows you're eligible for the exemption.

Eligible to purchase health coverage through the Marketplace, including catastrophic plans

Does David qualify for a hardship exemption?

YES” or “NO”

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Knowledge Check

The correct answer is YES.

According to the eligibility results, David does qualify.

Here is another question from the eligibility document.

Eligibility Results Review the table below for the results of your application. David Gomez - Based on the information provided, you would be eligible for free or low cost health care through Texas Medicaid. However, the state of TX has chosen not to offer you this health coverage at this time.

You won't owe a fee for not having health coverage. This is because of your income, and because the state of TX declined to expand Texas Medicaid to cover individuals in your situation. When you file your tax return, you'll need to enter the Exemption Certification Number (ECN) shown in the "Results" column below.

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Why did David qualify for a hardship exemption?

A. Because he qualified for CHIP and his state did not expand it.

B. Because he went bankrupt last year.

C. Because he qualified for Medicaid in a state that did not expand it. Answer According to his eligibility results, David qualifies for an exemption because he met the requirements for Medicaid but he lives in a state that has not expanded it for individuals in his situation. This is found in the “Eligibility Results” section of the PDF.


Submit Exemption

OK, it looks like David does qualify for an exemption and, if he chooses, a Catastrophic plan as well. Because he has stated he is interested in getting a Catastrophic plan, he needs to enter his ECN into his application. To do this, he’ll start at the Application Status screen. He’ll select the appropriate link and then complete the application.

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David should complete the “Add an exemption form” with his name and ECN number from the eligibility PDF. Once complete he will select the “SUBMIT EXEMPTION” button.

Since David is above age 30, catastrophic plans will not appear by default. After he adds his ECN, David can shop for Catastrophic plans using Plan Compare.


Key Points

• The information required on exemption applications varies by the type of exemption but all information will be kept private and secure.

• Consumers should keep copies of their exemption applications, the original documents submitted with them, proof of mailing, and their exemption certificates (if an exemption was granted).

• Consumers will need their ECNs when they claim approved exemptions on their federal income tax return and also if they choose to enroll in Catastrophic coverage (they'll use it for their federal income tax returns).

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Assisting Consumers with Eligibility Appeals

Introduction

Some consumers may not agree with their eligibility determinations or the response to their exemption applications. In these situations, you can help consumers understand the process of filing an appeal.

What Can Be Appealed? Identify the types of Marketplace decisions that consumers can appeal.

Notice of Eligibility Determination Describe the information provided in a Notice of Eligibility Determination.

Filing an Appeal List techniques consumers should use to protect their personally identifiable information (PII).

Role of Assister Describe the role of the assister in helping a consumer to file an appeal.

Steps in Appeals Process State the steps in the appeals process.

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Appeal Rights

If consumers don't agree with a decision made by a FFM, they may be able to file an appeal.

Consumers can appeal the following kinds of Marketplace decisions, whether in connection with an initial eligibility determination or a redetermination:

• Eligibility to buy or enroll in a Marketplace plan

• Denial of a SEP

• Denial of a premium tax credit or CSR

• Level of PTC and CSR

• Eligibility for Medicaid or CHIP

• An exemption from the MEC requirement

• Eligibility to enroll in a Catastrophic plan

• Length of time to provide a notice of eligibility determination

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Notice of Eligibility Determination: What to Appeal

After consumers submit their eligibility applications to an individual market Marketplace, the Marketplace verifies their information (e.g., household incomes, citizenship, or immigration status) against trusted data sources like the IRS. The Marketplaces use these sources to confirm if a consumer is eligible to purchase a QHP through the Marketplace, to qualify for programs to help lower costs, or to enroll in Medicaid or CHIP.

Based on a consumer’s eligibility application, the Marketplaces issue eligibility determination notices to tell consumers if they're eligible for coverage through the Marketplaces (including coverage in Catastrophic plans) or programs to help lower costs. Depending on a consumer’s state of residence, the notices may inform them about their eligibility for Medicaid and CHIP or the notices may explain that their applications have been forwarded to their state Medicaid or CHIP agency for a final decision about their eligibility for these programs.

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The eligibility determination notice will explain which programs the consumer is and isn't eligible for as well as how a Marketplace made its decision. It will provide details about enrollment in any programs for which the consumer is eligible.

All eligibility determination notices will contain information about how consumers may be able to appeal the decision if they’re dissatisfied with the outcome.


Appeal Process

Hi, I have a question. When can I request an appeal?

Consumers can request an appeal when they're dissatisfied with their final eligibility determination or redetermination, including if they were denied an exemption. Consumers can also request an appeal if they didn't receive their eligibility determination notices in a timely manner. Consumers have 90 days from the date they receive their eligibility determination notices to start an appeal.

What information will I need to provide with my appeal request?

Consumers must submit specific information to complete appeal requests. At a minimum, they should provide their first and last names, addresses, and the reason for their appeal.

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Knowledge Check

Maria met with Eda to determine if she can submit a request for an appeal.

Which of the following would not be a valid reason for Maria to request an appeal?

A. Maria is upset that her state has not expanded Medicaid, as provided under the Affordable Care Act, and appeals to ask that her state expand its Medicaid program.

B. Maria thought she was eligible for a QHP, Medicaid, CHIP, and/or programs to help lower her costs but the Marketplace determined she wasn't eligible.

C. Maria thought she was eligible for an exemption but the Marketplace determined she wasn't.

D. It's been several months since Maria filed her application and she still hasn't received an eligibility determination notice.

The correct answer is A. Consumers can submit appeal requests for any of the reasons listed except for answer choice A—if the appeal is to ask for a state to expand its Medicaid program.

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Where and How to Submit an Appeal

Consumers who think a mistake has been made or who aren't happy with their eligibility determinations may come to you for help with submitting an appeal.

For example, consumers may think that their premium tax credit amounts are insufficient based on their incomes or that they should be eligible for Medicaid or CHIP.

So where and how do consumers file appeals?

Depending on the state where consumers live, as well as their eligibility results, they may be able to submit an appeal through the Marketplaces or to their state Medicaid or CHIP agencies. Their eligibility determination notices will explain consumers’ next steps and where they should file their appeals.

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Appeals Assistance and Process

Consumers can file appeals in three different ways. Their eligibility determination notice will explain the appeals process in detail.

Generally, consumers can appeal their eligibility results by:

Writing a letter to:Health Insurance Marketplace Attn: Appeals 465 Industrial Blvd. London, KY 40750-0061

Mailing an appeal request form using the proper form for their states. All of the appeal request forms can be found at HealthCare.gov.

Faxing their appeal request to a secure fax line: 1-877-369-0129.

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Legal Advice and Appeals

Beginning with FFM Navigator grants awarded in 2018, FFM Navigators must help consumers understand the process of filing Marketplace eligibility appeals. Until FFM Navigator grants are awarded in 2018, FFM Navigators are permitted but not required to provide appeals assistance.

Remember that, in your role as an FFM assister, you should not provide legal advice regarding appeals or any other matter. For example, the Marketplace appeal request form has an option for an expedited appeal. While an FFM Navigator may help consumers understand the difference between an appeal and an expedited appeal, the FFM Navigator should not help a consumer decide which one is best suited to their circumstances. Consumers can decide to file requests for expedited (faster) appeals if the time needed for the standard appeal process would jeopardize their life, health, or ability to achieve, maintain, or regain maximum function.

CMS interprets FFM Navigators’ assistance with Marketplace eligibility appeals to include, where relevant to consumers’ needs, providing information about free or low-cost legal help in the consumer’s area, including local legal aid or legal services organizations and other state offices to help with the Marketplace eligibility appeals process. As long as they have sufficient knowledge to make these types of referrals, CACs and non-Navigator assistance personnel in FFMs may, but are not required to, provide them. You can tell consumers that they can have a friend, lawyer, or someone else help them with their

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appeal but that you cannot provide legal advice within your capacity as an assister. You can also refer consumers to free and low-cost legal service providers in your community such as legal aid organizations funded by the Legal Services Corporation, state Consumer Assistance Programs (CAPs), Health Insurance Ombudsmen, or other state agencies. When making such referrals, you should be sure to follow CMS guidance at: https://marketplace.cms.gov/technical-assistance-resources/assister-guidance-on-referrals-to-outside-organizations.pdf


Appeals Assistance and Process: Medicaid and CHIP

I want to share some additional information with you about special appeals situations as well as what happens once consumers file their appeals.

Determination Notice Consumers in states that delegated authority to the Marketplace to make final Medicaid/CHIP eligibility determinations may have received eligibility determination notices from the Marketplace that indicate they're eligible to enroll in Marketplace plans but not eligible to enroll in Medicaid or CHIP. Consumers may think they should have qualified for Medicaid or CHIP and may want to file an appeal. Generally, these notices will indicate that consumers can appeal their determination of Medicaid ineligibility to their state Medicaid/CHIP agency or file an appeal with the Marketplace if their state delegated authority to the Marketplace to hear such appeals.



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Some states don't allow the Marketplaces to make final eligibility determinations for Medicaid and CHIP. In these states, the Marketplace will assess whether consumers are eligible for Medicaid or CHIP. If consumers in these assessment states apply for financial assistance to help pay for their coverage, they will receive a notice from the Marketplace regarding their eligibility for enrollment in a QHP with premium tax credits or CSRs and an assessment by the Marketplace of their eligibility for Medicaid or CHIP. These consumers will receive a Medicaid/CHIP eligibility determination notice from their state Medicaid/CHIP agency. If they want to appeal their Medicaid/CHIP eligibility, the eligibility determination notice from the state Medicaid/CHIP agency will contain instructions for how to file an appeal with the state. Consumers in assessment states cannot file a Medicaid or CHIP appeal with the Marketplace.

Appeal Consumers in these states who want to appeal determinations indicating they are not eligible for Medicaid or CHIP should follow the instructions on their Medicaid or CHIP eligibility determination notice.

Unsuccessful Appeal If the appeal process results in a decision that the initial eligibility determination was correct, then that determination will stand and the consumer will not be eligible for Medicaid or CHIP. That is the end of the administrative process but the appeal decision explaining this will also include information about an available judicial review.

If consumers’ appeals for Medicaid or CHIP coverage are unsuccessful, as long as they are qualified individuals, they can still enroll in a Marketplace plan through a Special Enrollment Period (SEP). Additionally, if they were originally determined eligible for premium tax credits and/or CSRs through a Marketplace, consumers are also still eligible for those programs. Remember, consumers can appeal their eligibility determinations for premium tax credits and CSRs, too.

Sometimes consumers may appeal because they think they should have been determined eligible for a larger premium tax credit and don't want to pay the premium for coverage through a Marketplace until they get the larger amount. If the initial eligibility determination was correct, the consumer won’t be allowed to enroll in or change plans through the Marketplace if the original enrollment period in which they applied has ended.

Successful Appeal If it turns out the initial eligibility determination was wrong and consumers didn't enroll in a plan, they will receive an SEP to enroll in coverage through a Marketplace.

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Appeals Resolution

After consumers file an appeal, they will receive a letter that:

• States their appeal request was received

• Provides a description of the appeals process

• Includes instructions for submitting additional material for consideration

You can educate consumers on the appeals resolution process in its entirety so they understand what will happen after they submit their appeal requests. It's important to remind consumers that an appeal decision may result in a change in eligibility for other members of their households as well as for themselves.

For example, let's say a consumer appeals and a Marketplace determines that the wrong household income was used for the consumer’s eligibility determination. Since household income changed, if there were other household members who also applied for help paying for coverage, the eligibility of those household members might change too even if they didn't file the appeal request.

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Appeals Process Summary

Here is a summary of the process for resolving eligibility appeals in a Marketplace.

• A consumer disagrees with an eligibility determination.

• The complete appeal request is submitted.

• An informal resolution is attempted.

• The consumer decides whether or not to accept the informal resolution decision.

• If the consumer accepts, the appeal is closed and the decision is communicated through a notice.

• If the consumer doesn't accept, a formal hearing is scheduled and then conducted.

• After the hearing, the appeal is closed and the decision is communicated to the consumer through a notice.

• If the consumer is still dissatisfied, the consumer can seek review in court to the extent it's available by law.

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Knowledge Check

Let's pause for a second to make sure we understand what's going on before we continue.

Eda is helping Frederick through the appeals process. He needs help understanding what happens after he submits his appeal request and documentation.

Which of the following action(s) should Eda tell Frederick may occur after he submits his appeal request?

A. He may choose to participate in an appeal hearing if he disagrees with the informal resolution decision.

B. He will receive a notice informing him about the outcome of his appeal request in the mail.

C. An informal resolution decision will be made and he may accept that decision or proceed to a hearing.

D. He'll be informed about the outcome of his appeal by phone. The correct answers are A, B, and C. Once a request for an appeal has been submitted, Frederick’s appeal may be resolved through an informal resolution process or a hearing. The outcome will be mailed to him.

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Knowledge Check

Rashida wants to know what she needs to do at each step of the appeals process.

Which of the following statements is NOT true about the steps that Rashida can take during the appeals process?

A. Rashida can have you approve her appeal request and enroll in a QHP.

B. Rashida can mail a letter to request an appeal.

C. Rashida can use the appropriate form for her state, available at HealthCare.gov, to request an appeal.

D. If Rashida is dissatisfied with the appeal resolution, she can seek review in court to the extent it's available by law.

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The correct answer is A. You can’t approve Rashida’s appeal request. She can write a letter or use the appropriate appeal request form for her state (available at HealthCare.gov). If she's dissatisfied with the appeal resolution, she can seek review in court to the extent it’s available by law.


Key Points

• The Marketplaces issue eligibility determination notices to tell consumers if they're eligible to enroll in Marketplace coverage and programs to help lower costs.

• Consumers can submit appeal requests if they disagree with their eligibility determinations (including eligibility determinations for exemptions).

• FFM Navigators and non-Navigator assistance personnel can help consumers understand the eligibility appeals process and help them complete and submit appeal requests.

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Conclusion

Good work! You learned about the tax implications of the individual shared responsibility payment, possible exemptions, and the process that consumers will use to apply for exemptions, along with the appeals process.

You've successfully completed this course.

Select Exit to leave the course and take the Marketplace Exemptions and Appeals Assistance exam. Good luck!

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Resources

Marketplace Exemptions Assistance Resources

Consolidated Exemptions table: Provides a brief list of all of the different exemptions and who grants them. www.irs.gov/affordable-care-act/individuals-and-families/aca-individual-shared-responsibility-provision-exemptions

Applying for an Exemption: Information and Application: Provides information on the individual shared responsibility payment, types of exemptions, and links to exemption applications. www.healthcare.gov/health-coverage-exemptions/exemptions-from-the-fee/

Exemption Application - Exemption Based on Affordability of Coverage (FFM): A paper application for exemption in the Federally-facilitated Marketplace from the individual shared responsibility payment based on affordability of coverage. marketplace.cms.gov/applications-and-forms/affordability-ffm-exemption.pdf

Exemption Application - Exemption Based on a Hardship: A paper application for exemption from the individual shared responsibility payment based on hardship. https://marketplace.cms.gov/applications-and-forms/hardship-exemption.pdf

How to Claim an Exemption for Members of a Health Care Sharing Ministry: www.healthcare.gov/exemptions-tool/#/results/2017/details/healthcare-sharing-ministry

Exemption Application - Exemption Based on Membership in a Recognized Religious Sect: A paper application for exemption from the individual shared responsibility payment based on membership in a recognized religious sect whose members object to insurance. marketplace.cms.gov/applications-and-forms/religious-sect-exemption.pdf

Exemption Application - How to Claim an Exemption for American Indians, Alaska Natives, or People Eligible for Indian Health Services: www.healthcare.gov/exemptions-tool/#/results/2017/details/tribal

https://www.irs.gov/affordable-care-act/individuals-and-families/aca-individual-shared-responsibility-provision-exemptions

https://www.irs.gov/affordable-care-act/individuals-and-families/aca-individual-shared-responsibility-provision-exemptions

https://www.healthcare.gov/health-coverage-exemptions/exemptions-from-the-fee/

https://marketplace.cms.gov/applications-and-forms/affordability-ffm-exemption.pdf

https://marketplace.cms.gov/applications-and-forms/hardship-exemption.pdf

https://www.healthcare.gov/exemptions-tool/#/results/2017/details/healthcare-sharing-ministry

https://marketplace.cms.gov/applications-and-forms/religious-sect-exemption.pdf

https://www.healthcare.gov/exemptions-tool/#/results/2017/details/tribal

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