The last few posts in the health care reform primer looked at the premium tax credits and cost-sharing reductions that will make health care more affordable for eligible individuals (that's the "affordable care" part of the Patient Protection and Affordable Care Act.) Now let's look at how the government will determine whether someone is eligible for help.
The federal Department of Health and Human Services must create a program for determining:
- Whether an individual seeking coverage through an exchange or claiming premium tax credits or reduced cost-sharing has citizen or legal immigrant status
- Whether an individual claiming premium tax credits or reduced cost-sharing meets the income and coverage requirements and, if so, the amounts of the credits and reductions
- Whether an individual's coverage under an employer-sponsored plan meets the criteria for being "unaffordable"
- Whether to grant an individual a waiver from the mandate to purchase insurance coverage.
Every applicant for individual coverage through an exchange will have to provide:
- Name, address and date of birth for every person to be covered
- Proof of citizenship or legal immigration status, including a valid Social Security number and/or evidence to be determined by HHS and the Department of Homeland Security
Applicants for premium tax credits and cost-sharing reductions must provide:
- Income and family size information
- Changes in income, family size, marital status or other household circumstances, tax filing status, filing for unemployment insurance benefits, or other significant changes that affect eligibility,
Those claiming that their employer's plan does not meet coverage requirements or is unaffordable must provide:
- Employer's name, address and I.D. number
- Whether the individual is a full-time or part-time employee
- Whether the employer provides the minimum essential coverage
- The lowest cost coverage option the employer offers and the individual's required premium contribution under the plan
- Information on income, family size and changes in circumstances.
Employees who change jobs or take additional jobs must notify the exchange and provide the related information.
Individuals seeking an exemption from the individual coverage mandate must provide:
- Information prescribed by HHS in the case of a person seeking an exemption on religious grounds, as an Indian, or on the basis of hardship
- The information I described above regarding income, family size, circumstances, employer and employer-sponsored plans for those seeking an exemption based on lack of affordable coverge or because they have incomes below 100 percent of the poverty line.
The exchanges will provide individuals' information to HHS, which will, electronically or otherwise, verify citizenship or immigration status with the Social Security Administration and DHS and income and family size information with the Treasury Department. HHS has flexibility to modify the verification procedures to reduce administrative costs and burdens on coverage applicants, but it must meet IRS requirements for confidentiality, disclosure, maintenance and use of the information. HHS can devise its own methods for verifying information that does not have to be submitted to the SSA, DHS or Treasury Department. It has the option of requiring the exchanges to verify this information.
If DHS or the SSA finds inconsistencies regarding an applicant's citizenship or legal immigrant status, HHS will determine the person's eligibility the same way it does under the Medicaid program. If there are inconsitencies regarding income, family size, circumstances, etc., HHS will notify the exchange, which will:
- Make a reasonable effort to identify and address the causes of the inconsitencies, by contacting the applicant and other actions required by HHS
- Notify the applicant of unresolved inconsistences and provide 90 days for the applicant to resolve them.
If it cannot resolve the inconsistencies, HHS will refuse to grant the tax credit, cost-sharing reduction, or exemption. The applicant can appeal, following procedures set up by HHS in consultation with other agencies. Employers whose plans are found to be unaffordable or not meeting coverage requirements also have an appeals process. Employers generally cannot obtain employees' income tax returns when contensting an affordability claim.
Last points:
- Individuals receiving applicants' private information are subject to security and confidentiality requirements
- There is a maximum $25,000 penalty for providing false information unless HHS determines that the person acted in good faith. The penalty for knowing and willful violations is up to $250,000. The penalty for improperly disclosing or using personal private information is up to $25,000.
- HHS and the Treasury Department must conduct a study to ensure that the rights of employees to confidentiality and the rights of employers to due process and adequate information are protected. They must issue a report and any recommendations resulting from the study by the end of 2012.
Next time: How individuals can get the amounts of their tax credits and cost-sharing reductions determined in advance.
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