New Guidance on Eligibility Verifications

By Guest Blogger

Wonks, take note. The Internal Revenue Service (IRS) and the Center for Consumer Information and Oversight (CCIIO) recently released two new pieces of guidance on how health insurance exchanges and states will verify eligibility for coverage. The Affordable Care Act requires exchanges and state Medicaid/CHIP agencies to verify applicants’ eligibility electronically, using information from federal, state, and local databases. These electronic verifications should occur in real-time and eliminate the need for paper documentation.

 (1)  CCIIO Bulletin on Verification of Access to Employer-Sponsored Coverage 

On Friday, April 27th, CCIIO released a bulletin describing how the exchanges will verify whether or not people applying for premium tax credits have access to job-based coverage. Individuals with access to job-based coverage that is affordable and provides a “minimum value” are not eligible for premium tax credits. But this information isn’t easy to obtain today, since it changes all the time and isn’t something the federal government has ever had to keep track of in a systematic way. HHS is working on a solution to this problem, but they don’t expect to have these data sources prepared to support a real-time, automated verification process until 2016.

In the mean time, HHS is proposing a temporary solution: For the first two years of exchange operations (2014 and 2015), applicants can attest that they don’t have access to affordable “minimum value” employer-sponsored coverage. The exchange would then verify this attestation, to the extent feasible, with existing data sources. If the information the applicant provides is inconsistent with the information from the data sources, the exchange would be required to accept the person’s attestation and provide the premium tax credit for at least 90 days.

HHS is seeking comments on the proposed verification strategies outlined in the bulletin. There is no immediate deadline for these comments.

 (2)  IRS Proposed Regulation on Disclosure of Return Information to Verify Eligibility for Insurance Affordability Programs

On Monday, April 30th, the IRS published a proposed rule on how it will share tax return information to help exchanges and Medicaid agencies carry out eligibility verifications. According to the proposed regulation, the IRS will use an individual’s name and Social Security number (or taxpayer identification number) to obtain information like filing status, family size, and income, which can then be shared with the relevant health coverage program to make an eligibility determination.

This IRS data will be an important part of the federal data hub that exchanges and state Medicaid programs will use to ensure a simple and streamlined application and eligibility verification process for individuals.

The IRS is requesting comments on the proposed rule by July 30, and it has scheduled a public hearing on August 31st.


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