Early evidence from across the nation suggests that consumer assisters are playing a vital role in helping people enroll in the new coverage options made possible by the Affordable Care Act. The State Network has engaged with a number of states to develop easy-to-understand materials to educate consumer assisters about various issues that may confuse consumers and the assisters trying to help them during the eligibility determination and enrollment process. The following series of resource guides, prepared by Manatt Health Solutions, were developed to help consumer assisters answer some of the most common eligibility and enrollment questions.
Minimum Essential Coverage
Individuals who are eligible for health insurance that is considered “Minimum Essential Coverage,” or MEC, are not eligible for Advance Premium Tax Credits (APTCs) or Cost-Sharing Reductions (CSRs) through the Marketplace and may be subject to a penalty under the shared responsibility requirement if they do not enroll in the available MEC coverage. This guide describes the types of employer-sponsored, public health insurance or COBRA coverage considered MEC. The guide also explains the potential impact a change in MEC coverage during the year could have on eligibility determinations.
Household Composition Eligibility Rules
To be eligible for Medicaid, CHIP or APTCs and CSRs, an applicant’s total household income must be below a certain income level for the number of people in his or her household. This guide explains how to determine who is included in an applicant’s household and describes the tax filer and non-tax filer household composition rules. The guide also covers special Medicaid household composition rules for households that include a pregnant woman; grandparents; unmarried, divorced, separated or non-custodial parents; or institutionalized or incarcerated family members. The guide also explains how eligibility is re-determined when an applicant’s household size changes during the year.
MAGI Household Income Eligibility Rules
To be eligible for an Insurance Affordability Program (IAP)—Medicaid, CHIP or APTCs and CSRs—an applicant’s income must be below a certain eligibility level. Modified Adjusted Gross Income (MAGI) rules—primarily based on federal tax rules—are used to calculate income eligibility when an individual is applying for an IAP. This guide explains the types of income included and excluded when determining eligibility.
Immigrant Eligibility
To be eligible for health insurance coverage through the Marketplace or Medicaid, an applicant must be a citizen or meet certain immigration status requirements. This guide provides an overview of the complex rules governing immigration eligibility for insurance affordability programs. The guide explains the types of immigrants eligible for the Marketplace and Medicaid, the process by which immigration status is verified, and the eligibility requirements applicable to families where some family members are lawfully present and others are undocumented immigrants. The guide also explains the eligibility requirements for individuals who are lawfully present but do not have a Social Security Number; are waiting for asylum; have a student visa; or are sponsored by another individual.
