Sec. 4. Exchange use of relevant return information

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

An Exchange that receives relevant return information under section 3(d) with respect to a taxpayer who has provided consent under section 3(b)(1)(B) shall— minimize additional information (if any) that is required to be provided by such taxpayer for a household member to qualify for any insurance affordability program by, whenever feasible, qualifying such household member for such program based on— relevant information provided on the tax return filed by the taxpayer, including information on the supplemental form described in section 3(b)(3); and information from other reliable third-party data sources that is relevant to eligibility for such program but not available from the return, including information obtained through data matching based on social security numbers, other identifying information, and other items obtained from such return; determine the eligibility of any household member for the CHIP program and, where eligibility is determined based on modified adjusted gross income, the Medicaid program, as required under section 1413 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18083 ) and section 1943 of the Social Security Act ( 42 U.S.C. 1396w–3 ), subject to any right of notice and appeal under laws governing such programs, including section 1411(f) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18081(f) ); to the extent that any additional information is necessary for determining the eligibility of any household member for an insurance affordability program, obtain such information in the manner that— imposes the lowest feasible procedural burden to the taxpayer, including— in the case of a taxpayer filing their tax return electronically, online collection of such information at or near the time of such filing; and prior to a denial of eligibility or enrollment due to failure to provide such information, attempting to contact the taxpayer multiple times using the preferred contact methods described in section 3(b)(3)(A)(vi); and provides the individual with all procedural protections that would otherwise be available in applying for such program, including the reasonable opportunity period described in section 1137(d)(4)(A) of the Social Security Act ( 42 U.S.C. 1320b–7(d)(4)(A) ); and when an individual is found eligible for an insurance affordability program other than the Medicaid program— enable such individual, through procedures prescribed by the Secretary of Health and Human Services, to seek coverage under the Medicaid program or CHIP program by providing additional information demonstrating potential eligibility for such program, with any resulting determination subject to rights of notice and appeal under laws governing insurance affordability programs, including section 1411(f) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18081(f) ); and provide such individual with notice of such procedures.

In a State for which the Secretary of Health and Human Services is determining eligibility for individuals who apply for insurance affordability programs at the Exchange serving residents of the individual’s State, the Secretary of Health and Human Services shall present the State with not less than 3 sets of options for verification procedures and business rules that the Exchange serving residents of such State shall use in determining eligibility for the State Medicaid program and CHIP program with respect to individuals who are household members described in section 3(b)(1)(B).

Notwithstanding any other provision of law, the Secretary of Health and Human Services may present each State with the same 3 sets of options, provided that each set can be customized to reflect each State’s decisions about optional eligibility categories and criteria for the Medicaid program and CHIP program. The business rules described in subparagraph

(A)shall specify detailed eligibility determination rules and procedures for processing initial applications and renewals, including— the Secretary’s use of data from State agencies and other sources described in subsection (c)(3)(A)(ii) of section 1413 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18083 ); and the circumstances for administrative renewal of eligibility for the Medicaid program and the CHIP program, based on data showing probable continued eligibility. In the case of a State described in subparagraph

(A)that does not select an option from the set presented under such subparagraph within a timeframe specified by the Secretary of Health and Human Services, the Secretary of Health and Human Services shall determine the option that the Exchange shall use for such State for the purposes described in such subparagraph. Nothing in this paragraph shall be construed as requiring a State to provide benefits under title XIX or XXI of the Social Security Act ( 42 U.S.C. 1396 et seq. , 1397aa et seq.) to a category of individuals, or to set an income eligibility threshold for benefits under such titles at a certain level, if the State is not otherwise required to do so under such titles. If the Exchange in a State determines that an individual described in paragraph (1)(A) is eligible for benefits under the State Medicaid program or CHIP program, the Exchange shall send the relevant information about the individual to the State and, if consent has been given under section 3(b)(1)(B) to enrollment in a health plan or other form of minimum essential coverage with a zero net premium, the State shall enroll such individual in the State Medicaid program or CHIP program (as applicable) as soon as practicable, except as provided in subparagraphs

(B)and (D). A State shall not enroll an individual in coverage under the State Medicaid program or CHIP program without the affirmative consent of the individual if the individual would be required to pay a premium for such coverage. If the State Medicaid program or CHIP program requires an individual enrolled under subparagraph

(A)to receive coverage through a managed care organization or entity, the State shall use a procedure for assigning the individual to such an organization or entity (including auto-assignment procedures) that is commonly used in the State when an individual who is found eligible for such program does not affirmatively select a particular organization or entity. Notwithstanding subparagraph (A), an individual described in such subparagraph shall be given one or more opportunities to opt out of coverage under a State Medicaid program or CHIP program, using procedures prescribed by the Secretary of Health and Human Services. In the case where a taxpayer has filed their return of tax for a taxable year on or before the date specified under section 6072(a) of the Internal Revenue Code of 1986 with respect to such year and has provided consent described in section 3(b)(1)(B)(i), if the Exchange has determined that an applicable household member has not qualified for the Medicaid program or the CHIP program, such Exchange shall— in addition to any such period that may otherwise be available, provide a special enrollment period that begins on the date the taxpayer has provided such consent; and determine— whether the taxpayer would, pursuant to section 1412 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18082 ), be eligible for advance payment of the premium assistance tax credit under section 36B of the Internal Revenue Code of 1986 if such household member of the taxpayer were enrolled in a qualified health plan; and if the taxpayer has made the election described in section 3(b)(1)(B)(ii), whether such household member has one or more options to enroll in a qualified health plan with a zero net premium. In the case that a household member described in paragraph

(1)has one or more options to enroll in a qualified health plan with a zero net premium, and consent has been given under section 3(b)(1)(B) for enrollment of such household member in a qualified health plan with a zero net premium— the Exchange shall identify a set of options (as described in subparagraph (B)) for qualified health plans offering a zero net premium; and from such set, select a qualified health plan as the default enrollment choice for the household member in accordance with subparagraph (C). In the case that multiple qualified health plans with a zero net premium are available with more than 1 actuarial value, the Exchange shall limit the set of options under subparagraph (A)(i) to such qualified health plans with the highest available actuarial value. In the case described in clause (i), the Exchange may further limit the set of options under subparagraph (A)(i), among the qualified health plans that have the highest available actuarial value as described in clause (i), based on the generosity of such plans’ coverage of services not subject to a deductible. For purposes of this subparagraph, the term highest actuarial value means the highest actuarial value among— the levels of coverage described in paragraph

(1)of section 1302(d) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(d) ), without regard to allowable variance under paragraph

(3)of such section; and as applicable, the levels of coverage that result from the application of cost-sharing reductions under section 1402 of such Act ( 42 U.S.C. 18071 ). The Secretary of Health and Human Services shall establish procedures that Exchanges may use in selecting, from the set of options described in subparagraph (B), the default enrollment choice under subparagraph (A)(ii). Such procedures shall include— State options for randomization among health insurance issuers; and factors that may be used to weight such randomization. As soon as possible after an Exchange has identified a default enrollment choice for an individual under subparagraph (A)(ii), the Exchange shall provide the individual with notice of such selection. The notice shall include— a description of coverage provided by the selected qualified health plan; encouragement to learn about all available qualified health plan options before the end of the special enrollment period under paragraph (1)(A) and to select a plan that best meets the needs of the individual and the individual’s family; an explanation that, if the individual does not select a qualified health plan by the end of such special enrollment period or opt out of default enrollment in accordance with the process described in clause (iv), the Exchange will enroll the individual in such selected qualified health plan in accordance with subparagraph (E); an explanation of the opt-out process preceding implementation of default enrollment, which shall meet standards prescribed by the Secretary of Health and Human Services; and information on options for assistance with enrollment and plan choice, including publicly funded navigators and private brokers and agents approved by the Exchange. Subject to subparagraph (F), an Exchange shall enroll in a default enrollment choice any individual who— is sent a notice under subparagraph (D); and fails to select a different qualified health plan, or opt out of default enrollment under this paragraph, by the end of the special enrollment period described in paragraph (1)(A). At the time of the default enrollment described in clause (i), the Exchange shall send a notice to the individual explaining that default enrollment has occurred, describing the plan into which the individual has been enrolled, and explaining the reconsideration procedures described in subparagraph (F). Not later than 30 days after receiving a notice under subparagraph (E)(ii), the individual receiving such notice may use a method provided by the Exchange to indicate— the individual’s decision to disenroll from the qualified health plan selected under subparagraph (A)(ii); or in the case of a household member for whom the selected qualified health plan under such subparagraph is a high cost-sharing qualified health plan, the individual’s decision to enroll in a specified lower cost-sharing qualified health plan, identified by the Exchange, that is offered by the same health insurance issuer that sponsors the qualified health plan that was selected under such subparagraph. For purposes of this subparagraph: The term high cost-sharing qualified health plan means— in the case of a household member with a household income at or below 200 percent of the poverty line, a qualified health plan that is not at the silver level; or in the case of a household member with a household income above 200 percent of the poverty line, a qualified health plan that is not at the gold or platinum level. The term specified lower cost-sharing qualified health plan means— in the case of a household member with a household income at or below 200 percent of the poverty line, the lowest-premium qualified health plan offered by the health insurance issuer that is at the silver level; or in the case of a household member with a household income above 200 percent of the poverty line, the lowest-premium qualified health plan offered by the health insurance issuer that is at the gold level.

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