Navigator Manual - 08.29.16

Table Of Contents 1 3Navigator Job Aides 5 Qualtrics Definitions 7 Navigator Contact List 9 Navigator Daily Procedures Navigator Job Expectations 11 How to Access Grasshopper 13 19Eligibility 27 2015-16 Federal Poverty Level 33 Worksheet - Income when applying for Health Insurance 41 Minimum Essential Coverage and the Individual Mandate 45 Minimum Essential Coverage Reference Chart 51 Employer Based Coverage 55 Incarceration and the Marketplace SEP Triggers and Timing 57 SEP Details 61 Coverage Gap SEP 63 65Enrollment Materials 67 Generic Consent Form Consumer Income Worksheet Healthcare.gov Sign on Cheat Sheet Security Questions Marketplace Plan Comparison Worksheet

Application Checklist 69Post-Enrollment Materials 71 Attestation of zero income 73 Appeal Request Form 79Medicare/Medicaid 89 CMS Medicaid Fast Facts 91 Medicaid Resources 95 Medicare & The Marketplace 99 Medicare 103 Medicare Costs Medicaid - Medically Needy Program 105 111Immigration 113 Immigrant Eligibility 117 Immigrant Eligibility- Quick Guide Immigrant Eligibility - Federal Programs 123 Public Charge 125 129Outreach Materials 131 Happy Birthday! Turning 26 Flyer 135 Refugee Flyer - Eng-Spa-Cre Immigrant Flyer PCAN Brochure - Eng-Spa Navigator Brochures

Marriage SEP 143 Temporary Employee Flyer 145 SEP Half Sheet 147 New Baby SEP 149 Recently Moved - SPA-ENG 151 Open Enrollment - Coming Soon ENG 153Resources 155 Assister Newsletter Resources 157 Community Resource Guide 161 Health Center Resource Guide By County 177 Get Medical Records if a Doctor Is No Longer Practicing 179 US Preventive Services Task Force 183 Misc. Resources 189 Insurance plan Customer Service Phone Numbers 191 How to Upload a Document 193Terms and Definitions Florida Blue Only - Terms/Technical Assistance 195 197ACA and Taxes 205 Exemption Codes Form 1095 A - 1095 B - 1095 C Form 8965 instructions*unfiled



Navigator Job Aides



Qualtrics Quick Reference Guide: Events and OutreachOutreach Event: A community event that informs the public about the Health Insurance Marketplaceand the availability of Navigator services. Enrollments may take place as a collateral result of the event.Examples: tabling events.Enrollment Event: A community event that provides Navigator enrollment assistance and an opportunityfor individuals or groups of consumers to ask questions about and apply (by appointment or walk-in) forenrollment in Marketplace coverage. Example: Nav Labs.Educational Session: An activity where the target audience is consumers and the intent is to provideinformation that would allow consumer to make a decision about Marketplace health coverage, healthinsurance, or other relevant topic. Enrollment would generally not be offered at these types of activities.Example: Coverage 2 Care Workshops.Shop Educational Session: An activity where the target audience is employees or employers of a smallbusiness and the intent is to provide information about Small Business Health Options Program (SHOP)Marketplace health coverage, health insurance, or other relevant topic. Enrollment would generally notbe offered at this type of activity.Presentation: A speaking engagement where the target audience is an existing or potential communitypartner, which shares information about Marketplace health coverage and how it works, best practicesfor enrolling consumers and, the availability of Navigator services. Enrollment would generally not beoffered at these types of activities.Flyers: Educational messaging or advertisements delivered to consumer by hand or in bulk to partners.Mail-Outs: Educational messaging or advertisements sent out to consumers via postal service.Newsletters: Scheduled electronic bulletins to a consumer base. Consumers have opted in to haveadditional and on-going information.Email Blasts: Educational messaging or advertisements sent out to large distribution lists via electronicmail.Webinars: Web based education or training where the target audience is an existing or potentialcommunity partner, which promotes awareness about Marketplace health coverage, health insurance,or a relevant topic.Phone Calls: Calls at least 5 minutes in length that discuss consumer’s personal case (consent required)or provides general education to consumer about the Federally Funded Marketplace or another issuerelated to getting, keeping, or using health coverage.Other Helpful DefinitionsDirect Assistance at Events – Assistance includes starting a Marketplace application or having a valuableinteraction at least 5 minutes in length that discusses a consumer’s personal case (consent required) orprovides general education to consumer about the Federally Funded Marketplace or another issuerelated to getting, keeping, or using health coverage.



Navigator C Name Email Anne Packham annepackham2@gma Aracely Robledo arobledo.navigator@gm Margaret Gaffney mgaffney.navigator@gmElizabeth Hernandez Orlando Hulse liz1022nav@gmail. Darnell Barber [email protected] Doris Allen ddbarber53@gmail. Milda Elysee 2013navigatorallen@gm Onaney Hernandez Benny Santos milda.navigator@gma Jo-Ann Ortiz [email protected] Nancy Bennett Sonia Oyola oscnavigator@gmai Analise Alvarez joannog74@gmail. navigator.bennett@gm soyola.navigator@gm analisealvarezchain@gm

Contact List ail.com Phone Base County mail.com 407-489-2752 Project Directormail.com 407 595 2370 .com 407-595-4781 Seminolecom 407-580-7155 Seminole .com 407-558-9500 Orange/Seminole mail.com 407-595-1035 Orange/Seminole ail.com 407-595-0477 Orange com 407-558-9647 Orange il.com 407-595-1720 Orange .com 407-558-9801 Orangemail.com 407-558-9697 Osceolamail.com 352-630-8542 Osceola mail.com 352-630-8664 321-246-5278 Lake Lake Florida Chain Navigator





Navigator Daily ProceduresStarting Your Day Confirm Google Calendar is accurate Prepare consent form for first consumer Open Healthcare.gov, Navigator Reporting, CoveringCFL.netMeeting with your Consumer Greet consumer and have them sign a consent form Make sure Consumer leaves with your business card, folder and any documents (they brought or you provided) from the meetingAfter meeting with your Consumer Ask Consumer to Fill out Consumer Satisfaction Survey (English/Spanish), like us on Facebook and/or follow us on Twitter Open Connector, enter consumer's email address Enter Outcome of Appointment in Connector Report Outcome in Navigator Reporting (individual tab) Report Appointment in Qualtrics Put Filled Consent Form in secure locationConsumer Engagement/Outreach Reporting Year 3 Navigator Reporting: Your Personal Tab Year 3 Navigator Reporting: Consumer reporting link for USF (Qualtrics) Tab Year 3 Navigator Reporting: Future Events reporting Year 3 Navigator Reporting: Education, Enrollment, Presentation Events Tab Year 3 Navigator Reporting: Outreach reporting links for USF (Qualtrics) Tab Outreach 2015 (2016): Your Personal List of Outreach Efforts Future outreach events: Year 3 Outreach: Orange, Seminole, Osceola Note the day, date, time, contact information, cost, and any other relevant information

“Downtime” Activities Check and return messages on your phone If there are any canceled/no show appointments, immediately update in the Connector Answer emails from consumers or other navigators Call next day's appointments to confirm; leave your number and ask them to text or call you to confirm Return calls on Marketplace Inquiries Add to “The Month's Examples” of Navigators helping consumer through difficult situations and positive impact of getting assistance from a Navigator

Navigator Job ExpectationsConsumer Interactions Arrive to your work location in plenty of time to set up your equipment so you are ready for your consumer. Treat consumers with respect Offer language assistance (interpreter, braille, TDY, etc) Keep all information confidential Work in the best interest of the consumer (per your license and certification) Keep up to date with key issues affecting navigators via CMS and other Webinars Participate in “In the Loop”Equipment Maintain all devices in a safe location Update virus protection on all devices Keep secure pass code on all devices Report any loss or theft immediately to supervisor Delete any downloads/Cookies on computers (your own and those we borrow from our partner facilities)Communication Listen to, record and delete voicemails on your work phone promptly Answer voicemails within 24 hours business hours Leave an out of office message on your phone and email when you'll be gone for more than 2 days Maintain regular email/phone communications with supervisor/team Contact supervisor as soon as possible if you're not able to work Contact Partner Site Contact person if you're not going to be at work or you're changing your house Answer emails in a professional manner; spell check Communicate with supervisor the results of key meetings you attended *when time allows, call consumers to confirm next day appointments. Cancel any slots in ConnectorCalendars/Recording of Results Maintain Google Calendar with location of work, days off, events/meeting, etc. Maintain adequate and accurate appointment slots in the Connector Record appointments/activities in Navigator Reporting Check Connector daily to make sure you're aware of all appointments and open slots Record all individual appointments and substantial phone calls in Qualtrics on the same or next day of appointment

Record all outreach events in Qualtrics within 2 days Keep shared Google Spreadsheet up to date daily with location/appointments *when time allows, record outcome in ConnectorCalendars/Recording of Results Keep all signed consent forms in a secure location until they can be submitted to PCAN Assure you have enough consent forms in all languages with you Assure you have \"cheat sheets\" and other enrollment materials with you Assure you have pens, highlighters, paper, stapler, etc. Submit accurate timesheets and mileage forms to your respective agencies on time Replenish paper/ink toner at partner agencies if you're using their equipment Have your Navigator Certification Certificate with youTeam Work Check, remove and return calls on Grasshopper Circulate important issues to supervisor to circulate to the larger group Use \"reply all\" only when it makes sense Support your fellow navigators by helping them at events, if they are out sick, etc. Treat fellow navigators with respect Attend Staff Meetings; arrive on time Participate in staff meetingsOutreach Update outreach spreadsheets in a timely manner Maintain a contacts list of organizations to contact with updates Provide updated print materials to organizations in a timely manner Have your tablecloth and banner available for events (or static locations as appropriate) Obtain the portable projector, tent, chairs, table etc in advance when neededDress Dress in a professional manner Wear your PCAN Badge

How to Access GrasshopperLogin to [email protected] is navigator14Start taking calls in the order in which they came in, from the bottom upClick on “Play this Voicemail”Transcribe all pertinent information to the marketplace inquiries list to theappropriate tab with the information from that call. General Inquiries,Spanish or CreoleAfter you are 100% done with that grasshopper call, move that call toAnswered Emails in the pcanflorida accountMove on to the next one



Eligibility



2015 Federal Poverty Level2016 Federal Poverty Level



What You Need to Know about Health InsuranceApplying for Health InsuranceAnswering Questions about Your FamilyWhen Applying for Health InsuranceAbout this You may be able to get financial help with paying for healthfact sheet insurance. The amount of help you get depends on your income and the size of your family. But figuring out which family members to list on your application can be tricky. These questions can help guide you through the process.1. Why does the application ask questions aboutother people in my family?The amount of financial help you can get to lower the cost of marketplace healthinsurance depends on your family’s income and the number of people in your family.The application asks for information about family members who live with you andabout anyone else you include on your federal taxes (even if those other people do notneed health insurance) to learn about how much income is coming into the householdand how many people rely on that income.2. Why does the application ask for tax information?The marketplace relies on the information you report on your taxes to figure outwhether you should get financial help for health insurance and how much help youshould get.You have to file taxes in order to get financial help to lower the cost of marketplacehealth insurance. You do not have to file taxes to be eligible for Medicaid or theChildren’s Health Insurance Program (CHIP).Updated November 2015 www.FamiliesUSA.org

Answering Questions about Your Family When Applying for Health Insurance 3. How should I answer questions about my household on the application? The people you need to list on your application are the people who file taxes with you—your spouse, children, and other people you support financially. If you don’t file taxes, you should list your spouse and your children who live with you. If two or more people in your family file separate income tax returns, the primary taxpayer on each of the tax returns will need to complete a separate application for him or herself and any other people listed on his or her tax return. Are you married? Answer “yes” if you are legally married, including same-sex marriages and common-law marriages. (Note: If your spouse died during the year you will be enrolled in health insurance, you should still report that you are married to your spouse—unless you have remarried. This is because the IRS considers someone to be married for the whole year and allows that person to file a joint tax return, even if his or her spouse died during the year.) Answer “no”–even if you are legally married–if: 1. You do not file taxes jointly with your spouse because you are a survivor of domestic violence OR 2. You will be able to file taxes as a “head of household” because you: File a separate tax return from your spouse AND Lived separately (not including temporary absences) from your spouse during the last six months of the calendar year AND Paid more than half the cost of keeping up your home for the calendar year AND Can claim your child, stepchild, or foster child as a dependent (including if you can claim the child as a dependent but do not do so because of a custody agreement)2 WHAT YOU NEED TO KNOW ABOUT HEALTH INSURANCE

Answering Questions about Your Family When Applying for Health InsuranceDo you claim any dependents?Dependents include: Your biological child, adopted child, stepchild, foster child, or grandchild—if he or she: Is a U.S. citizen or legal resident of the United States, Canada, or Mexico AND Lives with you for more than half the calendar year AND Is under age 19, or under age 24 if a full-time student, or any age if totally and permanently disabled AND Is not providing more than half of his or her own financial support for the calendar year Your child who is age 19 or older, parent, sibling, in-law, or another adult member of your household—if he or she: Is a U.S. citizen or legal resident of the United States, Canada, or Mexico AND Is directly related to you (including stepchildren, in-laws, or half-siblings) or he or she lives with you for the full calendar year AND Relies on you for more than half of his or her financial support for the calendar year AND Does not earn more than the amount you get as a tax deduction for him or her (in 2014, that limit is $3,950) A dependent can be claimed by only one taxpayer and cannot claim dependents of his or her own. You may claim different dependents from year to year, for example, because of a child custody agreement. You should fill out the application based on how you will file taxes for the year you will be enrolled in health insurance. If you claim a child who does not live with you, you will also need to provide information about family members that child does live with, such as the child’s other parent or siblings. Help with Information on Dependents For help figuring out who you can claim as a dependent, use the IRS dependent status tool online at http://www.irs.gov/uac/Who-Can-I-Claim-as-a-Dependent%3F. If you are not sure whether you provide more than half the financial support for a person you may be able to claim as a dependent, use the IRS “Worksheet for Determining Support” online at http://apps.irs.gov/app/vita/content/globalmedia/ teacher/worksheet_for_determining_support_4012.pdf.www.FamiliesUSA.org 3

Answering Questions about Your Family When Applying for Health InsuranceDo you have children who live with you but MORE INFORMATIONwhom you do not claim as dependents onyour taxes? If you have tax questions, you can get help by calling the InternalYou might have a child who lives with you but whom you do Revenue Service (IRS) at 800-not claim as a dependent on your taxes because a) you do 829-1040 (TTY/TDD users maynot file taxes, or b) another person, such as the child’s other call 800-829-4059). In addition,parent or another family member, claims the child as a tax Volunteer Income Tax Assistancedependent. (VITA) programs provide free tax preparation in many communities.You should list this child on your application because he or Call 800-906-9887 to find the VITAshe lives with you. If someone else claims the child as a tax location closest to you.dependent, you will also need to provide information on theperson who claims the child.Families with Members Who Do Not Have Eligible Immigration StatusIf you are not a U.S. citizen, U.S. national, or lawfully present resident, you can stillapply for health insurance for other members of your family. You will need to provideinformation on citizenship or immigration status for anyone on your applicationwho is applying for insurance. For members of your household who are not applyingfor insurance, you will need to give only a date of birth and income information,not information on citizenship or immigration status. The marketplace will use thisinformation only to figure out how much financial assistance to give to your familymembers who are applying for health insurance.4 WHAT YOU NEED TO KNOW ABOUT HEALTH INSURANCE

Answering Questions about Your Family When Applying for Health Insurance4. What if the information I provided about my familychanges?You should tell the marketplace about any family changes as soon as possible. Family changescould affect the amount of financial help you can get, or they could allow you to change yourhealth plan or get a new family member covered.Some family changes will affect only the amount of financial help your family gets, or whether youcan get coverage through Medicaid or CHIP. Reporting these changes will ensure that you get theright amount of financial help, and it will help you avoid having to pay money back when you fileyour taxes. Contact the marketplace if: you get married or divorced you plan to change who you claim as a dependent on your federal taxes you or a member of your household become pregnant you are married and your spouse dies (even if he or she was not enrolled in marketplace health insurance)Some family changes can also give you or a family member a chance to get health insurancethrough the marketplace or to change your health plan even when it is not “open enrollment.”Contact the marketplace to change who is covered by your plan—or to buy a new plan for yourfamily—if you or a family member: get married have a baby adopt a child or have a child placed for adoption lose other health insurance leave prison, jail, or another correctional facility become a citizen, national, or lawfully present resident of the United States move to an area that offers different health plansNote: This fact sheet provides general information and is not intended as advice for individualtaxpayers.www.FamiliesUSA.org 5

The complete What You Need to Know about Health Insurance series:Applying for Health InsuranceAnswering Questions about Your Family When Applying for Health InsuranceAnswering Questions about Your Family’s Income When Applying for Health InsuranceApplying for a Marketplace Plan if You Can Get Health Insurance through Your JobWhat to Do if You Are Uninsured after February 15, 2015Getting Financial AssistanceGetting Financial Assistance to Pay for Health InsuranceDeciding How Much Financial Assistance to Use to Lower Your Monthly PremiumsWill I Be Able to Get Financial Help to Pay for Health Insurance?How Getting Financial Assistance to Pay for Health Insurance Affects Your TaxesGetting Extra Financial Assistance to Help Pay Health Care CostsChoosing a Health PlanChoosing the Health Plan that’s Right for YouChoosing a Health Plan You Can AffordUnderstanding the Differences between Platinum, Gold, Silver, and Bronze PlansUnderstanding Catastrophic Health InsuranceBuying Children’s Dental Coverage through the MarketplaceKeeping and Using Health InsuranceHow to Use Your Health InsuranceHow to Keep Your Marketplace Health InsuranceWhat to Do after You Buy Health Insurance in the MarketplaceUnderstanding the Requirement to Have Health InsuranceUnderstanding the Requirement to Have Health InsuranceUnderstanding Minimum Essential CoverageReference Charts and GraphicsIncome Guidelines for Getting and Using Financial Assistance for Health InsuranceIncome Guidelines for Getting Extra Financial Assistance to Pay for Health Care CostsTypes of Exemptions from the Requirement to Have Health InsuranceA complete list of Families USA publications is availableonline at www.FamiliesUSA.org/resources/publications.PUBLICATION ID: 002NAV1112151201 New York Avenue NW, Suite 1100 [email protected] | www.FamiliesUSA.org Washington, DC 20005 © Families USA 2015 202-628-3030

June 2, 2016Key Facts You Need to Know About:Minimum Essential Coverage and the IndividualMandate PenaltyThe Affordable Care Act (ACA) requires most individuals to have minimum essentialcoverage (MEC) or pay a penalty. The following questions and answers describe theindividual mandate, the types of coverage that are considered MEC, and the penalty for notmaintaining MEC.What are the ACA’s coverage disabilities. Children were generally covered atrequirements? higher income levels, but the income eligibility standards for parents in many states were veryThe ACA requires most individuals in the U.S. to low. Under the ACA, states now have the option tomaintain minimum essential coverage or pay a expand Medicaid to cover low-income adults withpenalty for each month they are uninsured. This incomes up to 138 percent of the federal povertyrequirement, known as the individual mandate, line. To date, 31 states and the District ofhas been in effect since January 2014. Most Columbia have expanded Medicaid.insured people already have MEC, and they cancontinue the coverage that they have in order to In addition, premium tax credits are available tocomply with the individual mandate. Many people people with incomes between 100 percent andare eligible to receive financial assistance to help 400 percent of the federal poverty line ($24,250them obtain health coverage for themselves and and $97,000 for a family of four in 2015) whotheir dependents, and some people are exempt purchase coverage in the marketplace. In general,from the mandate and won’t pay a penalty. to be eligible for premium tax credits, individuals must be U.S. citizens or lawfully present in theWhat financial assistance is available United States. They also cannot be eligible forto help uninsured people meet the other MEC, which includes most other types ofrequirement to have MEC? government-funded health insurance such as Medicare or Medicaid, or employer-sponsoredPeople with low and moderate incomes may coverage that is considered adequate andqualify for Medicaid or a premium tax credit affordable. Lawfully present immigrants who havetoward the cost of a plan in the marketplaces income below the poverty line and are not eligibleestablished by the ACA. for Medicaid because of their immigration status can also qualify for premium tax credits. For moreBefore 2014, Medicaid didn’t cover low-income information on premium tax credits, see Key Factsadults without dependent children unless they You Need to Know About: Premium Tax Credits.were pregnant, age 65 or older, or had serious

What types of insurance are MEC. The following are examples of non-MECconsidered MEC? insurance:Most health insurance that people already have is Coverage consisting solely of “exceptedconsidered MEC, including plans offered by benefits,” like policies that only cover vision oremployers, Medicare and Medicaid. All dental caremarketplace plans are also considered MEC. Plans that offer discounts on prescriptionTable 1 lists the various types of coverage that drugs or doctor visits but don’t pay for healthqualify as MEC. Enrollment in any of these plans care serviceswill satisfy the individual mandate requirements.On a case-by-case basis, the U.S. Department of Plans that pay for services that treat onlyHealth and Human Services (HHS) may recognize specific conditions, such as cancer plansother coverage that is not listed in Table 1 asMEC. The HHS website maintains a list of these Short-term health plansplans. Accident or disability insuranceWhat types of insurance are notconsidered MEC? Workers’ compensationNon-comprehensive plans that only provide AmeriCorps/AfterCorps coveragelimited benefits don’t meet the standards for Medicaid coverage providing only limited benefits. Table 1: Types of Coverage that Meets the Standards for Minimum Essential Coverage Employer-Sponsored Coverage Individual Health Coverage Coverage Under Government- Sponsored Programs Employee coverage (including self- Health insurance purchased Medicare Part A coverage insured plans) through the Health Insurance COBRA coverage Marketplace Medicare Advantage plans Retiree coverage Coverage under an expatriate Health insurance purchased Medicaid coverage that is health plan for employees directly from an insurance comprehensive company Other Coverage Children’s Health Insurance Grandfathered health plans in Program Certain foreign coverage (if force since March 23, 2010 or recognized as minimum essential earlier Most types of TRICARE coverage coverage by HHS) Certain coverage for business Health insurance provided through Comprehensive health care owners a student health plan programs offered by the Certain coverage recognized by Department of Veterans Affairs HHS as MEC Catastrophic coverage purchased inside or outside the Health Health coverage provided to Insurance Marketplace Peace Corps volunteers Coverage under an expatriate Department of Defense Non- health plan for non-employees, appropriated Fund Health Benefits such as students and missionaries Program Refugee Medical Assistance Basic Health Program (BHP) standard plan2

For more detailed information on the types of coverage or retiree coverage through an employer,coverage that are considered MEC for the purpose or if the only MEC a person is eligible for isof satisfying the individual mandate, see the coverage in the individual market. For moreMinimum Essential Coverage Reference Chart. detailed information on when eligibility for coverage bars eligibility for premium tax credits,What types of Medicaid coverage are see the Minimum Essential Coverage Referenceconsidered MEC and what types are Chart.not? Are U.S. citizens living abroad requiredMost Medicaid coverage provides full benefits and to have MEC?is considered MEC. People who are eligible for thiscoverage are ineligible for the premium tax credit. All U.S. citizens are subject to the mandate.Enrollment in MEC Medicaid satisfies the However, several exemptions are available forcoverage requirement. U.S. citizens who spend considerable time abroad. U.S. citizens who are not physically in the UnitedSome Medicaid programs do not offer States for a minimum of 330 full days within acomprehensive coverage and are considered non- one-year period are considered to have MEC forMEC. HHS maintains a state-by-state list of the the year and do not have to pay the penalty fortypes of Medicaid programs available and whether being uninsured. U.S. citizens who are bona fideeach is MEC or non-MEC. People who enroll in residents of a foreign country for an entire taxnon-MEC Medicaid coverage are eligible for a year are considered to have MEC for that year.hardship exemption from the penalty for failing to Individuals who qualify for this rule but are filing amaintain MEC. In addition, people who enroll in federal tax return should file Form 8965 andnon-MEC Medicaid can also enroll in a qualified indicate an exemption.health plan and receive a premium tax credit, ifotherwise eligible. Do non-U.S. citizens have to maintain MEC?In addition, Medicaid coverage that provideslimited benefits, or benefits related only to the All residents of the U.S., including non-citizens, aretreatment of specific medical conditions, are not required to have health insurance coverageconsidered MEC. These include Medicaid unless they qualify for an exemption to thecoverage for: coverage requirement. Family planning services In general, anyone who is “lawfully present” in the U.S. must maintain MEC. This includes individuals Tuberculosis-related services who are Lawful Permanent Residents (LPR/green card holders), refugees, and persons granted Emergency treatment asylum. Healthcare.gov maintains a list of immigration statuses that are eligible to purchaseDoes eligibility for other MEC bar marketplace coverage. People with theseeligibility for premium tax credits? immigration statuses are also required to maintain MEC during the year.In general, yes. If a person is eligible for othercoverage that is considered MEC, she is not A person who does not have an eligibleeligible for a premium tax credit even if she does immigration status will generally qualify for annot enroll in it. However, there are exceptions tothis, such as if someone is offered COBRA3

exemption from the coverage requirement. For People will report the months they did not havemore information on coverage for immigrants, MEC on their tax return at the end of the year. Ifplease see Key Facts You Need to Know About: taxpayers claim any tax dependents, they will alsoImmigrant Eligibility for Health Insurance need to report the months their tax dependentsAffordability Programs. did not have MEC. If the tax household had coverage all year, they can check a single box.Do children have to pay a penalty fornot having MEC? For months where taxpayers or their dependents do not have MEC, they can claim an exemptionIndividuals of all ages, including children, are from the requirement to maintain coverage orsubject to a penalty for not having MEC unless calculate a shared responsibility payment.they qualify for an exemption. The taxpayer whoclaims a child as a dependent on his or her tax Figure 1:return is responsible for How to Calculate the Penaltymaking the payment if thechild does not have MECand is not exempt from thecoverage requirement.What happens ifsomeone only hasMEC for part of themonth?People who have MEC forat least one day of themonth are considered tohave MEC for that entiremonth. For example, anuninsured person whostarts a job and gets job-based coverage on June20 is considered to haveMEC for the entire monthof June. Similarly,someone who losesMedicaid coverage on April3 is considered to haveMEC for the entire monthof April.How do peoplereport that they haveMEC?4

How will the IRS verify that a person How much is the penalty for not havinghas MEC? MEC?Entities that offer MEC – such as, health As illustrated in Figure 1, the penalty is either ainsurance plans, Medicaid, Medicare, and self- flat amount or a percentage of household income,insured employers – will report to the IRS and to whichever is greater. The amount of the penaltycovered individuals who had coverage and for increases each year. The penalty amount canwhich months. Taxpayers will get this information change depending on tax filing status andon Form 1095-B. household income.The IRS will also be informed of who had an offer The following examples walk through how toof coverage from a large employer and whether calculate the penalty for a family of four:that coverage met the affordability and minimumvalue standards. Form 1095-C will be issued to Annie and Max are married with two youngemployees of large employers to report both their sons. They have household annual income ofoffer of and enrollment in coverage. $39,500 and plan to file jointly. Figure 2 shows how to calculate the penalty if no one in theNeither form needs to be attached to the tax family had insurance in 2015.return. The IRS will receive this informationseparately from the form filer. Taxpayers that Now let’s assume that everyone in the familydisagree with the information on their Form 1095- had insurance except for Max, who wasB or –C should seek a correction from the entity uninsured all year. Figure 3 shows how thethat sent the form. penalty calculation changes in that scenario. It is important to note that even though Max is the only household member who is uninsured, only the flat dollar amount calculation changes. Figure 2: Calculating a Penalty for Family of Four (All Uninsured in 2015) Annie, Max, Oliver and Patrick Household and Coverage Details Flat $ Amount % of Income Full penalty for adults: $325 Tax filing threshold for married Full penalty for children: $162.50 filing jointly: $20,600 $325 x 2 adults = $650 $39,500 – $20,600 = $18,900 $162.50 x 2 children = $325 (income above filing threshold) Total: $975 $18,900 x 2% = $378Income: $39,500Filing status: Married filing jointlyHousehold size: 4 (2 adults, 2 kids)Who is uninsured: 2 adults, 2 kidsMonths uninsured: 12Months exempt: 0Penalty Calculations: $975 $378Final Penalty Amount (whichever is greater): $9755

Figure 3: Calculating a Penalty for Family of Four (One Uninsured in 2015) Annie, Max, Oliver and Patrick Household and Coverage Details Flat $ Amount % of Income Full penalty for adults: $325 Tax filing threshold for married Full penalty for children: $162.50 filing jointly: $20,600 $325 x 1 adults = $325 $39,500 – $20,600 = $18,900 (income above filing threshold) Total: $325 $18,900 x 2% = $378Income: $39,500Filing status: Married filing jointlyHousehold size:Who is uninsured: 4 (2 adults, 2 kids)Months uninsured: 1 adultMonths exempt: 12Penalty Calculations: 0 $325 $378Final Penalty Amount (whichever is greater): $378 The percentage of income calculation remains are without MEC, unless they qualify for an the same whether one member of the exemption from the individual mandate. household is uninsured or if every member is uninsured. The penalty is pro-rated for the number of months without coverage so that for each month a personIs there a cap on the penalty amount? goes without coverage, he or she will be assessed 1/12th of the annual penalty. For example:The penalty is capped in one of two ways,depending on which method is used. If using the Janet has an annual income of $22,000. Sheflat dollar amount, the penalty is capped at three was uninsured with no exemption for 6 monthstimes the penalty amount for an adult. If using the during the year. Figure 4 walks through how topercentage of income method, the penalty is calculate her penalty for the six months she didcapped at an amount equal to the national not maintain MEC.average premium for bronze level coverage in theHealth Insurance Marketplace. For 2015, that cap How do people pay the mandateis $2,484 a year ($207 per month) per individual, penalty?with a maximum of $12,420 a year ($1,035 permonth) for a family with five or more members. Individuals and households who don’t maintain MEC pay the penalty when they file their taxesDo people who have MEC for only part each year. The imposition of the penalty mayof the year have to pay the full-year result in reducing the refund on the tax return orpenalty? increasing the balance due. As with other tax debt, if there is a balance due and it isn’t paid, thePeople who don’t have MEC must pay a penalty IRS may offset that amount against any futurefor each full month that they or their dependents refund due to the taxpayer. Any balance due on6

Figure 4: Calculating a Partial-Year Penalty for Single Adult (in 2015) Janet Household and Coverage Details Flat $ Amount % of Income Full penalty for adults: $325 Tax filing threshold for single tax Full penalty for children: $162.50 filer: $10,300 $325 x 1 adult = $325 $22,000 – $10,300 = $11,700 Total: $325 (income above filing threshold) $11,700 x 2% = $234Income: $22,000 Penalty divided by months: Penalty divided by months:Filing status: Single $325/12 = $27.08 per month $234/12 = $19.50 per monthHousehold size: 1 Multiply by months uninsured:Who is uninsured: 1 adult 27.08 x 6 = $162.50 Multiply by months uninsured:Months uninsured: 6 19.50 x 6 = $117.00Months exempt: 0 $162.50 $117.00Penalty Calculations:Final Penalty Amount (whichever is greater): $162.50the penalty will accrue interest, but, unlike othertax debt, the IRS cannot impose liens or levies if itis not paid.7



Guide to Minimum Essen al Coverag What Types of Coverage Count to Meet the Individual R Coverage A ects PTC Eligibility The A ordable Care Act (ACA) requires most individuals to have minimum essenal covera that meets certain standards. Most insurance, such as coverage provided by employers, Me requirement (also referred to as the individual mandate). In general, an individual must not be eligible for MEC to be eligible for premium tax credits means the insurance is available to the individual, even if they don’t enroll in it. Therefore, tool that lists whether various types of coverage are considered MEC and sasfy the ACA’s individual ineligible for PTC. Other important notes to keep in mind: • Minimum Essenal Coverage (MEC) vs Minimum Value (MV): MEC, which is the cove should not be confused with minimum value (MV), a measure of a plan’s comprehensi the employer o ers at least one plan that meets both the a ordability and MV standa it covers inpaent and physician services and pays at least 60 percent of total medical and a ordability standards, a person may qualify for PTC in the marketplace. If an emp considered MEC and the individual will not be eligible for PTC. The Summary of Bene • One-Day Rule: For the purposes of the individual mandate, an individual who is enroll month. For example, an individual who loses Medicaid coverage and becomes uninsur Similarly, an uninsured individual who obtains job-based coverage on June 20 will sas • Transioning Between Marketplace Coverage and Government-Sponsored MEC: In g month in which an individual is eligible to receive bene ts. If the person is eligible for r a er being determined eligible for government-sponsored MEC. For example, John is e decrease in income that made him eligible for Medicaid, and he was found eligible for enre month of April even though he was found eligible for Medicaid for that month. • Failure to Enroll in Government-Sponsored MEC: For purposes of PTC eligibility, indivi by the last day of the third full calendar month following the event establishing eligibil calendar month following the event. For example, Sandra turns 65 and becomes eligib period. She is treated as eligible for government-sponsored MEC and will not qualify fo her Medicare eligibility (turning 65). • Coverage that is MEC But Does Not Bar Eligibility for PTC: Some types of coverage sa does not bar PTC eligibility. In these cases, a person is eligible for PTC as long as he or s that coverage will be considered MEC and the person will not be eligible for PTC. How enroll in marketplace coverage with PTC. (For more on special enrollment periods, the Timing outlines di erent circumstances that will qualify an individual for a special enro1 | MEC Reference Chart, June 2016

ge (MEC)Responsibility Requirement and How Eligibility for the age (MEC), or pay a penalty for each month they are uninsured. MEC is health coverage edicare and most Medicaid, is MEC and sas es the ACA’s individual responsibility s (PTC) in the marketplace, although there are a few excepons. Being eligible for MEC people who are eligible for MEC will generally not qualify for PTC. This chart is a reference individual responsibility requirement, and whether eligibility for that coverage makes an erage that an individual must maintain to meet the individual responsibility requirement, iveness. A person is not barred from PTC due to an employer o er of coverage unless ards. An employer-sponsored plan must have a MV of at least 60 percent, meaning that costs for a standard populaon to meet the MV standard. If no plan meets the MV ployer plan does not meet MV, but an individual enrolls in it anyway, that plan will be ts and Coverage for a plan must disclose if the coverage is MV. led in MEC for at least one day in a month is considered to have MEC for the enre red on April 3 is considered to have MEC and sasfy the individual mandate for all of April. sfy the individual mandate for all of June. general, people who receive PTC can connue to claim it unl the rst day of the rst full retroacve bene ts, then he or she is eligible for PTCs unl the rst day of the month enrolled in marketplace coverage with PTC. At the beginning of April, he reported a r Medicaid on April 17 with coverage retroacve to April 1. John can sll claim PTC for the iduals who meet the eligibility criteria for government-sponsored MEC, but fail to enroll lity, are treated as eligible for government-sponsored MEC as of the rst day of the fourth ble for Medicare on March 11, but fails to enroll in coverage during the inial enrollment or PTC as of July 1, the rst day of the fourth month following the event that establishes sfy the individual mandate if the individual enrolls in it, but eligibility for the coverage she is not currently enrolled in the other coverage. If the person enrolls in the coverage, wever, during an open or special enrollment period, the person can drop the coverage and e Center on Budget and Policy Priories’ Guide to Special Enrollment Period Triggers and ollment period.)

MEC REFERENCE CHARTTYPE OF COVERAGE IF ENROL INDIVIDUEMPLOYER-SPONSORED COVERAGE1,2,3Group health insurance coverage for employeesIncludes Federal Employees Health Bene®t program, coverage in the small or largegroup market within a state, and grandfathered health plans in a group marketSelf-insured group plan for employeesCOBRAReree coverageExpatriate health plan for employees 1. An employee or related individual is not considered eligible for MEC during a required waing pe 2. An employee who doesn’t enroll during the employer open enrollment period, or enrolls but fail for the next bene t year, is considered eligible for MEC. 3. An individual who can enroll in an employee’s employer plan but who is not claimed as a tax dep MEC (and therefore, ineligible for PTC) only for the months he/she is actually enrolled in the emp 4. For an employee and his/her dependent, an employer plan is a ordable if the employee’s share employee’s family—is 9.69 percent (for 2017) or less of the employee’s household income. 5. An employer plan meets minimum value (MV) if it covers inpaent hospital and physician serviceINDIVIDUAL HEALTH INSURANCEIndividual market health insurance Any metal level plan purchased through the Health Insurance Marketplace Catastrophic plan purchased inside or outside the Health Insurance Marketplace ACA-compliant plan purchased outside the Health Insurance Marketplace “Grandfathered” non-ACA compliant plan that has been in force since March 23, 2010 or earlierStudent health planExpatriate health plan for non-employees (e.g., students and missionaries)2 | MEC Reference Chart, June 2016

PAGE 2 OF 5LED, DOES COVERAGE SATISFY THE IF ELIGIBLE FOR COVERAGE, ELIGIBLE FORUAL MANDATE? PTC? YES NO, unless coverage is una ordable4 or not MV5 YES NO, unless coverage is una ordable4 or not MV5 YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage YES NO, unless coverage is una ordable4 or not MV5eriod before the eligible employer-sponsored coverage becomes e ecve.ls to pay the premiums for employer-sponsored coverage and cannot re-enroll unl the open seasonpendent by the employee (e.g., an adult non-dependent child under age 26) is considered eligible forployer plan. of the premium for the lowest priced plan available that would cover the employee only—not thees, and pays at least 60 percent of the total cost of medical services for a standard populaon.YES YESYES YES, unless actually enrolled in coverageYES YES, unless actually enrolled in coverageYES YES, unless actually enrolled in coverageYES YES, unless actually enrolled in coverageYES YES, unless actually enrolled in coverage

MEC REFERENCE CHARTTYPE OF COVERAGE IF ENROL INDIVIDUGOVERNMENT-SPONSORED COVERAGEMedicare6 Part A (without a premium) and Part B Part A (without a premium) only Part B only Voluntary Medicare (pays a premium for Part A and may or may not be enrolled in Part B) Medicare AdvantageMedicaid Full bene t Medicaid coverage Coverage only for family planning services Coverage only for Tuberculosis-related services Coverage only for emergency treatment Pregnancy-related Medicaid Medically needy May be referred to as Medicaid with a “spenddown” or “share of cost” Medicaid 1115 demonstraon waiverChildren’s Health Insurance Program (CHIP)Department of Veterans A airs (VA) coverage Veterans Health Care Program Civilian Health and Medical Program of the VA (CHAMPVA) Spina Bi da Health Care Bene ts Program3 | MEC Reference Chart, June 2016

PAGE 3 OF 5LED, DOES COVERAGE SATISFY THE IF ELIGIBLE FOR COVERAGE, ELIGIBLE FORUAL MANDATE? PTC? YES NO YES NO NO YES YES YES, unless actually enrolled in coverage YES NO YES NO12 NO YES NO YES NO YES Varies by state7, 9 Varies by state8Varies by state7, 9, 10 Varies by state—if MEC, ineligible for PTC Varies by state7 Varies by state—if MEC, ineligible for PTC YES NO11, 12 YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage

MEC REFERENCE CHARTTYPE OF COVERAGE IF ENROL INDIVIDUTRICARETRICAREIncludes TRICARE Prime, TRICARE Overseas Program (TOP) Prime, TRICARE PrimeRemote, TRICARE Prime Remote for Ac ve Duty Family Members, TRICARE Standardand TRICARE Extra, TOP Standard, TRICARE for Life (TFL), TFL Overseas, US FamilyHealth Plan, and TRICARE Plus with TFLTransional Assistance Management ProgramConnued Health Care Bene t ProgramTRICARE Young AdultTRICARE Reserve Select TRICARE Rered Reserve TRICARE programs o ering limited bene ts Includes TRICARE Plus, direct care, line-of-duty care, and transi onal care for service-related condi onsPeace Corps coverageDept of Defense Connuaon Coverage (Nonappropriated Fund HealthBene ts Program)Refugee Medical AssistanceBasic Health Program standard health planCurrently only exists in NY (The Essen al Plan) and MN (MinnesotaCare)AmeriCorps 6. Special rules apply to people who qualify for Medicare based on having End-Stage Renal Disease 7. Medicaid coverage for pregnant women, the medically needy, and under 1115 demonstraon wa by-state MEC designaons for such coverage. 8. New applicants who are determined eligible for pregnancy-related Medicaid that is MEC are not subsequently determined eligible for pregnancy-related Medicaid that is MEC can choose to stay 9. A hardship exempon from the penalty is available to individuals enrolled in pregnancy-related M their unborn child in CHIP, and individuals enrolled in medically needy coverage that is not MEC.10. Medically needy coverage that receives MEC designaon from HHS is considered MEC only for in individuals who qualify for comprehensive coverage only a er incurring medical expenses to me11. An individual who is subject to a waing period in CHIP is treated as not eligible for CHIP and is e12. An individual who is eligible for Medicaid or CHIP but who is not enrolled because of failure to pa loses coverage for failure to pay premiums and is subject to a lockout period is treated as eligible4 | MEC Reference Chart, June 2016

PAGE 4 OF 5LED, DOES COVERAGE SATISFY THE IF ELIGIBLE FOR COVERAGE, ELIGIBLE FORUAL MANDATE? PTC? YES NO YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage YES YES, unless actually enrolled in coverage NO YES YES NO YES NO YES NO YES NO NO YESe. For more informaon, see CMS’s FAQs Regarding Medicare and the Marketplace. aivers is MEC if it consists of or is equivalent to full Medicaid bene ts. HHS maintains a list of state- eligible for PTC. However, a woman enrolled in a marketplace QHP who becomes pregnant and isy in the QHP with PTC or enroll in Medicaid.Medicaid coverage that is not MEC, pregnant women who receive coverage through enrollment ofndividuals who qualify for it without a spenddown requirement. It is not considered MEC foreet a spenddown amount.eligible for PTCs during the waing period. ay any required premiums is treated as eligible for Medicaid or CHIP. Similarly, an individual whoe for Medicaid or CHIP and is not eligible for PTCs during the lockout period.

MEC REFERENCE CHARTTYPE OF COVERAGE IF ENROL INDIVIDUOTHER COVERAGECertain foreign coverageCoverage under a group health plan provided through insurance that is regulated by aforeign governmentCertain coverage for business ownersIncludes any plan, fund, or program that would be MEC with respect to an individualbut for the fact that the coverage is provided to business owners, or their spouses ordependentsCoverage recognized by HHS as MECHHS maintains a list of other coverage it recognizes as MECCoverage consisng solely of excepted bene ts, such as:• Stand-alone vision care or dental care• Worker’s compensaon• Accident or disability policies• Medical discount plans• Fixed-dollar indemnity plans• Crical-illness or speci c disease policiesShort-term, limited duraon coverageMay be referred to as “term” health insurance or transi onal coverageSources:• 26 CFR 1.36B-2: De nes eligibility for the premium tax credit, including when an individual is consid• 26 CFR 1.5000A-2: De nes what types of plans are or are not considered minimum essenal covera• 45 CFR 155.305: Describes eligibility for the premium tax credit, including requirement that people• IRS Noce 2013-41, Eligibility for Minimum Essenal Coverage for Purposes of the Premium Tax Cre premium tax credit (available at: www.irs.gov/pub/irs-drop/n-13-41.pdf).• November 7, 2014 Leer to State Health O cials and Medicaid Directors Regarding Minimum Esse for medically needy individuals, and under secon 1115 demonstraon waivers are considered MEC• August 1, 2014 Frequently Asked Quesons Regarding Medicare and the Marketplace: Describes in Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Downloads/Medicare-Marketplace_Mas• IRS Noce 2014-71, Eligibility for Minimum Essenal Coverage Under Pregnancy-Based Medicaid an related Medicaid and CHIP (available at: www.irs.gov/pub/irs-drop/n-14-71.pdf).5 | MEC Reference Chart, June 2016

PAGE 5 OF 5LED, DOES COVERAGE SATISFY THE IF ELIGIBLE FOR COVERAGE, ELIGIBLE FORUAL MANDATE? PTC?YES NOYES NOYES NONO YES NO YESdered eligible for government-sponsored minimum essenal coverage.age.e must not be eligible for other minimum essenal coverage.edit: Provides guidance on whether or when an individual is eligible for MEC for purposes of theenal Coverage (SHO #14-002): Provides guidance on when Medicaid coverage for pregnant women, C (available at: www.medicaid.gov/federal-policy-guidance/downloads/sho-14-002.pdf).nteracons between Medicare and Marketplace eligibility (available at: www.cms.gov/Medicare/ster_FAQ_8-28-14_v2.pdf). nd CHIP Programs: Provides guidance on eligibility for MEC for purposes of the PTC for pregnancy-