220 R.I. Code R. 220-RICR-90-00-1.7

Current through December 26, 2024

Section 220-RICR-90-00-1.7 - Eligibility and Special Rules on the Advanced Payments of the Premium Tax Credit and Cost Sharing Reductions

A. Advanced Payments of the Premium Tax Credit

1. In General - §1401 of the ACA creates a new §36B of the Internal Revenue Code (the Code, U.S.C. Title 26), which provides for a premium tax credit for eligible individuals who enroll in a QHP through an Exchange. §1402 of the ACA establishes provisions aimed at reducing the cost-sharing obligations of certain eligible individuals enrolled in a QHP offered through an Exchange, including standards for determining Indians eligible for certain categories of cost-sharing reductions. The ACA and its implementing regulations, found in 45 C.F.R. § 155.305, incorporated above at § 1.3 of this Part, authorize the Exchange to determine qualified individuals' eligibility for advance payments of the premium tax credits. In order to qualify for advance payments of the premium tax credits, an applicant must meet both the eligibility requirements to enroll in a Qualified Health Plan as described at § 1.5 of this Part and the eligibility requirements for the advance payment of premium tax credits as described in this section and 45 C.F.R. § 155.305, incorporated above at § 1.3 of this Part. An applicant determined eligible for a premium assistance amount may elect not to take the full monthly premium assistance amount for which he or she is determined eligible. The amount of the premium tax credit the applicant should have received over the course of the Benefit Year will be reconciled when the applicant files a tax return for that year.

2. Eligibility for Advance Payments of the Premium Tax Credit - The Exchange shall find an applicant eligible for advance payments of the premium tax credit if the Exchange determines that he or she meets the criteria in 45 C.F.R. § 155.305, incorporated above at § 1.3 of this Part, including the following:

a. He or she is expected to have a household income, as defined in the Internal Revenue Code, 26 U.S.C. § 36B(d)(2), of greater than or equal to one hundred percent (100%) of the FPL and less than four hundred percent (400%) of the FPL for the Benefit Year for which coverage is requested; and

b. He or she plans to file a Federal tax return, and, if married, to file a joint return, for the Benefit Year;

c. He or she may not be claimed by another tax filer as a tax dependent under the Internal Revenue Code, 26 U.S.C. § 151.

3. Individuals for Whom a Premium Assistance Amount Can be Provided - An applicant will be eligible for a premium assistance amount only for a month that one (1) or more members of the tax filer's family (the tax filer or the tax filer's spouse or tax dependent) meet the following criteria:

a. Are enrolled in one (1) or more QHPs; and

b. Are not eligible for minimum essential coverage as defined in 26 C.F.R. § 1.36B-2(c), incorporated above at § 1.3 of this Part, other than individual market coverage described in the Internal Revenue Code, 26 U.S.C. § 5000A(f)(1)(C).

4. Special Rule for Non-Citizens Who are Lawfully Present Immigrants and Who Are Ineligible for Medicaid by Reason of Immigration Status - In accordance with 45 C.F.R. § 155.305(f)(2), incorporated above at § 1.3 of this Part, lawfully present immigrants who are ineligible for Medicaid based on immigration status and whose household income is below one hundred percent (100%) of the FPL shall be eligible for an APTC if they meet all other eligibility requirements for advance payments of the premium tax credit.

5. Calculation of Advance Payments of the Premium Tax Credit - The Exchange shall calculate any applicant's advance payment of the premium tax credit in accordance with the requirements of 26 C.F.R. § 1.36B-3, incorporated above at § 1.3 of this Part.

6. Appeals - An applicant has the right to an appeal of an eligibility determination based on this section and pursuant to the appeals process as described in § 1.14 of this Part and as set forth in 210-RICR- 10-05-2, Appeals Process and Procedures for EOHHS Agencies and Programs, if applicable.

B. Cost Sharing Reductions

1. In General - §1401 of the ACA and its implementing regulations, 45 C.F.R. § 155.305, incorporated above at § 1.3 of this Part, establish eligibility requirements for an applicant to receive cost sharing reductions. To receive cost sharing reductions, an applicant must meet the eligibility requirements to enroll in a Qualified Health Plan as described in § 1.5(B) of this Part, the eligibility requirements for the advance payments of a premium tax credit as described at § 1.7(A) of this Part, and the eligibility requirements as described in § 1.7(B) of this Part.

2. Eligibility Criteria - The Exchange will determine an applicant eligible for cost-sharing reduction if he or she:

a. Is expected to have household income, as defined in the Internal Revenue Code, 26 U.S.C. § 36B(d)(2), that does not exceed two hundred fifty percent (250%) of the FPL for the Benefit Year for which coverage is requested; and

b. Meets the eligibility criteria for enrollment in a QHP; and

c. Meets the eligibility criteria for an advance payment of a premium tax credit.

3. Provided Only to Enrollees in a Silver Level Qualified Health Plan - With the exception of Indians, the Exchange will provide cost-sharing reductions only to enrollees who enroll in a silver level Qualified Health Plan as defined by §1302(d)(1)(B) of the ACA.

4. Use of Eligibility Categories - The Exchange will use the CSR eligibility categories set forth in 45 C.F.R. § 155.305(g), incorporated above at § 1.3 of this Part.

5. Special Rule for Lawfully Present Immigrants Below One Hundred Percent (100%) FPL - The Exchange will follow the Federal Rule set forth in 26 C.F.R. § 1.36B-2, incorporated above at § 1.3 of this Part, for lawfully present immigrants with income below one hundred percent (100%) FPL who are eligible for a cost-sharing reduction.

6. Special Rules for Indians - The Exchange will follow the special Rules for Indians as set forth in 45 C.F.R. § 155.350, incorporated above at § 1.3 of this Part.

a. The Exchange will find Indians with expected household income equal to or less than three hundred percent (300%) of the FPL, who are eligible for an APTC, and who enroll in a QHP, eligible for a zero cost-sharing plan.

b. The Exchange will find Indians who apply for an insurance affordability program eligible for the limited cost-sharing plan regardless of their income level.

7. Special Rule for Multiple Tax Households - To the extent that enrollment in a QHP includes individuals who expect to be in different tax households, the Exchange will apply only the category of eligibility last listed below for which all the individuals covered by the policy would be eligible:

a. No cost sharing reduction

b. Limited cost-sharing reduction plan (for Indians)

c. Category 3 cost-sharing reduction plan (for two hundred one percent (201%) FPL to two hundred fifty percent (250%) FPL)

d. Category 2 cost-sharing reduction plan (for one hundred fifty-one percent (151%) FPL to two hundred percent (200%) FPL)

e. Category 1 cost-sharing reduction plan (for one hundred percent (100%) FPL to one hundred fifty percent (150%) FPL)

f. Zero cost-sharing reduction plan (for Indians below three hundred one percent (301%) FPL)

8. Appeals. An applicant has the right to an appeal of an eligibility determination based on this section and pursuant to the appeals process as described in § 1.14 of this Part and as set forth in 210-RICR- 10-05-2, Appeals Process and Procedures for EOHHS Agencies and Programs, if applicable.

220 R.I. Code R. 220-RICR-90-00-1.7

Amended effective 12/22/2019
Amended effective 12/31/2020
Amended effective 4/2/2023