Tag Archives: eligibility

Finishing up Eligibility

As we are reminded nearly daily, the election is 44, 43, 42, 41 days away. That was my self-imposed deadline (at least the latest one) for finishing going through the PPACA. Given that we are on page 123 of 955, we may not make it. But, we’ll do our best.

Sections 1412, 1413, 1414, 1415, and 1416 all deal with different topics of eligibility for the various benefits and responsibilities imposed by the PPACA. We discussed in the previous post (1411), the requirements for eligibility for the Exchanges. We’ll look at the rest of the sections in this post.

1412 allows the Treasury to determine in advance the premium tax credit and cost-sharing reduction eligibility for certain groups of people. So, for example, if a business was pre-determined to not offer minimum essential coverage, then all of its employees would be presumed to be eligible for the tax credit (depending on income), without each employee having to provide the documentation required by section 1411. It also sets up a mechanism by which the tax credits can be paid in advance, rather than waiting through the entire tax year cycle.

1413 requires that HHS set up a system by which people who apply for the Exchange are actually eligible for a state assistance program, such as CHIP (Children’s Health Insurance Plan) that those people are enrolled in those systems – which have different funding mechanisms.

While no one has really mentioned this part of the plan (giving credence to the idea that they haven’t actually read most of it) I actually see some potential resistance to this part of the Plan by various groups of people. While much discussion recently has centered around people who are characterized as being happy to be dependent on the government, there are many people who are eligible for these programs, who don’t apply for them. According to this article 2/3rds of all children eligible for SCHIP and Medicaid are uninsured (Article) Since children can’t apply on their own, one can assume that their parents either don’t know about, or don’t want to apply for, these programs. Purely anecdotally, I’ve been on several Baby Boards (bulletin boards where women discuss babies, before and after they are born) and there were many women there who knew they were eligible for assistance, but considered it to be a matter of pride that they didn’t take it. It will be an interesting research question as to whether these families, if they choose to apply for the Exchanges and are funneled into the more traditional assistance programs, will choose to go without any insurance rather than take the assistance offered.

Lots of information about security, and forms, and secretarial standards.

1414 allows HHS to have access to the tax returns to make the eligibility of aforementioned premium tax credits. The Federal Government does try to take privacy and confidentiality of information seriously, which I can attest to, having worked in the VA. I’m not saying they are perfect, but then neither is Sony, GoDaddy, and various Credit Card companies, all of whom have been hacked for private information in the recent past.

1415 says that if you get a premium tax credit, or a cost-sharing reduction payment, it doesn’t count as income for the purposes of eligibility for federal assistance. And in a rare show of brevity, section 1415 is only 115 words longer than the previous sentence explaining it.

1416 authorizes a study of the Federal Poverty Line, seeing if adjustments need to be made to it.

So that finishes up the eligibility section. Progress! Progress has been made!


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Can I, Can I?

We’ve talked a bunch about the Exchanges, or the place where you go to buy health insurance if you can’t, or choose not, to buy it from your employer. However, there are rules governing who is actually allowed to purchase insurance on these Exchanges. There are also guidelines for who can receive premium assistance, whose employer based insurance in unaffordable, and who is exempt from tax penalty if they don’t have insurance.

Most of these requirements were laid out in previous sections, but the next 6 sections, including this one, 1411, explicitly state that the Secretary of Health and Human Services has to come up with a program to assess the eligibility of people for these various items. So, yes, they said previously that you have to meet these requirements, and now they are saying that the government has to make sure they determine whether you meet these requirements. I suppose that is better than the alternatives – either saying you have to do something and then not caring if you do it, or worse, making requirements that you have no possible way to prove you meet. That last one sounds like something the Vogons would do.

So the Secretary of HHS has to make this program. Then what? You have to give them information, name, date of birth, SSN, etc. If you are claiming a tax credit because your employer doesn’t provide minimum coverage, then you have to include a lot of details about your employment status, and the cost of the coverage, and the cost-sharing. I hope there is a form. I’m sure there will be a form. J

The thing you really need to understand about the PPACA is that is references a lot of other sections of the PPACA and many other laws. For instance, if you wanted to claim an exemption from having to hold insurance, which is allowed in section 1311, subpart d, subsubpart 4, subsubsubpart H, in order to be exempt from the tax penalty as laid out in section 5000A of the tax code, then section 1411 tells you how to do that.

Just as aside, this is the first mention of WHO might be eligible for such an exemption. These include religious exemptions, people who are members of health care sharing ministries (oh, you’ve never heard of those – well – are you in for a treat! See the footnote.), Indian, or eligible for a hardship exemption.

There are then pages, and pages, and pages about exactly how the Secretary can develop this system, what happens if there are problems, liability for false information, confidentiality of information….and so on for six pages. We’ll assume that the Secretary has read them too.

Remember – there are 5 more sections about eligibility. We’ll finish those out this week.

Footnote: A Health Care Sharing Ministry is a group of people who pay money into the system, and then when they need health care services, they receive money from the pool, after meeting some basic level of out-of-pocket expense. They are typically not-for-profit. They are faith-based, being predominately Christian, and usually expect their members to live a “Christian lifestyle”. The members have no guarantee of payment. But they aren’t health insurance. No siree-Bob. Even though Washington State shut one such organization down, for not registering as an insurer.


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