February 28th, 2014
As we move into the last month of the 2014 open enrollment period, the Centers on Medicare and Medicaid Services continues to make mid-course corrections. On February 27, 2014, the CMS issued a “Bulletin to Marketplaces on the Availability of Retroactive Advance Payments of the PTCs and CSRs in 2014 Due to Exceptional Circumstances.” The Bulletin makes it possible for exchanges to allow individuals to obtain advance premium tax credits (PTCs) and cost-sharing reductions (CSRs) retroactively if they have been unable to obtain eligibility determinations and to enroll in qualified health plans (QHPs) through the exchange because the exchange experienced technical difficulties during the 2014 open enrollment period.
Presumably the Bulletin is intended to assist enrollees in states like Massachusetts, Oregon, Maryland, Nevada, and Hawaii, where technical problems have made it difficult or impossible for individuals to enroll in QHPs through the exchange on a timely basis. It could also, however, apply to the federal exchange. Each exchange must apparently decide whether or not to effectuate this policy.
Under the Affordable Care Act, PTCs and CSRs are only available to individuals who enroll in a QHP through an exchange. This Bulletin does not change that. CMS continues to require individuals to be determined eligible for PTC and CSR payments and to be enrolled in a QHP through an exchange. To qualify for assistance under the Bulletin, individuals must also have applied to the exchange using a federally approved application during the open enrollment period.
However the Bulletin allows exchanges to permit individuals who have experienced “exceptional circumstances” related to technical difficulties in enrollment, such that they have not been able to have their eligibility determined and to be enrolled in a QHP through the exchange, to qualify for retroactive PTC and CSR eligibility under two circumstances.Read the rest of this entry »