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Frequently Asked Questions

The following FAQs provide answers to many of the common questions that arise when helping consumers apply for and enroll in health coverage through the marketplace, Medicaid, and CHIP.


Modified Adjusted Gross Income (MAGI)
What income counts when determining eligibility for premium tax credits and Medicaid?
What types of income does Modified Adjusted Gross Income count?
What types of income are not counted as part of gross income?
How is gross income adjusted to result in Adjusted Gross Income (AGI)?
How are Social Security benefits counted in Modified Adjusted Gross Income (MAGI)?
Do Social Security benefits received by a dependent child count as part of Modified Adjusted Gross Income (MAGI)?
If a child claimed as a dependent receives Social Security survivor’s benefits and has earnings from a summer job, would the Social Security benefits be counted in the family’s income for premium tax credits?
Are Supplemental Security Income (SSI) benefits counted as part of Modified Adjusted Gross Income (MAGI)?
Why is child support received not counted as income, whereas alimony received is counted?
Does the MAGI methodology apply in all state Medicaid programs, even those that did not expand Medicaid?
What poverty levels will be used to determine eligibility for premium tax credits and cost-sharing reductions?
When the 2014 poverty levels are used to determine eligibility for Medicaid and CHIP and the 2013 poverty levels are used to determine eligibility for premium tax credits and cost-sharing reductions, will fewer people qualify for Medicaid?
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Tax Filing Status and Eligibility for Premium Tax Credits
What are the different ways people file their taxes and how does that affect a person’s eligibility for premium tax credits?
My client didn’t file his taxes in 2012. Is he still eligible for a premium tax credit for 2014?
Do people earning less than the threshold for filing taxes have to file taxes in order to receive premium tax credits?
Is the household used to determine eligibility for premium tax credits the same as the household size that buys coverage as a family?
How do you indicate a “Head of Household” filing status on the marketplace application?
Who can file as “Head of Household”?
Is there a way for people who are separated from their spouses, and who don’t file a joint return, to qualify for premium tax credits?
Can someone who is estranged from her spouse but not divorced, and who claims her granddaughter as a tax dependent qualify for premium tax credits?
Under what circumstances can a married person decide not to file taxes with a spouse and still claim the premium tax credit?
What happens when a married person receives premium tax credits, but then for personal reasons need to file as married filing separately? Do they need to return the full premium tax credit?
Can someone file as head of household if they are divorced and do not have custody of his child, but pays child support that equals over half of the child’s expenses?
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Dependents for Premium Tax Credits
Who can be claimed as a tax dependent (and be included in the premium tax credit household) on someone’s return?
What are the rules for claiming children on a tax return?
Other than children, who else might qualify as a dependent on a tax return?
Can an adult child living with his parents be claimed as a dependent?
Can an adult child or relative who is a tax dependent apply for premium tax credits to be used for his own individual health plan?
If a tax dependent does not provide more than half of his own support, but makes more than the tax filing threshold of $6,200 per year (2014 figures), would that income need to be included in the parent’s MAGI?
If a child lives with one parent (custodial parent) but is claimed by the other (non-custodial parent), who may claim the premium tax credit for the child?
Can a person qualify for a premium tax credit on her own if she could be claimed as a dependent on another taxpayer's return but is not claimed?
Can a taxpayer decide not to claim an eligible dependent on his tax return and avoid responsibility for their insurance coverage?
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Determining Household Size for Medicaid
How do you determine the household of an adult child who is applying for Medicaid when he is claimed as a dependent by his parents on their tax return? Is he always in his parent’s household or is there an age limit when he would be considered as his own household?
When someone applying for Medicaid is claimed as a tax dependent by her parents, is her age ever a factor in figuring out which rule to apply to determine who is in her household?
When is a child’s age a factor in figuring out which rule to apply to determine who is in a child’s household for Medicaid?
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Young Adult Coverage
Can someone who is under 26 and can gain coverage under her parents’ health plan be eligible for premium tax credits?
Does a student who is enrolled in student health coverage need to wait until a marketplace open enrollment in order to enroll in a qualified health plan (QHP) and be eligible for premium tax credits? Alternatively, could she enroll in a QHP even if she is already enrolled in a student health plan?
Can someone who is under 26 and currently covered under her parent’s employer plan stay on that plan even if she starts a job that offers health coverage?
When do adult children who live with their parents need to include their parents’ information on a Medicaid application?
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Coordination between Medicaid and Premium Tax Credits
Do people whose income is between 100 and 138 percent of the poverty line have a choice of eligibility between Medicaid and premium tax credits?
Are there types of Medicaid coverage that do not disqualify people from receiving premium tax credits?
Could someone who is eligible for Medicaid with a “spend down” qualify for premium tax credits?
Is pregnancy-related Medicaid coverage considered minimum essential coverage?
If a woman receiving advance premium tax credits becomes pregnant and eligible for Medicaid based on her pregnancy, does she have to change her coverage?
Could a pregnant woman enroll in Medicaid coverage for pregnant women and receive advance premium tax credits?
What happens when someone living in a state that has not expanded Medicaid receives advance payments of premium tax credits based on an estimate that income would be over the poverty line, but ends up with income below the poverty line? Does he have to pay back all the advance payments he received when he files his taxes?
What happens when someone living in a state that expanded Medicaid receives advance payments of premium tax credits, but whose actual income for the year ends up being 125 percent of the poverty line (which would have made her eligible for Medicaid)? Does she have to pay back the advance payments when she files her taxes?
If someone who is receiving advance payments of premium tax credits is found retroactively eligible for Medicaid after reporting a drop in income, does she have to pay back advance payments of premium tax credits received during the retroactive period because she was eligible for Medicaid during those months?
When the income of someone who is receiving premium tax credits falls below the poverty line for the year, would they have to pay back the credits they received? How does reconciliation work in this case?
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Changes in Income
When people report a change in income to the marketplace, how does the marketplace compute the new amount of their premium credit?
If the number of a person’s dependents changes during the year, how does that affect the premium tax credit?
What happens when someone reports a change in income that changes the cost-sharing reduction they are supposed to receive?
How are cost-sharing reductions affected if income at the end of the year ends up being higher or lower than estimated?
If someone ends up changing from a marketplace plan to Medicaid and back to a marketplace plan because their income fluctuates during the year, does she get credit for cost-sharing charges she already paid while she was in the marketplace plan when she returns to it from Medicaid?
What happens to cost-sharing charges people have already paid if their income drops and they become eligible for a different level of cost-sharing reductions?
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Immigrant Eligibility for Premium Tax Credits and Medicaid
Are individuals who are lawfully present in the United States and have incomes below the federal poverty line eligible for premium tax credits?
Can someone who has been a Lawful Permanent Resident (LPR) for more than five years qualify for premium tax credits if his income is below the poverty line and he is not eligible for Medicaid because his state hasn’t expanded?
If a husband, who became a Lawful Permanent Resident (LPR) last year, is applying for coverage in a Medicaid expansion state with his wife, who is a citizen, and their income is below 100% of the poverty line, are they eligible for Medicaid or premium tax credits?
How is the size of the premium tax credit calculated for a lawfully present individual who is eligible for it, even though his income is below the federal poverty line?
If an adult living in a Medicaid expansion state arrived in the United States as a refugee four years ago and became a Lawful Permanent Resident (LPR) two years ago, is he ineligible for Medicaid based on his immigration status because he became an LPR less than five years ago?
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Employer Coverage
Is someone who is offered affordable employer-based health coverage, but misses the open enrollment period, eligible for premium tax credits on the marketplace?
Is there an exemption from the penalty for not having health coverage for someone who is offered affordable health coverage from their employer but misses the open enrollment period?
Can someone who is eligible to enroll in COBRA or other continuation coverage be eligible for premium tax credits?
Can a person who loses their job outside of the marketplace open enrollment period and becomes eligible for COBRA qualify for premium tax credits and enroll in a marketplace plan instead of enrolling in COBRA coverage?
When can someone who is enrolled in COBRA drop that coverage and enroll in a marketplace plan?
If an employer-sponsored health plan does not provide inpatient hospital benefits, is the employee eligible for premium tax credits?
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Coordination with International Coverage
Would a U.S. citizen living outside the U.S. need to pay the penalty if they do not have health insurance coverage?
How do I enter the address of someone who does not live in the U.S. into Healthcare.gov?
Do parents who claim their children living outside the U.S. as a tax dependent have to show that their children have access to minimum essential coverage before they can be found eligible for Medicaid?
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Special Enrollment Periods
Are there any restrictions on plan selection when a person is eligible for and uses a special enrollment period?
Does being released from prison trigger a special enrollment period?
Does marriage trigger a special enrollment period for someone who is not already enrolled in a qualified health plan in the marketplace?
Does divorce trigger a special enrollment period in the marketplace?
Does job loss alone allow someone to access a special enrollment period in the marketplace?
When a person voluntarily leaves his job and loses employer-based coverage, does that trigger a special enrollment period?
When one member of a family loses minimum essential coverage (MEC), does that trigger a special enrollment period for the entire family?
How can a person who is losing minimum essential coverage (MEC) enroll in a marketplace plan in a way that avoids or minimizes a gap in coverage?
Does the birth of a baby trigger a special enrollment period for just the baby or for the entire family?
When the birth of a baby triggers a special enrollment period, what is the effective date of coverage for the baby and the family?
How far must a person move to trigger a special enrollment period?
If a person is making a permanent move that will trigger a special enrollment period, can she start the process of selecting a plan before the move occurs?
When will coverage begin for a person who is making a permanent move and enrolling in a new health plan through a special enrollment period?
Does a rise in income above the poverty line trigger a special enrollment period for a consumer who did not qualify for Medicaid due to her state’s decision not to expand Medicaid?
Does losing Medicaid coverage for pregnant women trigger a special enrollment period?
Do people need a special enrollment period if they just want to change plans?

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Exemptions from the Individual Responsibility Requirement
If employer-sponsored insurance is considered affordable for the employee, but the cost of covering the family is unaffordable, does the entire family qualify for an exemption from the penalty?
How and when can someone apply for an exemption based on a lack of affordable coverage?
Will someone who would have qualified for Medicaid but lives in a state that has not expanded Medicaid automatically qualify for a hardship exemption from the penalty for not having insurance coverage?
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Renewals
During an open enrollment period, do enrollees have to return to the marketplace to get their premium tax credit eligibility re-determined for the next coverage year even if their income hasn’t changed?
During open enrollment, what will happen to enrollees’ coverage if they don’t select a new plan for the following coverage year?
Can a person who is auto-enrolled in a plan switch plans after January 1?

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Plan Design
Do copayments count towards the deductible?
Does the premium cost of a health plan count towards the out-of-pocket maximum?
Are out-of-network expenses counted towards the deductible?
Are out-of-network expenses counted towards the out-of-pocket maximum?
Are qualified health plans required to cover the ten essential health benefits at no cost to a consumer, or are essential health benefits subject to cost-sharing?
If a consumer enrolls in a Marketplace health plan after January 1st, does the plan continue for the subsequent 12 months or will it end at the end of the calendar year?

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