56.04 Eligibility for alternate APTC and CSR verification procedures

Eligibility for alternate verification procedures for decreases in annual household income and situations in which tax data are unavailable.48 AHS will determine a tax filer’s annual household income for purposes of APTC and CSR based on the alternate APTC and CSR verification procedures described in §§ 56.05 through 56.07 if: An individual attests to the tax filer’s projected annual household income; 48 45 CFR § 155.320(c)(3)(iv). Eligibility-and-Enrollment Procedures Part 7 – Page 22 (Sec.56.00, Sub.56.05) (b) The tax filer does not meet the criteria specified in § 56.03(c) (attestation of increase in household income); (c) The individuals in the tax filer’s household have not established income through the process specified in § 56.02(b) (verification of income for Medicaid) that is within the applicable Medicaid income standard; and (d) One of the following conditions is met: The Secretary of the Treasury does not have tax data that may be disclosed under § 6103(l)(21) of the Code for the tax filer that are at least as recent as the calendar year two years prior to the calendar year for which APTC or CSR would be effective; The individual attests that: (i) The tax filer’s applicable family size has changed or is reasonably expected to change for the benefit year for which the individuals in the tax filer’s household are requesting coverage; or (ii) The members of the tax filer’s household have changed or are reasonably expected to change for the benefit year for which the individuals in their household are requesting coverage; The individual attests that a change in circumstances has occurred or is reasonably expected to occur, and so the tax filer’s annual household income has decreased or is reasonably expected to decrease from the tax data described in § 56.01(a) for the benefit year for which the individuals in the tax filer’s household are requesting coverage; The individual attests that the tax filer’s filing status has changed or is reasonably expected to change for the benefit year for which the individual(s) in tax filer’s household are requesting coverage; or An individual in the tax filer’s household has filed an application for unemployment benefits. 56.05 Alternate APTC and CSR verification procedure: small decrease in projected household income49 (01/01/2026, GCR 25-055) If a tax filer qualifies for an alternate APTC and CSR verification process and the individual’s attestation to the tax filer’s projected annual household income is no more than twenty-five percent below the tax-based income calculation (§ 56.03(b)(2)), the individual’s attestation will be accepted without further verification. 56.06 Alternate APTC and CSR verification procedure: large decrease in projected household income and situations where tax data are unavailable50 (01/15/2019, GCR 18-064) In general. AHS will attempt to verify the individual’s attestation of the tax filer’s projected annual household income with the process specified in paragraph (b) of this subsection and in §§ 56.07 and 56.08 if the tax filer 49 CMS, Center for Consumer Information and Insurance Oversight Guidance, “Annual Income Threshold Adjustment FAQ” (7/21/2016). 50 45 CFR § 155.320(c)(3)(vi). Eligibility-and-Enrollment Procedures Part 7 – Page 23 (Sec.56.00, Sub.56.07) qualifies for an alternate APTC and CSR verification process under § 56.04 and: The individual’s attestation to the tax filer’s projected annual household income is greater than twenty-five percent below the tax-based income calculation (§ 56.03(b)(2)); or The tax data described in § 56.01(a) are unavailable. (b) Applicable process. The alternate APTC and CSR verification process is as follows: Data. Data from non-tax income sources, as described in § 56.01(b), will be annualized (non-tax-based income calculation). Eligibility. To the extent that the individual’s attestation indicates that the non-tax-based income calculation under paragraph (b)(1) of this subsection represents an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, the tax filer's eligibility for APTC and CSR will be determined based on such data. If the individual’s attestation indicates that the tax filer’s projected annual household income is more than twenty-five percent below the non-tax-based income calculation under paragraph (b)(1) of this subsection, AHS will request additional documentation using the procedures specified in § 57.00(c)(1) through (4)(i). If, following the 90-day period described in § 57.00(c)(2)(ii), the individual has not responded to the request for documentation or AHS remains unable to verify the individual’s attestation, AHS will follow the applicable procedures described in § 56.08. 56.07 Alternate APTC and CSR verification procedure: Increases in household income when tax data are unavailable51 (01/15/2017, GCR 16-100) Attestation sufficient. Except as provided in paragraph (b) of this subsection, the individual’s attestation for the tax filer’s household will be accepted without further verification if: The individual's attestation indicates that a tax filer's annual household income has increased or is reasonably expected to increase from the non-tax-based income calculation (§ 56.06(b)(1)); and AHS has not verified the individual’s income through the process specified in § 56.02(b) to be within the applicable Medicaid income standard. (b) Additional verification required. Additional documentation will be requested using the procedures specified in § 57.00 if AHS finds that an individual's attestation of a tax filer's annual household income is not reasonably compatible with other information provided by the individual or the non-tax data available to AHS under § 56.01(b). 56.08 Alternate APTC and CSR verification procedure: following 90-day period (01/15/2017, GCR 16- 100) 51 45 CFR § 155.320(c)(3)(vi)(C). Eligibility-and-Enrollment Procedures Part 7 – Page 24 (Sec.57.00, Sub.0) Individual does not respond to request/data indicate individual’s income within Medicaid standard. If, following the 90-day period described in § 57.00(c)(2)(ii) as required by § 56.06(b)(3), an individual has not responded to a request for additional information and the tax data or non-tax data indicate that an individual in the tax filer's household is eligible for Medicaid, the application for a health-benefits program (for example, Medicaid, APTC or CSR) will be denied. (b) Attestation cannot be verified/tax data available. If, following the 90-day period described in § 57.00(c)(2)(ii) as required by § 56.06(b)(3), AHS remains unable to verify the individual's attestation, AHS will determine the individual's eligibility based on AHS’s tax-based income calculation (§ 56.03(b)(2)), notify the individual of such determination, and implement such determination in accordance with the effective dates specified in § 73.06. (c) Attestation cannot be verified/tax data unavailable. If, following the 90-day period described in § 57.00(c)(2)(ii) as required by § 56.06(b)(3), AHS remains unable to verify the individual's attestation for the tax filer and tax data necessary for a tax-based income calculation (§ 56.03(b)(2)) are unavailable, AHS will determine the tax filer ineligible for APTC and CSR, notify the individual of such determination, and discontinue any APTC or CSR in accordance with the effective dates specified in § 73.06. 56.09 [Reserved] (01/01/2026, GCR 25-055)