75.03 Renewal procedures for Medicaid

Renewal on basis of available information A redetermination of eligibility for Medicaid will be made without requiring information from the individual if AHS is able to do so based on reliable information contained in the individual's account or other more current information available, including but not limited to information accessed through any data bases. If eligibility can be renewed based on such information, the individual will be notified: (i) Of the eligibility determination, and basis; and (ii) That the individual must inform AHS if any of the information contained in such notice is inaccurate, but that the individual is not required to sign and return such notice if all information provided on such notice is accurate. (b) Eligibility renewal using pre-populated renewal form. If eligibility cannot be renewed in accordance with paragraph (a)(2) of this subsection, AHS will: Provide the individual with: (i) A renewal form containing information available to AHS that is needed to renew eligibility; (ii) At least 30 days from the date of the renewal form to respond and provide any necessary information through any of the modes of submission specified in § 52.02(b), and to sign the renewal form in a manner consistent with § 52.02(h); (iii) Notice in a timely manner of the decision concerning the renewal of eligibility in accordance with the requirements specified in § 68.00; Verify any information provided by the individual in accordance with §§ 53.00 through 56.00; Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination without requiring a new application; Not require an individual to complete an in-person interview as part of the renewal process; and Include in its renewal forms its toll-free customer service number and a request that individuals call if they Eligibility-and-Enrollment Procedures Part 7 – Page 72 (Sec.76.00, Sub.0) need assistance. (c) Medicaid continues for all individuals until they are found to be ineligible. When a Medicaid enrollee has done everything they were asked to do, Medicaid will not be closed even though a decision cannot be made within the required review frequency. Termination of QHP enrollment or coverage166 (01/01/2026, GCR 25-055) General requirements. AHS will determine the form and manner in which enrollment in a QHP may be terminated. (b) Termination events167 Enrollee-initiated terminations (i) An individual will be permitted to terminate their coverage or enrollment in a QHP, including as a result of the individual obtaining other MEC, with appropriate notice to AHS. (ii) An individual will be provided an opportunity at the time of plan selection to choose to remain enrolled in a QHP if they become eligible for other MEC and the individual does not request termination in accordance with paragraph (b)(1)(i) of this section. If an individual does not choose to remain enrolled in a QHP in such a situation, AHS will initiate termination of their enrollment upon completion of the process specified in § 73.00. (iii) AHS will establish a process to permit individuals, including enrollees’ authorized representatives, to report the death of an enrollee for purposes of initiating termination of the enrollee’s enrollment. AHS may require the reporting party to submit documentation of the death. (iv) AHS will permit an enrollee to retroactively terminate or cancel their coverage or enrollment in a QHP in the following circumstances: The enrollee demonstrates to AHS that they attempted to terminate their coverage or enrollment in a QHP and experienced a technical error that did not allow the enrollee to terminate their coverage or enrollment through VHC, and requests retroactive termination within 60 days after they discovered the technical error. The enrollee demonstrates to AHS that their enrollment in a QHP through VHC was unintentional, inadvertent, or erroneous and was the result of the error or misconduct of an officer, employee, or agent of AHS or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. Such enrollee must request cancellation within 60 days of discovering the unintentional, inadvertent or erroneous enrollment. For purposes of this paragraph, misconduct includes the failure to comply with applicable standards under this rule or other applicable federal or state laws, as determined by AHS. 166 45 CFR § 155.430. 167 45 CFR § 155.430(b). Eligibility-and-Enrollment Procedures Part 7 – Page 73 (Sec.76.00, Sub.0) The enrollee demonstrates to AHS that they were enrolled in a QHP without their knowledge or consent by any third party, including third parties who have no connection with AHS, and requests cancellation within 60 days of discovering of the enrollment. AHS or issuer-initiated termination. AHS may initiate termination of an individual’s enrollment in a QHP, and must permit a QHP issuer to terminate such coverage or enrollment, in the following circumstances: (i) The individual is no longer eligible for coverage in a QHP; (ii) Non-payment of premiums for coverage of the individual, and The 3-month grace period required for individuals who when first failing to timely pay premiums are receiving APTC168 has been exhausted; or Any other grace period not described in paragraph (b)(2)(ii)(A) of this section has been exhausted; (iii) The individual’s coverage is rescinded; (iv) The QHP terminates or is decertified; (v) The individual changes from one QHP to another during an AOEP or SEP in accordance with § 71.02 or § 71.03; or (vi) The enrollee was enrolled in a QHP without their knowledge or consent by a third party, including a third party with no connection with AHS. (c) Termination of coverage or enrollment tracking and approval.169 AHS will: Establish mandatory procedures for QHP issuers to maintain records of termination of enrollment; Send termination information to the QHP issuer and HHS, promptly and without undue delay, at such time and in such manner as HHS may specify; Require QHP issuers to make reasonable accommodations for all individuals with disabilities (as defined by the ADA) before terminating enrollment of such individuals; and Retain records in order to facilitate audit functions. (d) Effective dates for termination of coverage or enrollment170 For purposes of this section: 168 45 CFR §§ 156.270(d) and (g). 169 45 CFR § 155.430(c). 170 45 CFR § 155.430(d). Eligibility-and-Enrollment Procedures Part 7 – Page 74 (Sec.76.00, Sub.0) (i) Reasonable notice is defined as at least fourteen days from the requested effective date of termination; and (ii) Changes in eligibility for APTC and CSR, including terminations, must adhere to the effective dates specified in § 73.06. In the case of a termination in accordance with paragraph (b)(1) of this section, the last day of enrollment is the last day of the month during which the termination is requested by the individual, unless the individual requests a different termination date. If an individual requests a different termination date, the last day of enrollment is: (i) The termination date specified by the individual, if the individual provides reasonable notice. (ii) If the individual does not provide reasonable notice, fourteen days after the termination is requested by the individual. (iii) If the individual is newly eligible for Medicaid or other MEC, and the individual so requests, the last day of the month two months prior to the month during which the termination is requested by the individual, subject to the determination of the individual’s QHP issuer. (iv) If the individual is in a grace period, and the individual so requests, the last day of the first month of the grace period. In the case of a termination in accordance with paragraph (b)(2)(i) of this section, the last day of enrollment is the last day of eligibility, as described in § 73.06, unless the individual requests an earlier termination effective date per paragraph (b)(1)(i) of this section. In the case of a termination in accordance with paragraph (b)(2)(ii)(A) of this section, the last day of enrollment will be the last day of the first month of the 3-month grace period. In the case of a termination in accordance with paragraph (b)(2)(ii)(B) of this section, the last day of enrollment should be consistent with existing State laws regarding grace periods. In the case of a termination in accordance with paragraph (b)(2)(v) of this section, the last day of coverage in an individual’s prior QHP is the day before the effective date of coverage in their new QHP, including any retroactive enrollments. In the case of termination due to death, the last day of enrollment is the date of death. In cases of retroactive termination dates, AHS will ensure that appropriate actions are taken to make necessary adjustments to APTC, CSR, premiums and claims. In case of a retroactive termination in accordance with paragraph (b)(1)(iv)(A) of this section, the termination date will be no sooner than the date that would have applied under paragraph (d)(2) of this section, based on the date that the enrollee can demonstrate they contacted AHS to terminate their coverage or enrollment through VHC, had the technical error not occurred. In case of a retroactive cancellation or termination in accordance with paragraph (b)(1)(iv)(B) or (C) of this Eligibility-and-Enrollment Procedures Part 7 – Page 75 (Sec.77.00, Sub.0) section, the cancellation date or termination date will be the original coverage effective date or a later date, as determined appropriate by AHS, based on the circumstances of the cancellation or termination. In the case of cancellation in accordance with paragraph (b)(2)(vi) of this section, AHS may cancel the enrollee’s enrollment upon its determination that the enrollment was performed without the enrollee’s knowledge or consent and following reasonable notice to the enrollee (where possible). The termination date will be the original coverage effective date. In the case of retroactive cancellations or terminations in accordance with paragraphs (b)(1)(iv)(A), (B) and (C) of this section, such terminations or cancellations for the preceding coverage year must be initiated within a reasonable timeframe and are subject to QHP issuer review. This timeframe will not apply to cases timely adjudicated through the appeals process except that AHS cannot guarantee an effective date retroactive to the preceding coverage year. (e) Termination, cancellation, reinstatement defined Termination. A termination is an action taken after a coverage effective date that ends an enrollee’s enrollment through VHC for a date after the original coverage effective date, resulting in a period during which the individual was enrolled in coverage through VHC. Cancellation. A cancellation is specific type of termination action that ends a qualified individual’s enrollment on the date such enrollment became effective resulting in enrollment never having been effective. Reinstatement. A reinstatement is a correction of an erroneous termination or cancellation action and results in restoration of an enrollment with no break in coverage. Administration of APTC and CSR171 (10/01/2021, GCR 20-004) Requirement to provide information to enable APTC and CSR.172 In the event that a tax filer is determined eligible for APTC and the Vermont Premium Reduction, if applicable, or an individual is eligible for federal or state CSR, or that such eligibility for such programs has changed, AHS will, simultaneously: Transmit eligibility and enrollment information to HHS necessary to enable HHS to begin, end, or change APTC or federal CSR; and Notify and transmit information necessary to enable the issuer of the QHP to implement, discontinue the implementation, or modify the level of APTC, the Vermont Premium Reduction or federal or state CSR, as applicable, including: (i) The dollar amount of the advance payment including the Vermont Premium Reduction; and 171 45 CFR § 155.340. 172 45 CFR § 155.340(a). Eligibility-and-Enrollment Procedures Part 7 – Page 76 (Sec.77.00, Sub.0) (ii) The CSR eligibility category. (b) Requirement to provide information related to employer responsibility173 AHS will transmit the individual’s name and tax filer identification number to HHS in the event that it determines that an individual is eligible for APTC or CSR based in part on a finding that an individual’s employer: (i) Does not provide MEC; (ii) Provides MEC that is unaffordable, within the standard of § 23.02; or (iii) Provides MEC that does not meet the minimum value requirement specified in § 23.03. If an individual for whom APTC are made or who is receiving CSR notifies AHS that they have changed employers, AHS must transmit the individual’s name and tax filer identification number to HHS. In the event that an individual for whom APTC are made or who is receiving CSR terminates coverage from a QHP during a benefit year: (i) AHS will transmit the individual’s name and tax filer identification number, and the effective date of coverage termination, to HHS, which will transmit it to the Secretary of the Treasury; and (ii) AHS may transmit the individual’s name and the effective date of the termination of coverage to their employer. (c) Requirement to provide information related to reconciliation of APTC.174 AHS will comply with the requirements of § 78.00 regarding reporting to the IRS and to tax filers. (d) Timeliness standard.175 All information required in accordance with paragraphs (a) and (b) of this section will be transmitted promptly and without undue delay. (e) Allocation of APTC and the Vermont Premium Reduction among policies.176 If one or more advance payments of the premium tax credit, including the Vermont Premium Reduction, if applicable, are to be made on behalf of a tax filer (or two tax filers covered by the same plan(s)), and individuals in the tax filers’ households are enrolled in more than one QHP or stand-alone dental plan, then that portion of the APTC, including the Vermont Premium Reduction, that is less than or equal to the aggregate monthly premiums, as defined in § 60.05, for the QHP policies properly allocated to essential health benefits must be allocated among the QHP 173 45 CFR § 155.340(b). 174 45 CFR § 155.340(c). 175 45 CFR § 155.340(d). 176 45 CFR § 155.340(e). Eligibility-and-Enrollment Procedures Part 7 – Page 77 (Sec.78.00, Sub.0) policies based on the number of enrollees covered under the QHP. (f) If either or both APTC and the Vermont Premium Reduction are received for a partial coverage month consistent with § 73.06, APTC and the Vermont Premium Reduction amounts are prorated by the number of days of coverage in the month.177 Information reporting by AHS178 (01/15/2017, GCR 16-100) Information required to be reported179 Information reported annually. AHS will report to the IRS the following information for each QHP: (i) The name, address and taxpayer identification number (TIN), or date of birth if a TIN is not available, of the tax filer or responsible adult (an individual on behalf of whom APTC is not paid); (ii) The name and TIN, or date of birth if a TIN is not available, of a tax filer’s spouse; (iii) The amount of advance credit payments paid for coverage under the plan each month; (iv) For plans for which advance credit payments are made, the premium (excluding the premium allocated to benefits in excess of essential health benefits) for the ABP for purposes of computing advance credit payments; (v) For plans for which advance credit payments are not made, the premium (excluding the premium allocated to benefits in excess of essential health benefits) for the ABP that would apply to all individuals enrolled in the QHP if advance credit payments were made for the coverage; (vi) The name and TIN, or date of birth if a TIN is not available, and dates of coverage for each individual covered under the plan; (vii) The coverage start and end dates of the QHP; (viii) The monthly premium for the plan in which the individuals enroll, excluding the premium allocated to benefits in excess of essential health benefits: (ix) The name of the QHP issuer; (x) The AHS-assigned policy identification number; 177 See, also, 45 CFR § 155.240(e). 178 26 CFR § 1.36B-5. 179 26 CFR § 1.36B-5(c). Eligibility-and-Enrollment Procedures Part 7 – Page 78 (Sec.79.00, Sub.0) (xi) AHS’s unique identifier; and (xii) Any other information required in published guidance. Information reported monthly. For each calendar month, AHS will report to the IRS for each QHP, the information described in (1) above and the following information: (i) For plans for which advance credits are made: The names, TINs, or dates of birth if no TIN is available, of the individuals enrolled in the QHP who are expected to be the tax filer’s dependent; and Information on employment (to the extent this information is provided to AHS) consisting of: (I) The name, address and employer identification number (EIN) of each employer of the tax filer, the tax filer’s spouse, and each individual covered by the plan; and (II) An indication of whether an employer offered affordable minimum essential coverage that provided minimum value, and, if so, the amount of the employee’s required contribution for self-only coverage; (ii) The unique identifying number AHS uses to report data that enables the IRS to associate the data with the proper account from month to month; (iii) The issuer’s EIN; and (iv) Any other information specified in published guidance. (b) Time for reporting. AHS will submit the annual report required under § 78.00(a)(1) on or before January 31 of the year following the calendar year of coverage. AHS will submit the monthly reports required under § 78.00(a)(2) as required by federal law. (c) Annual statement to be furnished to individuals. On or before January 31 of the year following the calendar year of coverage, AHS will furnish to each tax filer or responsible adult a written statement showing the name and address of the recipient and the information described in (a)(1) of this section. (d) Manner of reporting. AHS will comply with all guidance published by the Commissioner of the IRS180 for the manner of reporting under this section. [Reserved] (01/15/2017, GCR 16-100) 180 See § 601.601(d)(2) of chapter one of the Code.