Sec. 14.35.07.08. Eligibility Requirements for Advance Payments of the Premium Tax Credit

A. A tax filer shall be determined eligible for APTC if:

(1) The tax filer attests to a household income, as defined in 26 CFR §1.36B-1(e), greater than or equal to 100 percent but not more than 400 percent of the FPL for the benefit year for which coverage is requested; and

(2) One or more applicants for whom the tax filer attests to claiming a personal exemption deduction on the applicant’s federal tax return for the benefit year:

(a) Meet the requirements for eligibility for enrollment in a QHP through the Individual Exchange, as specified in Regulation .05 of this chapter; and

(b) Are not eligible for minimum essential coverage, with the exception of coverage in the individual market as set forth in 26 CFR §1.36B-2(a)(2) and (c).

B. A non-citizen tax filer who is lawfully present and ineligible for Medicaid or MCHP by reason of immigration status, and is not otherwise eligible for APTC, shall be eligible for APTC if:

(1) The tax filer meets the requirements specified in §A(2) of this regulation;

(2) The tax filer attests to household income of less than 100 percent of the FPL for the benefit year for which coverage is requested; and

(3) One or more applicants for whom the tax filer attests to claiming a personal exemption deduction on the tax filer’s return for the benefit year is a non-citizen who is lawfully present and ineligible for Medicaid or MCHP by reason of immigration status.

C. A tax filer is eligible for APTC for another qualified individual only if one or more qualified individuals, for whom the tax filer attests that the tax filer expects to claim a personal exemption deduction for the benefit year, including the tax filer and the tax filer’s spouse, is enrolled in a QHP that is not a catastrophic plan through the Individual Exchange.

D. If one or more APTC amounts are to be made on behalf of a tax filer, or two tax filers covered by the same plan or plans, and individuals in the tax filers’ tax households are enrolled in more than one QHP, or stand-alone dental plan, then the APTC amounts shall be allocated as follows:

(1) That portion of the APTC that is less than or equal to the aggregate adjusted monthly premiums, as set forth in 26 CFR §1.36B-3(e), and that is properly allocated to essential health benefits shall be allocated among the QHPs according to the premium level appropriate for each individual’s age-rating band premium; and

(2) Any remaining APTC may be allocated to the essential health benefit portion of any stand-alone dental plans.

E. A tax filer may not be eligible for APTC if:

(1) HHS notifies the Individual Exchange that APTC was made on behalf of the tax filer, or either spouse if the tax filer is a married couple, for a year for which tax data would be utilized for verification of household income and family size set forth in 45 CFR §155.320(c)(1)(i); and

(2) The tax filer or spouse did not file a federal income tax return and reconcile the APTC received for that year, or previous years.

F. APTC shall be calculated in accordance 26 CFR §1.36B-3.

G. To receive the APTC, the tax filer shall attest that:

(1) No other tax filer will claim the tax filer as a tax dependent for the benefit year; and

(2) The tax filer will claim a personal exemption deduction on the income tax return for the applicants identified as members of the tax filer’s family, including the tax filer, who:

(a) Meet the requirements for eligibility for enrollment in a QHP through the Individual Exchange, under Regulation .05 of this chapter; and

(b) Are not eligible for minimum essential coverage elsewhere.

H. An enrollee may accept less than the full amount of the APTC for which the enrollee is determined eligible.

I. Effective Dates for Changes in Eligibility for APTC for Enrollees.

(1) Except as otherwise specified under this regulation, changes in eligibility for APTC determined by the Individual Exchange are effective the first day of the month following the date on which the determination is made.

(2) When an enrollee is determined newly eligible for Medicaid or MCHP, the enrollee shall be ineligible for APTC beginning the first of the month after the enrollee is determined newly eligible for Medicaid or MCHP.

(3) When an applicant or enrollee is eligible for a special enrollment period under Regulations .12-.19 of this chapter, the applicant or enrollee shall be in accordance with the applicable effective date specified for each special enrollment period under Regulations 12-.19 of this chapter.

(4) When an enrollee’s enrollment is terminated by the enrollee as set forth in 45 CFR §155.430(b)(1) or terminated by the Exchange under 45 CFR §155.430(b)(2)(i)-(vii),the applicant or enrollee shall be in accordance with the applicable effective date of the termination set forth in 45 CFR §155.430(d).

J. Eligibility under this regulation is contingent upon verification of the applicant’s attestation that the applicant meets the criteria stated in this regulation.