Sec. 14.35.07.09. Eligibility Requirements for Cost — Sharing Reductions

A. An applicant shall be determined eligible for cost-sharing reductions if the applicant:

(1) Meets the requirements for eligibility for enrollment in a QHP through the Exchange under Regulation .05 of this chapter;

(2) Meets the requirements for APTC under Regulation .08 of this chapter; and

(3) Except as provided under §E of this regulation, attests to household income that does not exceed 250 percent of the FPL for the benefit year for which coverage is requested.

B. An applicant is eligible for:

(1) A CSR plan for up to 150 percent FPL for an individual who attests to household income greater than or equal to 100 percent of the FPL and less than or equal to 150 percent of the FPL for the benefit year for which coverage is requested, or, for an individual who is eligible for advance payments of the premium tax credit under Regulation .07B of this chapter, a household income less than 100 percent of the FPL for the benefit year for which coverage is requested;

(2) A CSR plan for 151-200 percent FPL for an individual who attests to household income greater than 150 percent of the FPL and less than or equal to 200 percent of the FPL for the benefit year for which coverage is requested;

(3) A CSR plan for 201-250 percent FPL for an individual who attests to household income greater than 200 percent of the FPL and less than or equal to 250 percent of the FPL for the benefit year for which coverage is requested; or

(4) Except as provided under §E of this regulation, any coverage level for an individual who attests to household income greater than 250 percent for the FPL for the benefit year for which coverage is requested.

C. To the extent that an enrollment in a QHP under a single policy covers two or more individuals who, if the individuals were to enroll in separate individual policies, would be eligible for different CSR plan variations, the individuals under the policy are collectively eligible only for the category of eligibility listed below for which all the individuals covered by the policy would be eligible:

(1) Individuals not eligible for changes to cost sharing;

(2) Individuals described in §E(2) of this regulation;

(3) Individuals described in §B(3) of this regulation;

(4) Individuals described in §B(2) of this regulation;

(5) Individuals described in §B(1) of this regulation; and

(6) Individuals described in §E(1) of this regulation.

D. Except as set forth in §E of this regulation, to receive cost-sharing reductions, an applicant shall enroll in a silver-plan variation of a QHP.

E. Special Cost-Sharing Rules for Indians.

(1) An applicant who is an Indian is eligible for the zero cost sharing plan variation of a QHP if the applicant:

(a) Meets the requirements for eligibility for enrollment in a QHP through the Individual Exchange pursuant to Regulation .05 of this chapter;

(b) Meets the requirements for APTC pursuant to Regulation .08 of this chapter; and

(c) Attests to household income, set forth in 26 CFR §1.36B-1(e) that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested.

(2) An applicant who is an Indian and is enrolled in a QHP shall owe no cost-sharing under the plan for items or services furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services.

F. Changes in enrollment in a plan with a CSR under this regulation are effective based on the effective dates under Regulation .08I of this chapter.

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