Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 23, 2017

Program Area: Enrollment and Eligibility (ENR)

Question: If an issuer receives a Health Insurance Casework System (HICS) case in which the member has lost eligibility for Advance Payments of the Premium Tax Credit (APTC) due to an income Data-Matching Issue (DMI), subsequently returns to the Marketplace and updates his or her household income information, which restores the member's eligibility for APTC prospectively, should the issuer provide a retroactive effective date for the restored APTC if the 834 enrollment transaction includes a prospective effective date?

Answer: No. Consumers who lose eligibility for APTC due to an expired household income data-matching issue and subsequently update their household income information may qualify for a Special Enrollment Period (SEP) to enroll in, or change, coverage with APTC. However, that SEP will provide a prospective effective date. Consumers do not qualify for a retroactive effective date based only on updated household income information. The issuer should advise the consumer of his or her right to file an appeal of the final eligibility determination notice with the Marketplace. If a consumer is granted retroactive application of the APTC amount based on an eligibility appeal, the request for retroactive application of the APTC amount will be communicated to the issuer via a HICS case [or 834]. The HICS case will be recorded in the 'Plan and Issuer Concerns' category and the 'Eligibility Appeals OHI Related Use Only' subcategory with a narrative that includes the effective date that the issuer should apply. Where a request for retroactive application of the APTC amount is based on an eligibility appeal, the issuer should follow the instructions in the HICS case. **Source: HICS FAQ #7 at https://www.regtap.info/reg_librarye.php?i=1036

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