3) Marketplace Enrollment and Sponsorship

  • Question 1

    When is the “open enrollment” period for 2017?


    ·         The 2017 open enrollment period is from November 1, 2015 through December 15, 2017.

    In addition, for American Indians and Alaska Natives meeting the eligibility criteria for Indian-specific benefits under the Affordable Care Act, enrollment in the Marketplace can occur all year.  This is referred to as the “Monthly Special Enrollment Period”.   And, in Federally-Facilitated Marketplace (FFM) states, non-tribal members applying on the same application as a tribal member can take advantage of this Monthly Special Enrolment Period.  For state-based Marketplaces, check with the state’s website for its policy.  

    Individuals eligible for Medicaid or CHIP are able to apply for coverage at any time during the year.

  • Question 2

    When does health insurance coverage become effective when enrolling through a Marketplace?


    In general, for coverage to be effective on the first of the next month, an individual needs to enroll in a health plan by the 15th of the prior month.  If someone enrolls in a plan after the 15th of a month, the coverage would not be effective until the first day of the following month (the month after the next month).

    For example, for coverage to be effective on March 1, 2015, an individual needs to enroll in a plan by February 15, 2015.

    There are three steps to “enroll” in a health plan through the Marketplace. 

    – The first step is to apply for coverage through the Marketplace by:  a) applying online at the HealthCare.gov website, or b) calling the Call Center (1-800-318-2596), or c) mailing in a paper application.  After applying, applicants will be told if they are eligible for premium tax credits and cost-sharing reductions.

    – The second step is to pick a health plan offered through the Marketplace.  This can be done on HealthCare.gov or through the Call Center.

    – The third step is to pay the premium to the health plan for the first month.

    Each of these steps needs to occur on or before the 15th of the month for coverage to begin on the 1st of the next month.  A health plan may allow payment of the premium for the initial month to be made after the 15th of the month and still have coverage effective on the 1st of the next month, but this is at the discretion of the health plan.  An applicant should check with the health plan directly about their payment policy.

    For residents in states with a state-run Marketplace, check the website of the state-based Marketplace to learn the due dates that apply.  The websites for state-based websites can be accessed directly or through the federal HealthCare.gov website. 

    In addition to the Marketplace website (HealthCare.gov) and the Marketplace Call Center (1-800-318-2596), the Center for Medicare and Medicaid Services Native American Contacts (NACs) are available to assist with navigating Marketplace enrollment.  A list of NACs is accessible at here.

  • Question 3a

    How do special enrollment periods work?


    American Indians and Alaska Natives (AI/ANs) who meet the eligibility criteria under section 4 of the Indian Health Care Improvement Act (as a “Member of an Indian Tribe,” which includes members and shareholders in Alaska Native regional and village corporations) qualify for monthly special enrollment periods under the Affordable Care Act.  This means that a qualifying AI/AN can enroll in health insurance coverage through a Marketplace throughout the year and not just before February 15, 2015.

    Other family members who are not qualifying AI/ANs are eligible to enroll after the open enrollment period IF they enroll with an eligible family member.

    Individuals eligible for the monthly special enrollment periods should inform the Call Center staff that they are eligible and would like assistance with applying for coverage, if needed.  Individuals eligible for the monthly special enrollment periods may apply through the Call Center, or the Website, or a paper application.

    For the 2015 coverage year, the general open enrollment through a Marketplace continues through February 15, 2015.

    • From November 15, 2014 to February 15, 2015, all eligible individuals may enroll in a health plan through a Marketplace.
    • After February 15, 2015, only individuals eligible for special enrollment periods may apply until the next open enrollment period in late 2015.

    In addition to the AI/AN monthly special enrollment periods, others can have a special enrollment period if they have a qualifying event.  Qualifying events for other special enrollment periods include loss of employer-based coverage, birth of a child, etc.

    It is important to remember, though, that typically there are delays in the effective date once someone enrolls in coverage through a Marketplace.   (In contrast, when enrolling in Medicaid, the coverage is effective immediately, as well as having a look-back period for services provided immediately prior to enrolling.)  The enrollment dates below apply to individuals enrolling under the monthly special enrollment period for AI/ANs.

    • When enrolling in coverage between the 1st and the 15th of a month, the coverage is effective on the first day of the next month (e.g., if an individual enrolls on the 14th of May, the coverage is effective on the first day of June).
    • When enrolling in coverage between the 16th and the end of a month, the coverage is effective on the first day of the second next month (e.g., if an individual enrolls on the 18th of May, the coverage is effective on the first day of July).

    Some special enrollment period categories permit expedited enrollment, meaning an applicant’s coverage may be effective immediately or at the 1st of the next month no matter what day of the prior month someone applies for coverage. 

    • For example, if eligible for a special enrollment period due to loss of minimum essential coverage, an individual may enroll through a Marketplace plan at any time during a month and have effective coverage on the first day of the next month (i.e., not required to enroll by the 15th of the month).
    • For the birth or adoption of a child, enrollment is effective on the day of the birth or adoption.

    AI/ANs may want to see if they are eligible for other special enrollment periods if expedited enrollment is needed.

  • Question 3b

    When I called, the HealthCare.gov Call Center did not know about monthly special enrollment periods for American Indians and Alaska Natives. What do I do?


    The experience of many American Indians and Alaska Natives (AI/ANs) in the 2014 enrollment cycle was that incomplete or inaccurate information was provided by Marketplace Call Center representatives.  Hopefully, for the 2015 enrollment, Call Center staff will receive more thorough training.  Individuals who believe they are not getting accurate answers on Indian-specific provisions should ask to speak with an “advanced Call Center representative.”

    With regard to the monthly special enrollment periods, if applying through the Marketplace Call Center, AI/ANs eligible for the monthly special enrollment periods should inform Marketplace Call Center staff that they are eligible and would like assistance with applying for coverage.  (Individuals eligible for the monthly special enrollment periods may apply for coverage through the Call Center, the HealthCare.gov Website, or a paper application.)

    Tribal representatives have communicated the need for additional training of Marketplace Call Center staff.  For more information, please see materials formatted for enrollment assisters in 2014 and presented by Mim Dixon in Webinar #2 sponsored by the TSGAC.  The materials and a recording of the Webinar are on posted here.

  • Question 4

    I cannot remove an application for health insurance coverage through a Marketplace Website. How do I do this?


    Recently, the federal HealthCare.gov Website added a capability to delete an application from an individual’s account.  (HealthCare.gov is the Website used for the Marketplaces operated by the federal government.)  The individual could then re-apply, if they wish to do so.  For state-based Marketplaces, there may not be a similar option on the state-based Website.

    The HealthCare.gov Web site states: “You can remove problem applications. If you’ve experienced problems filling out your online application, you can start over with a brand new application. To do this, you’ll first need to log in to your account; select your current application; and then choose to “Remove” the application. You will then need to close out your web page and then log back in using your same account. You can then start a brand new application.”

    Alternatively, if an individual applies for coverage (and is not able to delete the application) but does not wish to purchase the insurance coverage, the applicant should not submit the first premium payment to the insurance company.  The application will expire.  An individual has the option of submitting a separate application (whether or not the initial application has already expired).

  • Question 5

    If an American Indian/Alaska Native (AI/AN) enrolls in a Marketplace plan, but the provider the individual wants to see is not on the “preferred”/“in-network” list, can the individual change to a plan that includes his or her provider as an in-network provider?


    Yes, but with some limitations.

    AI/ANs who are eligible as a “member of an Indian Tribe” (including shareholders in Alaska Native village and regional corporations) are able to change plans throughout the year under the “monthly special enrollment periods.”  As such, they may enroll in a different plan that includes the preferred provider, but moving from one health plan to another health plan is not instantaneous.  There is a delay in moving from one plan to another of between 13 days and 45 days, depending on when the plan change was requested.

    For the general population, Marketplace enrolled individuals are not able to change plans, except in two instances:

    • During the open enrollment period.  The change must be requested during the initial open enrollment period, which continues until February 15, 2015.
    • If eligible for a special enrollment period during the year.

    To select a different health plan:

    • The steps to change plans are outlined here.
    • When changing plans with the same insurance company, the health plan is to apply any cost-sharing paid under the initial plan to the out-of-pocket maximum under the second health plan.
  • Question 6

    How do I file a complaint about health insurance purchased through a Marketplace?


    There are three different avenues for reporting problems with decisions or actions taken by a Qualified Health Plan (QHP) or by the Marketplace.

    Marketplace Appeal:  Appeals of an eligibility determination made by a Marketplace are to be filed with the Marketplace through a paper form. The forms may be accessed at: https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/.  For example, an applicant may appeal an eligibility determination if there may be a mistake about the applicant’s income, household size, citizenship or immigration status, Indian status, or residency.

    QHP Appeal:  Appeals of health care coverage decisions are to be filed through the QHP’s appeal process.  A “health coverage decision” typically involves a QHP’s approval or denial of authorized services.  Contact your QHP directly to determine the process to file an appeal of a health service coverage decision.  The first step is an internal appeal with the QHP.  If not satisfied, an enrollee may file for an external review of an appeal.

    A review of the second-level appeal process requirements on QHPs (External Review) is contained in this link.  For FFM states, this second-level appeal is referred to as the “HHS-Administered Federal External Review Process for Health Insurance Coverage”.

    Complaint to Marketplace:  Each Marketplace is to establish a complaint system to assist QHP enrollees.  For the Federally-Facilitated Marketplace (FFM), the FFM established a complaint system for use in the 36 FFM states.  The system is referred to as the Health Insurance Casework System (HICS). The HICS is described in detail below.

    For non-FFM states, each state-based Marketplace is also required to set up a mechanism to process complaints from QHP enrollees.  For enrollees in state-based (non-FFM) Marketplace states, contact the Marketplace to inquire about the process for filing complaints.

    Health Insurance Casework System (HICS) for FFM Enrollee Complaints
    The HICS is to be used in FFM states: a) when an enrollee is unsuccessful resolving an issue directly with a QHP; and, b) if the complaint is not an “appeal” of an eligibility determination by a Marketplace or an appeal of a coverage decision (i.e., an “alternative benefit determination”) by a QHP.

    Examples of potential complaints that are appropriate to file with the HICS include:  The wrong cost-sharing amounts being charged an enrollee; the QHP stating that the enrollee is not covered by the QHP; or the QHP charging the wrong insurance premium amount.  Other complaints might involve lack of access to specialty (or other) providers and failure of a QHP to issue accurate enrollee cards.

    Complaints in FFM states (under the HICS) may be filed through the FFM Call Center at 1-800-318-2596.  The complaint may be filed by you or someone authorized to interact with the Marketplace on your behalf.  (An individual may also wish to contact the state’s insurance regulator to file a complaint.)  At this time, there does not appear to be an ability to file a complaint through the HealthCare.gov Web site.

    When calling the Call Center, the Call Center will enter your information into HICS, and the complaint will be provided to the QHP for resolution.  An FFM caseworker will be assigned to the complaint.
    There are timeframes established for QHPs to resolve complaints:

    • Urgent Issue:  Complaints regarding “urgent” issues are to be resolved by the QHP within 72 hours of receiving the complaint from the FFM.  Urgent cases are those in which there is an immediate need for health services; and, if the non-urgent standard were used, could seriously jeopardize the enrollee’s or potential enrollee’s life; health; or ability to attain, maintain, or regain maximum function, or one in which the process for non-urgent cases would jeopardize a potential enrollee’s ability enroll in a QHP through FFMs.
    • Other Issues:  Non-urgent issues are to be resolved within 15 calendar days of receiving the complaint from the FFM.

    The QHP is to communicate resolution of the complaint to the enrollee within three days of resolving the issue.  This may be done in writing or verbally.  If verbally, the QHP is to follow-up and provide a written statement to the enrollee “in a timely manner.”  In 2014, the FFM will consider the QHP in compliance with the timeframes for resolving issues “as long as [the QHP is] making good faith efforts to comply with the regulatory requirements.”  The QHP is also to enter – within 7 days of resolving the issue – a description of the resolution into HICS, so the FFM staff will have information on how the QHP represents it responded to the complaint.  For 2015, QHPs may be required to more strictly meet the processing time standards above.

    More information on the HICS can be accessed here.

    Additional Avenues

    CMS (Centers for Medicare and Medicaid Services) Central Staff:  In addition to HICS, complaints may be filed with the Centers for Medicare and Medicaid Services (CMS) central office staff by sending an email to Nancy Goetschius at Nancy.Goetschius@cms.hhs.gov.  The types of complaints that are most appropriate to file with Ms. Goetschius are Indian-specific issues, particularly issues that appear to be systemic.

    NACS (Native American Contacts):  In addition to HICS and the central CMS staff, regional CMS Native American Contacts (NACS) may be contacted to seek assistance with Marketplace and QHP-related issues.  A listing of regional NACS may be accessed here (Updated 2/12/16)

  • Question 7

    Is the list of Tribes on the Marketplace website accurate?


    The ACA’s definition of “Indian Tribes” includes Federally-recognized Tribes as well as Alaska Native regional and village corporations.

    Here are the links to “Indian Tribes”, as defined in the ACA:

    This is the link to the  Bureau of Indian Affairs website referenced on the Marketplace website.

    There have been reports that some tribal entities that meet the definition of “Indian tribe” under the ACA are not included in the links on the Marketplace website.  If an eligible Indian tribe is not listed in the drop down box on the Marketplace website, report this omission to:

    In addition, it has been reported that some eligible tribes in California are not showing on the Marketplace list.  Please contact the California Rural Indian Health Board if you have concerns with California Tribes that are not included on the list. (http://www.crihb.org/)

  • Question 8

    Should an American Indian or Alaska Native (AI/AN) eligible to enroll in a catastrophic plan through a Marketplace enroll in a catastrophic plan?


    No, it is not recommended.  Because individuals enrolled in a catastrophic plan are not eligible for premium tax credits (PTCs), the modest savings on premiums achieved by enrolling in a catastrophic plan would potentially lock someone out of receiving substantially more beneficial PTCs.  In addition, AI/ANs enrolled in a catastrophic plan are not eligible for cost-sharing reductions (CSRs).  This means AI/AN who enroll in catastrophic plans would have to pay the high deductibles and co-pays for the catastrophic plan.

    BACKGROUND:  In general, individuals younger than 30 years old and others with a hardship exemption may enroll in a catastrophic plan through a Marketplace.  A catastrophic plan offers a high deductible, with the plan covering health care costs above the deductible amount.   A catastrophic plan is not much different than a bronze plan, as most bronze plans offered are largely high-deductible plans.  A typical catastrophic plan has a deductible of $6,350, except for coverage of three primary care visits before the deductible is reached.

    Some individuals who have a projected income below 100 percent of the federal poverty level (FPL)–and as a result would not be eligible for a PTC–may see the lower premiums for a catastrophic plan as attractive.  This is likely not to be the most advantageous pick.  First, although someone may anticipate having very low earnings in 2014 (and as a result of having an income under 100 percent FPL, not being eligible for a PTC), if the individual ends the year with an income at or above 100 percent FPL ($11,490 per year; $14,350 per year in Alaska), the individual will become eligible for a PTC on their federal income taxes IF enrolled in metal-level coverage (bronze, silver, gold, or platinum).  However, if the individual had not been enrolled in one of the metal-level plans, the individual would not be eligible for a PTC during that period.  Second, the comprehensive Indian-specific cost-sharing reductions are only available if enrolled in a “metal level” plan like a bronze plan.  Catastrophic plans are not considered “metal level” plans.

    EXAMPLE:  In one state reviewed, there is a savings of approximately $25 per month between the premium charged a 27-year-old for a catastrophic plan and the premium for a bronze plan (before tax credits are applied). The catastrophic plan is $300 cheaper for the year.  But, this $300 per year in lower premium costs from enrolling in a catastrophic plan is much smaller than if the same person enrolled in a bronze plan with slightly higher premiums but with PTCs.  In the same state, someone enrolling in a bronze plan and earning $15,000 would be eligible for PTCs in the range of $3,275 (21 years old) to $10,403 (64 years old), reducing their premium costs dramatically.  In addition, the CSRs (cost-sharing reductions) under a bronze plan would provide an average of $1,700 in reduced out-of-pocket costs compared to a catastrophic plan with no CSRs.

  • Question 9

    A family wants to purchase health insurance, but because the family has children who qualify for CHIP, the family cannot apply for coverage through the Marketplace (for the children). Can the family decline the CHIP coverage and all family members enroll in coverage through a Marketplace?


    All individuals (and families) that are in the United States legally are able to purchase health insurance coverage through a Marketplace if they live in the service area of the Marketplace and are not incarcerated.  But, if an individual is eligible for Medicaid or CHIP, the individual is not eligible to receive premium tax credits through the Marketplace.  If an individual or a family were eligible but did not want Medicaid or CHIP coverage, the individual or family would have to pay the full cost of coverage themselves, without assistance from the Federal government.  Individuals and families are also able to purchase health insurance coverage outside a Marketplace, but again they would have to pay the full cost themselves and would not be able to access premium tax credits.

    With regard to cost-sharing reductions, eligible AI/ANs would be able to secure the Indian-specific “limited” cost-sharing reductions, even if not eligible for premium tax credits.  This means that if an AI/AN meeting the definition of Indian under the ACA enrolls in a Marketplace plan but is not eligible for premium tax credits because the individual is eligible for CHIP or Medicaid, the individual would be able to cost-sharing requirements eliminated when being served by an Indian health care provider and when referred to non-Indian health care providers by an Indian health care provider.

  • Question 10

    If Tribal members receive per capita checks that are taxable, do they have to report this to the Marketplace for Medicaid eligibility determination?


    First, if Indian-specific income is subject to federal taxes, it should be reported on the federal income tax filing, and it will be included in the Modified Adjusted Gross Income (MAGI) calculation.  Second, some Indian-specific income that is taxable is excluded from Medicaid eligibility determinations.  There is a section on the Marketplace application that asks applicants to lists certain types of income that are not counted for Medicaid eligibility purposes.  The income that is reported in this section of the Marketplace application is subtracted from MAGI for Medicaid eligibility determination.

    Per capita from gaming revenues is taxable, is included in the MAGI, and is not reported separately (and not subtracted) on the Marketplace application to determine Medicaid eligibility.

    Almost all other types of per capita payments that are taxable are excluded from income in Medicaid eligibility determinations, and those should be reported on the Marketplace application, including:

    • Income from natural resources, usage rights, leases or royalties; and
    • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian land by the Department of Interior (including reservations and former reservations).

    A detailed review of the treatment of “Indian income” for health insurance eligibility purposes has been prepared by Sam Ennis, J.D. (Sonosky, Chambers, Sachse, Endreson & Perry, LLP) and others.  The analysis is linked here.

  • Question 11

    Is a Tribal Employee whose employer does not/or is not currently providing insurance eligible to apply through the insurance marketplace?


    Yes. There are two steps to this answer.

    First, all persons legally residing in a state (and not incarcerated) are permitted to enroll in coverage through the state’s Marketplace, but unless meeting additional criteria, would not be eligible for premium tax credits to help cover the cost of premiums. (An individual could have an offer of coverage from an employer and, nonetheless, decide to enroll in coverage through a Marketplace if the individual paid the full premium.)

    Second, for individuals meeting the criteria above and who do not have an offer of coverage through a current employer, these individuals would be eligible to enroll in coverage through a Marketplace. And, these individuals would be eligible for premium tax credits if there incomes were between 100 percent and 400 percent the federal poverty level applicable in the state. (Note: An offer of “COBRA” coverage does not prevent a former employee from accessing premium tax credits when enrolling through a Marketplace.)

    Enrollment through a Marketplace is permitted to take place: (1) during the annual open enrollment period or (2) during a special enrollment period.

  • Question 12

    We have had many people who have applied for healthcare coverage and are members of a Federally Recognized Tribe, however, the Tribal registration office is backlogged almost 2 years with applications and cannot rush anyone’s application just to fulfill the requirements for documentation needed for proof of Tribal citizenship for the Marketplace. Is there any other documentation these people can use so they don’t lose their coverage?


    On the Marketplace application, the following is identified as acceptable documentation:

    “Member of an Indian tribe or shareholder in an Alaska Native corporation.

    Submit ONE of the following:

    • Enrollment or membership document from a federally-recognized tribe or the Bureau of Indian Affairs (BIA). It must be on tribal letterhead or an enrollment/membership card that contains the tribal seal and/or an official signature, or a Certificate of Degree of Indian Blood (CDIB) issued by the BIA or a tribe, if the CDIB includes tribal enrollment information.
    • Document issued by an Alaska Native village/tribe, or an Alaska Native Corporation Settlement Act (ANCSA) regional or village corporation acknowledging descent, or affiliation, or shareholder status, or participation in village or Alaska Native community affairs. The document can also include a CDIB issued by the BIA or tribe, if the CDIB includes ANSCA shareholder status or information regarding membership in an Alaska Native village.”

    Alternatively, although the Marketplace website identifies a couple of specific examples of documentation that may be provided, “any relevant documentation” issued by a federally recognized tribe indicating tribal membership is acceptable, without specifically being an enrollment card. One option might be issuing a letter on tribe letterhead that states something akin to the following:

    “This person is known to me as a [ Tribe] Tribal Member. Their family has lived in our area for several generations. They are registered to use the Indian Health Service clinic, and they presented documentation showing tribal membership at the time of their registration. They have applied for a Tribal Enrollment card, but our enrollment office is backlogged, so we hope you will accept this letter as documentation for eligibility for Indian status under ACA until such time as our Enrollment Office can issue a card.”

    If documentation is not immediately available that meets this standard, it may be possible to submit an application for coverage through a Marketplace and provide documentation at the point the documentation becomes available. The general guideline on this is applicants are requested to submit documentation within 90 days from the date the Marketplace asks for documentation. (This might occur in the eligibility determination letter.) But, during this phase-in period of Marketplace operations, it may be allowable to extend beyond the 90-day period.

    As long as no fraud is being committed (meaning the applicant in fact meets the definition of Indian contained in the Affordable Care Act), an individual might apply for coverage and then submit documentation when it becomes available. If the Marketplace imposes a cut-off date by which the documentation must be provided, and the documentation is not provided, the Marketplace may then terminate coverage or may simply cut-off providing the comprehensive Indian-specific cost-sharing protections.

    And, for reference, the regulation on providing documentation for Indian status under the Affordable Care Act is linked here.

  • Question 13

    An American Indian patient is offered insurance through their employer, but doesn’t take it because this individual can’t afford it (even though it is considered affordable). The Tribe would like to enroll this individual into the Marketplace under Tribal sponsorship. This individual is legally married to an individual unauthorized to be in the United States and files her taxes as “single”. To enroll this individual in the marketplace, should they be enrolled as single to stay consistent with their tax filing process?


    There are a few issues to address here:

    • Persons in the country illegally cannot purchase insurance through the Marketplace, even if they pay the full premium. They can purchase it outside the Marketplace, though, and the QHP issuers are supposed to charge the same premium (if it is the same product) outside the Marketplace, if they offer it outside the Marketplace.
    • The American Indian patient will not be eligible for premium tax credits because she had an offer of “affordable” coverage. So, for that purpose, her income does not matter.
    • With regard to the “limited” and “zero” cost-sharing protections, income level does matter. She has the option of asking for an income determination and, if between 100 – 300% FPL, getting the zero cost-sharing protections (or limited cost-sharing protections if other income). Or, she can decide not to have a “financial assistance” (or some other term used) determination, and she will be eligible for the limited cost-sharing protections (assuming she is a member of a FRT).
    • It is unclear whether she should file taxes as single or something else for tax purposes. Therefore, we suggest that this individual contact an accountant or tax attorney to advise. The individuals’ coverage type, though, would need to be “single” (separate from their tax-filing status) as the spouse is not eligible to enroll through the Marketplace.
  • Question 14

    If a Tribe's per capita payment fluctuates annually, this changes an individual's income. Has this been a problem? Any Suggestions?


    When enrolling in the Marketplace, an individual is to make their best assessment of annual income. Based on this estimate of annual income, the amount of the premium tax credit is calculated (estimated) by the Marketplace.

    Once the Marketplace calculates the amount of the premium tax credit available to the individual, an individual (and their Tribal sponsor) is able to determine the amount of the (estimated) premium tax credit they would like to receive as an Advanced Premium Tax Credit (APTC). The APTC can be set from 0 percent to 100 percent.

    A Tribal sponsor has a number of policy decisions to make related to the claiming and liability for premium tax credits. Will a sponsored individual need to repay the Tribal sponsor if they receive a portion of the premium tax credit as a refund on their taxes (because too little was applied to premiums during the year as APTC)? Will the Tribal sponsor reimburse the sponsored enrollee if the enrollee had too much APTC applied to their premiums during the year and is required to repay a portion of the APTC on their federal s taxes?

    When determining: (1) the per capita payment amount to include in projected annual income; and, (2) the percentage of the APTC to be applied to premiums, a Tribal sponsor may wish to balance the potential for excess (or under payment) of the premium tax credit with the administrative requirements to collect from or issue a refund to the enrollee.

    To ensure the Tribal sponsor has sufficient resources to reimburse the sponsored enrollee for any tax liability associated with Marketplace coverage (if this is the policy established), the Tribal sponsor may wish to establish a reserve for potential repayment of excess APTC paid by the federal government on behalf of an sponsored enrollee.

    When a Tribe decides on the amount of a per capita distribution, the group that manages the Tribal sponsorship program should determine whether the amount of the distribution is higher or lower than what was projected at the time of application. Sponsored Marketplace enrollees should be notified at that time to participate in updating the enrollee’s Marketplace account to make a change in the projected income for the year, which will then recalculate the APTC amount. (Marketplace enrollees are required to update their accounts with respect to eligibility standards within 30 days of a change.) The premium amount paid by the Tribal sponsor for the remainder of the year will then need to be adjusted (higher or lower) based upon the change in the available APTC. If this is done in a timely way, the reconciliation process during tax time should have little deviation from the APTC amount paid out over the year.

  • Question 15

    What happens at tax time with the tax credits if the the Tribe pays for the plan?


    It is important to understand that – even if an individual is sponsored by a Tribal organization when enrolling in a health plan offered through a Marketplace – the premiums, premium tax credits, and potentially tax liability if excess premium tax credits are paid out during the year, are tied to the individual enrollee.

    As such, the sponsored enrollee may have a tax liability if excess Advanced Premium Tax Credits (APTCs) were paid to a Qualified Health Plan (QHP) issuer on behalf of the enrollee. This might occur if the sponsored individual’s projected income for the year was lower than the actual income earned over the year. Alternatively, if the sponsored enrollee is eligible for more premium tax credits than the amount of APTCs paid out over the year by the federal government to the QHP on the enrollee’s behalf, the enrollee will be eligible for a “refund” on the enrollee’s federal income taxes.

    In all instances, an individual is required to file federal income taxes if they receive APTCs; otherwise, the individual will be required to repay all APTCs.

    The Tribal sponsor may wish to establish policies that ensure the sponsored enrollee is repaid by the Tribal sponsor for any APTC-related amounts owed to the federal government. For instance, a Tribal sponsor may commit to reimbursing the sponsored enrollee for any excess APTCs paid out on their behalf by the federal government. In addition, a Tribal sponsor may decide to pay for professional tax-filing assistance for a sponsored enrollee.

  • Question 16

    Who covers the portion of the cost-sharing reductions (CSRs) that are waived under the Indian-specific cost-sharing variations (e.g., “zero” or “limited” cost-sharing variations)? Does the Qualified Health Plan (QHP) pay 100 percent of the payment owed to the provider (including the CSR amount not paid by the patient), or does the provider lose this revenue?


    When a patient is enrolled in an Indian-specific cost-sharing plan variation, the QHP is required to make full payment to the provider, including the amount of CSRs not paid by an enrollee with Indian-specific cost-sharing reductions. For instance, if the approved provider charge is $100, with standard patient cost-sharing of $20, for an individual enrolled in a zero or limited cost-sharing variation, then (1) the patient would not be liable for the co-payment and (2) the provider would be paid the full $100 by the health plan.

  • Question 17

    Is it okay to limit eligibility in a sponsorship program to high-cost members?


    Yes, Tribal sponsors are able to determine the eligibility criteria for their sponsorship programs.  For instance, sponsorship programs are permitted—but not required—to apply eligibility criteria such as financial need.  For more information about Tribal sponsorship programs, click here.

  • Question 18

    How do we let providers know that Native Americans are covered by the Indian-specific cost-sharing protections and that they do not pay co-payments, coinsurance, or deductibles? Sometimes, the private provider says that the Tribe’s Purchase/Referred Care (PRC) program is responsible for the bill.


    It is the responsibility of the Qualified Health Plan (QHP) issuer to inform a provider of any cost-sharing amounts owed by a patient.  This includes informing the provider if no cost-sharing is owed because the patient is eligible for the comprehensive Indian-specific cost-sharing protections whereby all cost-sharing amounts are covered by the QHP (although a PRC referral may be needed to secure the cost-sharing protections when enrolled in a “limited” cost-sharing variation).

    To assist in informing a provider that a patient does have comprehensive cost-sharing protections because he or she is enrolled in the “zero” or “limited” cost-sharing variation, if a Tribal health organization issues a “referral for cost-sharing” the Tribal health organization may wish to include a statement on the referral such as: “This referral for cost-sharing is for an individual enrolled in a health insurance plan through the Health Insurance Marketplace with comprehensive cost-sharing protections under 45 CFR § 156.410(b)(3) (“limited cost-sharing variation”).”

    Unless a Tribal health organization is agreeing to make payments for some or all of the services provided to a QHP enrollee, the Tribal health organization should not issue a PRC “authorization” for payment.  In fact, a Tribal health organization may wish to explicitly indicate this by including a statement, such as: “This referral does not serve as an authorization for payment by the Purchased/Referred Care Program (aka contract health services).”

  • Question 19

    Are there samples of referral forms used to secure the “limited” cost-sharing protections from non-Indian health care providers?


    Linked here are two sample referral forms.

    Sample Form – 1

    Sample Form – 2

    As the requirement to gather and maintain documentation pertaining to the Indian-specific cost-sharing protections has been placed on the Qualified Health Plan (QHP) issuer, Tribal health organizations will need to work with QHPs on acceptable forms and processes for documentation of a referral.  But, requirements placed on a Tribal health organization by QHP issuers pertaining to the issuance of a referral for cost-sharing should be no more restrictive (or burdensome) than is provided for in the Centers for Medicare and Medicaid Services (CMS) guidance on this issue, dated May 9, 2014. The CMS guidance is linked here.

    It is important to note that referrals for cost-sharing may be issued by a Tribal health organizations before or after an item(s) or service(s) is provided to an enrollee.

    Example of Sample #2 / Additional Information
    A referral for cost-sharing protections is for purposes of meeting the documentation requirements contained in the CMS Center for Consumer Information and Insurance Oversight (CMS/CCIIO) guidance document issued on May 9, 2014 and titled “Cost-Sharing Reductions for Contract Health Services.”

    Namely, a QHP issuer is to “document eligibility for reimbursement for cost-sharing reductions provided to an enrollee on an EHB provided through referral under contract health services, as defined in 25 U.S.C. 1603(5) and any implementing guidance, and to meet the standards set forth at 45 CFR 156.480”,

    Referral form Sample #2 is designed so that the full documentation required to be gathered and maintained by the QHP issuer is secured through a combination of information (1) provided by the referring Tribal health organization (THO) and (2) provided by the QHP issuer.

    The Sample #2 referral for cost-sharing protections is designed to ensure the required THO-suppliedinformation is provided and documented:

    • Identification information for patient receiving an item or service through referral (name of patient; date of birth of patient)
    • Name of the Indian health program (aka THO) issuing the referral under contract health services
    • Contact information for the THO issuing the referral
    • Date of the referral

    The information contained in the THO’s referral for cost-sharing protections (namely, the four bullet points above) is designed to be combined with the following QHP issuer supplied service-specific information:

    • Name and address of the provider delivering the item or service
    • Description of the item or service furnished through referral under contract health services
    • Date(s) the item or service was provided

    The term “contract health services” was renamed “Purchased/Referred Care” in the Consolidated Appropriations Act of 2014.


  • Question 20

    Mechanism for Payment for ACA Plan Sponsorship: We are currently piloting a sponsorship program and have signed up two patients so far. We have tried to set up a payment mechanism with Blue Cross Blue Shield of Michigan, but have been told by them that they have no mechanism in place for tribes to make bulk payments. We are required to have patients bring monthly invoices to us so that we can call or mail payments into the plan individually. This is fine for a handful of citizens, but would be very inefficient if we were to enroll on a larger scale.


    There is no requirement for QHPs to arrange aggregate billing for sponsored individuals. But in some locations, tribal sponsors have reached agreement with the QHP to send a list of sponsored individuals to the QHP, and the QHP identifies the amount of the premiums due.  The tribal sponsor then makes a single payment for those on the list.

    Alternatively, it may be possible to have a hard copy of the monthly bill sent to the enrollee and an electronic copy sent to an email address of the tribal sponsor (or the reverse of this).  The tribal sponsor would then be able to have timely access to the information, even if the tribal sponsor had to submit (electronically or with a paper check) payment for each enrollee.  Having this secondary mailing address also may be useful for the tribal sponsor to receive Explanation of Benefits for its sponsored enrollees (as would the enrollee).
    Another approach is the tribal sponsor makes payment for the entire coverage year at once.  This is typically in situations where the monthly premium amount is very low.

  • Question 21

    Q. Does a tribal representative need to have training, certification, etc. to assist with Marketplace enrollment?


    No.  Individuals and entities in a state with a Federally-Facilitated Marketplace (FFM) that provide application and enrollment assistance related to health insurance or insurance affordability programs do not have to have certification as application counselors, whether by the Marketplace or state Medicaid or CHIP agencies, or receive designation by the Marketplace to continue providing those services or communicating with consumers.  This applies to both existing and potential application and enrollment assistance programs.


    There are two optional avenues to secure training and certification, if you and your organization prefer to do so.  The first is the certified application counselor (CAC) program.  The certification of an individual as a CAC provides an assurance to consumers that they will receive assistance from individuals trained by the Marketplace and overseen by organizations that protect personally identifiable information.  Individuals not certified as application counselors can take the certified application training, which the Centers for Medicare and Medicaid Services (CMS) makes available to the general public and expects to help many types of organizations and assistance personnel provide Marketplace-related education and application and enrollment assistance.  However, someone not certified as a CAC cannot present themselves to the general public as a CAC.


    The second avenue is the Navigator program.  Funded through state and federal grant programs, Navigators assist consumers in completing electronic and paper applications to establish Marketplace eligibility, determine whether they qualify for health insurance affordability programs, and enroll them in coverage.  In addition, these individuals provide outreach and education to consumers to raise awareness about the Marketplace and refer consumers to ombudsmen and other consumer assistance programs when necessary.  In states with State-Based or State Partnership Marketplaces, non-Navigator assistance personnel, funded through grants or contracts administered by a state, generally perform the same functions as Navigators.


    A step-by-step overview of enrollment assister training for the FFM for 2016 is accessible at https://marketplace.cms.gov/technical-assistance-resources/training-materials/launch-ffm-assister-training.pdf.

    The CMS Enterprise Portal, which houses the training materials, is accessible at https://portal.cms.gov/wps/portal/unauthportal/home/ (NOTE:   new users must create an account)


    A series of additional training materials made available by CMS is accessible at https://marketplace.cms.gov/technical-assistance-resources/training-materials/training.html.


    For additional information on requirements for persons providing Marketplace enrollment assistance, see the final rule issued by CMS on July 17, 2013, and titled “Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel; Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors.”



    For information on any additional requirements on enrollment assisters imposed by states, you should contact your state department of insurance.  A list of state departments of insurance is accessible at http://www.naic.org/state_web_map.html.

  • Question 22

    Q - We currently have a high cost patient that we would like to sponsor premiums for under an ACA plan, however, the patient’s spouse, who is not a Tribal citizen and not eligible for our sponsorship program, wishes to obtain a marketplace plan as well. Is it possible to sign the citizen up for an individual plan which we (the Tribe) would sponsor and then the spouse could sign herself up under her own individual plan? How would having to use combined household income to determine tax credits affect the enrollees? Do you know what other Tribes are doing in these types of cases?


    A – Yes.  In fact, you need to have the two individuals sign-up in two separate plans.  If an Indian and a non-Indian enroll in the same plan, the least comprehensive cost-sharing protections that one of the individuals is eligible for is applied to all enrollees in the plan.


    The sign-up of the two individuals can happen at the same time or separately.


    The Tribe (and Tribal member) will need to establish a policy of how much of the premium tax credit in this situation goes to the Tribal member and how much to the spouse.  50/50 would be a reason approach.  You can also set the premium paid out in advanced at 50% when on the Marketplace, so each person would only access 50% of the total.

  • Question 23

    Q. I live in Arkansas. My total family income is more than 300 percent of the federal poverty level. ? I was told we were at about 364%. I am Indian but my husband is not. I was told I was at a 03 level for cost-sharing protections but I would need a referral from an Indian health care provider to receive the cost-sharing protections. I don't live near an Indian Health Care Provider. Would I have to have a referral to be able to go to my family doctor here who is a non-Indian health care provider, or any other doctor for that matter? In fact, my Tribe does not operate health care facilities. I was told there was no program for me as a Delaware tribal member by Marketplace other than the normal Silver 3500 Plan. Just wondering if that was true? Is there an insurance program I can enroll in? I understand that I would have to be on my own policy for Indian benefits.


    You are correct that under the “03” or “limited cost-sharing variation”, you need a referral to secure the 100% cost-sharing protections when receiving services from a provider that in not an Indian health care provider.  And, you are correct that you need to enroll in a plan separately from your spouse who does not have Indian status in order to receive the comprehensive Indian-specific cost-sharing protections.


    Your Tribe or the closest I/T/U would need to provide the referral.  As I understand it, another Tribe is operating health facilities on behalf of members of your Tribe.  You can contact that Tribe to inquire about receiving a referral for the cost-sharing protections.  Alternatively, you might contact the closest Indian health care provider (sometimes referred to as an “I/T/U”) to ask if they would issue a referral for you to secure the Indian-specific cost-sharing protections.

  • Question 24

    Q. Do Tribes and THOs that sponsor IHS beneficiaries need to report to the Internal Revenue Service (IRS) (such as on Form 1095 (A, B or C)), or report to the federal Department of Health and Human Services (HHS)?


    Tribal sponsorship activities do not need to be reported to the IRS or HHS, at least for the 2015 and 2016 coverage years.  (This is a separate issue from reporting requirements on employers, whereby Tribes are likely to be subject to the reporting requirements.)

    Forms 1095 A, B and C are:

    • 1095-A:  Reporting by Health Insurance Marketplace to enrollees and to IRS
    • 1095-B:  Reporting by issuers and carriers to IRS, except for enrollees through a Marketplace
    • 1095-C:  Reporting by employers for full-time employees to the IRS

    And, the forms 1094-B and 1094-C are transmittal forms for 1095-B, and 1095-C, and as such are not required to be submitted by Tribal sponsors.

    Explanatory materials on Affordable Care Act reporting requirements from the Internal Revenue Service can be accessed at:  https://www.irs.gov/uac/About-Form-1095-C

    A Webinar on employer reporting requirements presented by the National Congress of American Indians can be accessed at: : https://www.youtube.com/watch?v=QPrNChaVsKw&feature=youtu.be

    However, in the proposed HHS regulation titled Notice of Benefit and Payment Parameters for 2017, there is a proposed rule that would require sponsors to report on their intention to conduct sponsorship.  The relevant section from the comments submitted by the Alaska Native Tribal Health Consortium (ANTHC) to the Centers for Consumer Information and Insurance Oversight (CCIIO)on this proposed rule is copied below:

    “4. Modification of Provisions Pertaining to Acceptance of Third Party Payments by QHP Issuers [§156.1250]

    Analysis:  The Proposed Rule would require entities authorized to make third party payments of premiums to notify CMS of their intent to pay the premiums of individuals enrolling through a Marketplace, a practice sometimes referred to as “sponsorship.”  The notices would be required to be made in a format and timeline specified in subsequent guidance.  At a minimum, the notification by the sponsoring entities would have to reflect the intent of the entity to make payments of premiums for Marketplace enrollees and to indicate the number of consumers for whom the entity intends to make payments.  In addition, in the Proposed Rule, CMS requests comments on this proposed requirement and on what additional information entities should have to provide as part of the notification.   To date, CMS has clarified that requirements imposed on other entities authorized to sponsor individuals through a Marketplace (namely private, non-profit foundations) do not apply to Indian Tribes, tribal organizations, and urban Indian organizations.  These requirements pertain to the eligibility criteria applied to sponsored individuals and the length of sponsorship of Marketplace enrollees.

    We believe that requiring Tribes, tribal organizations, and urban Indian organizations to report on the number of AI/ANs that might potentially enroll in coverage through a Marketplace as a result of sponsorship is redundant to existing reporting and data available to the Marketplace.  In addition, we believe the data that are currently readily available to the Marketplace are more accurate and more useful than data generated from projections of potential sponsors of enrollees through a Marketplace.

    Information on AI/AN enrollment is already readily available and identifiable to CMS as, at the time of enrollment through a Marketplace, AI/ANs are asked to indicate (1) whether they meet the definition of Indian under the Affordable Care Act, (2) whether they are eligible for services from an IHCP, and (3) whether they identify as AI/AN.

    The information that is already available to the Marketplace is derived from AI/ANs who are actually enrolled through a Marketplace, rather than projections on who might enroll, and as such, the information that might be requested from tribal sponsors would be less useful than the data that is already available to the Marketplace.

    Finally, Indian Tribes, tribal organizations, and urban Indian organizations are just beginning to engage in sponsorship of tribal members.  Imposing reporting requirements at this early stage that will require an Indian Tribe, tribal organization, or urban Indian organization to project how many individuals will be sponsored and over what period of time, as well as to report on other factors that might be imposed by CMS, is likely to hinder efforts of tribal entities to engage in sponsorship.

    Recommendation:  We ask CMS to clarify, as it has done previously with other requirements placed on some sponsoring entities, that Indian Tribes, tribal organizations, and urban Indian organizations are not subject to the reporting requirements at this time.”

    The final rule on the Notice of Benefit and Payment Parameters for 2017 was sent from HHS/CCIIO to the Office of Management and Budget in early February.  We anticipate the final rule will be released over the next few weeks.

  • Question 25

    Q. What is the definition of “Indian Tribe” used for purposes of the Indian-specific cost-sharing protections?


    Answer: There are two Indian-specific cost-sharing protections.

    • One of the Indian-specific cost-sharing protections is referred to as the “zero cost-sharing variation.”
      • Sometimes identified as the “02” cost-sharing protections.
      • Provides comprehensive coverage of cost-sharing.
      • Available to Indians enrolled through a Marketplace with household income between 100% and 300% of the federal poverty level.
    • A second Indian-specific cost-sharing protection is referred to as the “limited cost-sharing variation.”
      • Sometimes identified as the “03” cost-sharing protections.
      • Provides comprehensive coverage of cost-sharing, with a referral.
      • Available to Indians enrolled through a Marketplace with any household income level.

    For purposes of eligibility for the Indian-specific cost-sharing protections, “Indian” is defined as a person who is a member of an Indian Tribe.  An “Indian Tribe” is defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (ISDEAA) (25 U.S.C. 450b(d)).  ISDEAA section 4(d) reads:

    • ‘‘Indian tribe’’ means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
  • Question 26

    Q. Are premium sponsorship payments (and / or payments covering out-of-pocket costs) made by a Tribe or tribal organization sponsor considered taxable income for the recipient?


    Answer 1: First, it is important for a Tribe or tribal organization to present this question to their tax attorney / accountant.  Here is some background information on the subject.


    The Internal Revenue Service (IRS) has issued a guidance document on the tax treatment of what are referred to as “qualified Indian health care benefits,” which relate to section 139d of the Internal Revenue Code.  Here is the link:




    In summary, on the specific issue of premium sponsorship payments made by a Tribe or tribal organization, here are the eligibility criteria for the exemption from taxation:


    • Premium payments made by a Tribe or tribal organization are not taxable to the recipient if the recipient is:
      • An enrolled tribal member or ANCSA shareholder; or
      • A dependent or spouse of an enrolled tribal member or ANCSA shareholder.
    • For an individual who is or was a dependent of a tribal member or ANCSA shareholder (and who might have received tax-free premium sponsorship payments), when that individual no longer is a dependent of the tribal member or ANCSA shareholder (because of age or other circumstance), the premiums paid by a Tribal sponsor after the person no longer is a dependent are taxable (if the former dependent has not become an enrolled tribal member or ANCSA shareholder).

    Tribes and tribal organizations are advised to check with their tax attorney and / or accountant to determine under what circumstances the Tribe or tribal organization is required to issue a Form 1099 to a recipient of premium payments.


    A detailed review of the treatment of “Indian income” for health insurance eligibility purposes is linked here.

  • Question 26b

    Q. If our Tribe is paying for Medicare Part B and Part D premiums for our elders, is this considered taxable income?


    Answer 2:  Similar to the answer to the question of whether premium payments made by a Tribe or tribal organization to sponsor Tribal members for Marketplace coverage are taxable:

    • Payments for Medicare Part B premiums and Part D premiums made by a Tribe or tribal organization are not taxable to the recipient if the recipient is:
      • An enrolled tribal member or ANCSA shareholder; or
      • A dependent or spouse of an enrolled tribal member or ANCSA shareholder.

    Additional information on the Internal Revenue Service (IRS) tax treatment of what are referred to as “qualified Indian health care benefits,” which relate to section 139d of the Internal Revenue Code, can be accessed in a guidance document at the following link:

  • Question 27

    Q.: Does eligibility for a retiree health insurance coverage from a former employer (or through the former employer of a spouse) impact eligibility for premium tax credits for Marketplace coverage?


    A.: The short answer is, not unless the retiree / spouse enrolls in the coverage.  Meaning, if a retiree does not enroll or disenrolls from employer sponsored retiree coverage, for the months not enrolled in the employer plan and enrolled in Marketplace coverage, the individual may be eligible for premium tax credits.

    The longer answer is:

    For purposes of determining eligibility for a premium tax credit, IRS does consider retiree health insurance coverage minimum essential coverage, but only if the retiree actually enrolls in the coverage.  At § 1.36B-2, Eligibility for premium tax credit, paragraph (a) provides that individuals can receive a premium tax credit for any month that they do not qualify for “minimum essential coverage (within the meaning of paragraph (c) of this section).”  Paragraph (c)(3)(iv) on post-employment coverage reads, “A former employee (including a retiree), or an individual related (within the meaning of paragraph (c)(3)(i) of this section) to a former employee, who may enroll in eligible employer-sponsored coverage or in continuation coverage required under Federal law or a State law that provides comparable continuation coverage is eligible for minimum essential coverage under this coverage only for months that the former employee or related individual is enrolled in the coverage.”

    Here is a link to the federal regulation on this topic: