CurrentMedicarePolicy N/A
Guidance on Annual Redetermination and Re-enrollment for Marketplace Coverage for 2024 and Later Years
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Guidance describing alternative annual redetermination and re-enrollment procedures for Health Insurance Marketplaces using the federal eligibility and enrollment platform for benefit years 2024 and later; affects Marketplace operations, enrollees receiving APTC and income-based CSR, and issuers.
Policy Summary
PayerMedicare
PolicyGuidance on Annual Redetermination and Re-enrollment for Marketplace Coverage for 2024 and Later Years
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionRequest updated IRS data for enrollees who authorized the Marketplace to do so for annual redetermination.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2024+benefit years covered
3redetermination options
30reporting timeframe (days)
2FTR threshold (tax years)
removedupper APTC limit (2024-25)
Eligibility determination & re-enrollment criteria
inv-01: Establishing upcoming-year eligibility for non-contacting enrollees
How the Marketplace establishes upcoming-year eligibility for enrollees who do not contact the Marketplace by the plan-selection deadline:
Apply the following ordered determinations based on enrollee group membership and available data.
FIRST
- If the enrollee was in the Opt-Out Group or the Repeat Passive Re-Enrollee Group, or in the special notice or Failure-to-File-and-Reconcile group when in operation, the Marketplace will discontinue APTC and income-based CSR and re-enroll the enrollee without APTC/CSR where re-enrollment is possible in accordance with 45 CFR 155.335(j).
- If the enrollee provided household income for the current benefit year by creating or updating an application associated with an enrollment and is not in the opt-out/repeat groups, the Marketplace will project annual household income and family size from that most recent application, adjust to the upcoming benefit year using updated FPL tables, and use upcoming benchmark plan premium information to calculate APTC and determine eligibility for income-based CSR for the upcoming benefit year.
- If the enrollee contacts the Marketplace and obtains an updated eligibility determination by the plan-selection deadline but does not select a QHP (and does not change household composition or location), the Marketplace will use the updated determination for automatic re-enrollment; if the updated determination shows Medicaid/CHIP eligibility and the enrollee does not cancel the QHP, the Marketplace will auto re-enroll in a QHP while discontinuing APTC/CSR when Medicaid/CHIP eligibility is verified.
All re-enrollees will receive an eligibility determination notice and an enrollment confirmation at the point of re-enrollment explaining the results of the annual eligibility and re-enrollment process.
inv-02: APTC/CSR determination and re-enrollment criteria — ordered sequence of methods to determine projected annual household income and APTC/CSR eligibility
Marketplace will apply a sequence of methods to determine projected annual household income and eligibility for APTC and income-based CSR for enrollees with APTC or income-based CSR who are not in opt-out or repeat passive re-enrollee groups.
Method 1: If the enrollee provided household income information for the current benefit year by creating or updating an application associated with an enrollment, use the projected annual household income and family size from that most recent application adjusted to the upcoming benefit year, updated FPL tables, and upcoming benchmark plan premium information to calculate APTC and determine eligibility for income-based CSR.
Method 2: If the enrollee was automatically re-enrolled for the current benefit year, did not submit an updated application, and IRS income data is available: evaluate IRS income with the family size from the most recent application, compare to updated FPL tables, adjust IRS income to the upcoming benefit year, and use that to calculate APTC and determine income-based CSR. If resulting projected income exceeds the applicable upper household income limit for APTC, discontinue APTC and income-based CSR; if the IRS-based projected income is below the applicable lower household income threshold for APTC eligibility, proceed to Method 4.
Method 3: If IRS income is unavailable or the IRS-based evaluation results in income under the lower threshold, use the projected annual household income (adjusted to the upcoming benefit year) and family size from the most recent application associated with an enrollment, updated FPL tables, and benchmark plan premium information to calculate APTC and determine eligibility for income-based CSR for the upcoming benefit year.
Automatic re-enrollment: Federal Marketplaces will automatically re-enroll current benefit year enrollees who do not select a QHP by the last day to select a plan for coverage effective January 1, to the extent the enrollee can be re-enrolled; re-enrollees receive an eligibility determination notice and enrollment confirmation and may still obtain updated eligibility and select a QHP through the end of open enrollment.
Limits: There is no upper household income limit for eligibility for APTC for benefit years 2024 and 2025. The upper limit for income-based CSR for enrollees who are not members of federally-recognized tribes or Alaska Native shareholders is 250% FPL.
Inputs, thresholds, and coding-related rules
Eligibility redetermination inputsmixed
| Uses updated FPL tables and benchmark plan as defined at 26 CFR 1.36B-3(f) and indexed percentages per 26 CFR 1.36B-3(g) when redetermining eligibility for enrollees who contact the Marketplace. |
inv-04: FTR threshold — 2 consecutive tax years leads to ineligibility for APTC
FTR threshold2 consecutive tax years of Failure to File and Reconcile (FTR) leads to ineligibility for APTC
Triggering conditionApplicable tax filer did not file an income tax return and reconcile past APTC for two consecutive tax years
Marketplace actionMarketplace will receive IRS information for enrollees with two consecutive tax years of FTR and notify enrollees in the MOEN; if enrollee does not contact the Marketplace and select a QHP by the plan-selection deadline, APTC will be discontinued
Effective dates and noticeDiscontinuation of APTC follows effective date rules in 45 CFR 155.410(f) or 155.420(b) and enrollees receive MOEN with instructions to demonstrate compliance
Actions Marketplaces should take
Documentation Required
Request updated IRS data for authorized enrollees
The Marketplace will request updated IRS data for all enrollees receiving APTC or income-based CSR who have authorized the Marketplace to request such data for annual redetermination; this request is made from the Internal Revenue Service for purposes of annual redetermination.
Billing Rule
Automatically re-enroll eligible non-selecting enrollees
Federal Marketplaces will automatically re-enroll current benefit year enrollees who do not select a QHP by the last day to select a plan for coverage effective January 1, to the extent the enrollee can be reenrolled; re-enrollees receive an eligibility determination notice and an enrollment confirmation at the point of re-enrollment.
- Enrollees who do not obtain an updated eligibility determination and select a QHP by the plan selection deadline may still update eligibility and pick a QHP through the end of open enrollment.
- Automatic re-enrollment is performed consistent with 45 CFR 155.335(j) and applicable effective date rules.
Key terms and method descriptions
inv-07: Benefit year terminology — 'current benefit year', 'upcoming benefit year', 'prior benefit year' usage and example
Current benefit yearThe benefit year in which coverage is active at time of guidance publication (example: 2023)
Upcoming benefit yearThe benefit year for which the Marketplace is establishing eligibility and planning re-enrollment (example: 2024)
Prior benefit yearThe benefit year preceding the current benefit year (example: 2022)
Usage exampleAt time of publication: current=2023, upcoming=2024, prior=2022
inv-08: Opt-Out Group — enrollees who did not authorize the Marketplace to request updated tax return information
DefinitionEnrollees who did not authorize the Marketplace to request updated tax return information for use in annual redetermination
ImplicationIf in this group and do not contact the Marketplace by the plan-selection deadline, Marketplace will discontinue APTC and income-based CSR and re-enroll without APTC/CSR where possible
Notice to enrolleesMOEN will include steps enrollees in this group should take to obtain an updated eligibility determination to maintain APTC or CSR, if eligible
inv-09: Repeat Passive Re-Enrollee Group — definition for enrollees auto re-enrolled in current and prior benefit years
DefinitionEnrollees who authorized IRS data requests, were auto re-enrolled in the current and prior benefit years with APTC or income-based CSR, did not submit an updated application used for those enrollments, and lack IRS income data or IRS data could not be requested for the two prior tax years
Marketplace outcomeIf these enrollees do not contact the Marketplace and select a QHP by the deadline, Marketplace will discontinue APTC and income-based CSR at end of current year and re-enroll the enrollee in a QHP for the upcoming year without APTC/CSR, to the extent re-enrollment is possible
MOEN contentMOEN will explain steps to obtain updated eligibility determination to retain APTC/CSR
inv-10: FTR — Failure to File and Reconcile definition and revised rule (two consecutive tax years)
DefinitionFailure to File and Reconcile (FTR) occurs when the applicable tax filer did not file an income tax return and reconcile past APTC
Revised ruleCMS revised the rule so FTR status requires two consecutive tax years of failure to file and reconcile to trigger APTC ineligibility (changed from one year)
Marketplace processMarketplace will receive IRS information on enrollees with two consecutive tax years of FTR, notify them in the MOEN with instructions, and discontinue APTC for those who do not contact the Marketplace and select a QHP by the plan-selection deadline
inv-11: Description of ordered methods used by the Marketplace to calculate projected annual household income and determine APTC and income-based CSR eligibility for upcoming benefit year
Primary method (updated application)Use projected annual household income and family size from the most recent application associated with an enrollment adjusted to the upcoming benefit year, updated FPL tables, and upcoming benefit year benchmark premium to calculate APTC and determine income-based CSR
IRS-based methodIf auto re-enrolled and did not submit an updated application but IRS income is available and shows projected income above the applicable lower threshold, use IRS income adjusted to upcoming year with family size from most recent application, updated FPL, and benchmark premium to calculate APTC/CSR; discontinue APTC/CSR if above the applicable upper income limit
Fallback to application projectionIf IRS income is unavailable or IRS-based evaluation results in income under the lower threshold, use projected annual household income from the most recent application adjusted to the upcoming benefit year with updated FPL and benchmark premium to determine APTC/CSR
Order of methods summaryMarketplace applies these methods in sequence to determine projected annual household income and eligibility for APTC and income-based CSR for the upcoming benefit year
Policy Summary
PayerMedicare
PolicyGuidance on Annual Redetermination and Re-enrollment for Marketplace Coverage for 2024 and Later Years
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionRequest updated IRS data for enrollees who authorized the Marketplace to do so for annual redetermination.
SourceLink
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