1. THE AFFORDABLE CARE ACT:
ELIGIBILITY & ENROLLMENT

2. PAGE 2
OVERVIEW
• Eligibility Requirements
• Exchange Enrollment
• Eligibility & Enrollment Verification
• Penalties
• Appeal Process
• Key Dates

3. PAGE 3
EXCHANGE ELIGIBILITY

4. PAGE 4
ELIGIBILITY: REQUIREMENTS
• For an individual to qualify for the Exchange they need to:
o Be a U.S. citizen, national, or legal resident
o Must reside in the same state that they are applying for coverage
o For programs that require an income eligibility, income will be
based off Modified Adjusted Gross Income
• An individual is not eligible for coverage through the Exchange if
incarcerated, unless charges are pending
• For CHIP, Medicaid, and Medicare, individual must meet that
program’s specific eligibility requirements

5. PAGE 5
ELIGIBILITY: EXEMPTIONS
• Individuals must have the minimum level of healthcare coverage
provided or face a penalty
• The following categories provide exemptions for individuals
from this coverage requirement:
o Religious Exemptions
o Undocumented Immigrants
o American Indians
o Financial Hardships
o Incarceration

6. PAGE 6
ELIGIBILITY: PROHIBITED FACTORS
• Issuers can no longer deny coverage to individuals with
pre-existing conditions
• Issuers are no longer able to drop individuals due to the
diagnosis of serious illnesses
• Issuers are no longer allowed to set annual and/or lifetime
limits

7. PAGE 7
ELIGIBILITY: GOVERNMENT BASED
HEALTHCARE
Medicaid
• A state-based healthcare program that provides coverage to low-
income households and individuals with disabilities
CHIP
• CHIP is the Children’s Health Insurance Program
Medicare
• A government health insurance program administered by the
Centers for Medicare and Medicaid Services

8. PAGE 8
ELIGIBILITY: MEDICAID
Medicaid Eligibility Before ACA Medicaid Eligibility After ACA
- Pregnant women and children (<6 years)
whose family income is ≤ 133% of the
Federal Poverty Level
- Children under 19 whose families are at or
below the FPL
- Families with children that meet the Aid to
Families with Dependent Children
- Most Supplemental Security Income
recipients
- Recipients of adoption or foster care
individuals
- Special protected groups
- Certain Medicare beneficiaries
- Certain optional groups
Source: CMS.gov - Brief Summaries of Medicare and
Medicaid and Kaiser Family - Medicaid A Primer
- Eligibility groups streamlined to
- children
- pregnant women
- parents and caretaker relatives
- adults (ages 19-64)
- Income eligibility will be based off modified
adjusted gross income and household
income
- Eligibility based off monthly income at time
of application
- Minimum income eligibility for adults is
133% of FPL
Source: Federal Register - Medicaid Program Eligibility
Changes under the ACA and Kaiser Family - Medicaid and
the uninsured

9. PAGE 9
ELIGIBILITY: CHIP
• CHIP covers children whose family income is too high for
Medicaid
• The ACA will keep the same eligibility standards in place
through 2019
• The ACA has expanded eligibility beyond the original
requirements of children under 19 and household
incomes of 200%

10. PAGE 10
ELIGIBILITY: MEDICARE
• Overall eligibility for Medicare does not change with
the enactment of the ACA
• Medicare eligibility requirements include:
o Being a U.S. citizen or legal immigrant
o Being age 65 or older
Source: SocialSecurity.gov Medicare and Proof of Citizenship

11. PAGE 11
ELIGIBILITY: MEDICARE
Medicare Part Eligibility Requirements
Part A
Individual is eligible if under age 65 and:
- Receives Social Security Disability Insurance for minimum of 24 months,
- Receives disability from Railroad Retirement Board,
- Receives disability due to Lou Gehrig’s disease,
- Has worked 10 years in a governmental job where Medicare taxes were paid and
meet requirements for Social Security Disability; or be the child/widower of
someone who has met those requirements, or
- Has permanent kidney failure or has received a kidney transplant
Individual is eligible if age 65 or older and:
- Receives benefits from Social Security or Railroad Retirement,
- Has an eligible spouse,
- Has worked (either individual or spouse) in a government job where Medicare
taxes were paid, or
- A dependent parent of a fully insured deceased child
Part B - Anyone eligible for Part A can enroll in Part B
- Monthly premium is based off income
Part C - Anyone who is eligible for Parts A and B can enroll in Part C
Part D - Anyone who is enrolled in Parts A, B, or C is eligible for the prescription drug
coverage
- Monthly premium is based off income
Source: SocialSecurity.gov Medicare

12. PAGE 12
ENROLLMENT PROCESS

13. PAGE 13
ENROLLMENT PROCESS: APPLICANT
• Applicants can enroll in an Exchange through the Exchange
website, in person at a designated assistance center, via toll-free
telephone number, or by mail
• The following information will be needed when completing an
Exchange application:
o Name
o Address
o Date of birth
o SSN
o Proof of U.S. citizenship/immigration status

14. PAGE 14
ENROLLMENT PROCESS: APPLICANT
• Notifications of eligibility are sent out once the determination is
complete
• Notifications letters should explain
o the applicant’s eligibility determination
o the steps taken and any remaining steps needed to complete
enrollment process
o the appeal process available to the applicant

15. PAGE 15
ENROLLMENT PROCESS: APPLICANT
• Through enrollment process, if applicant is found eligible for
government-based healthcare (e.g., Medicare, CHIP, or
Medicaid) the Exchange will automatically enroll applicant into
program
• Applicants can shop through Exchange to find the best coverage
option for their situation
• The Exchange will provide notification to the chosen insurance
issuer

16. PAGE 16
ENROLLMENT PROCESS: EMPLOYER
• Employers can submit an application to the Small Business
Health Options Program (SHOP) Exchanges to determine
eligibility*
• Once employer’s application is approved, the SHOP will help the
employer both enroll and select health plan options for their
employees

17. PAGE 17
*UPDATES TO SHOP PROGRAM
• The requirement that a SHOP must allow employers the option to
offer employees a choice among all qualified health plans (QHPs) at
the metal level (i.e., bronze, silver, gold, or platinum) chosen by the
employer has been delayed for one year.
• For plan years beginning before January 1, 2015 federally facilitated-
SHOPs will not offer an employee-choice option but will instead allow
employers to offer their employees a single QHP from the SHOP's
available choices. State-operated SHOPs may, but are not required to,
offer an employee-choice option.
• SHOP special enrollment period has been changed from 60 days to 30
days after a qualifying event.
• HHS has posted an application for SHOP eligibility for employers that
are not able to apply online or are not working with a broker and an
application for employees to submit to check their eligibility for SHOP
coverage from their employer.
As of
6/2013,
HHS has
issued final
regulations
around the
SHOP
program

18. PAGE 18
ENROLLMENT PROCESS:
EMPLOYER/SHOP
• The SHOP will provide notification to:
o employers regarding eligibility to participate in the Exchange
o employees regarding the plan options and how to enroll
o the insurer containing the employees’ enrollment information
• The SHOP is also required to notify HHS that the employer is
providing insurance and the eligible employees have enrolled in
a QHP

19. PAGE 19
ENROLLMENT VERIFICATION

20. PAGE 20
ENROLLMENT VERIFICATION:
APPLICANT
• U.S. citizenship and incarceration status will be verified by:
o Comparing records at the Social Security Administration
o If the information cannot be confirmed, HHS will go to the
Department of Homeland Security for confirmation
• Other application criteria will be verified against the respective
federal agencies

21. PAGE 21
ENROLLMENT VERIFICATION:
APPLICANT
• HHS will conduct annual redeterminations to determine
eligibility for upcoming plan year
o If applicants are approved, they will receive notification showing
data used to make the decision and their eligibility status
o If applicants are not approved, they will receive coverage for one
month after notification and can no longer claim tax benefits
• Applicants will need to supply any information that has changed
• Applicants will need to sign and return the notification
• After the signed notification is received, applicants can re-
enroll/terminate/change health plans

22. PAGE 22
ENROLLMENT VERIFICATION:
EMPLOYER
• To verify employer submitted information, the SHOP will cross
reference the employer’s information with government agencies
• The SHOP will redetermine employer eligibility through review
of the annual report submitted to it by the employer

23. PAGE 23
PENALTIES

24. PAGE 24
PENALTIES:
INDIVIDUALS AND EMPLOYERS
Individuals
• Penalties will be imposed for failure to maintain the
minimum level of individual coverage
o Penalties will either be a flat rate or a percentage of income,
whichever is higher
o Penalty rates will be adjusted annually
o IRS will administer and collect the penalty
Employers (50+ employees)
• If coverage is inadequate or not provided, a penalty will be
assessed based on the annual applicable dollar amount and
number of full-time employees

25. PAGE 25
APPEAL PROCESS

26. PAGE 26
APPEAL PROCESS: APPLICANT
• Each state will be responsible for creating their own appeal
process
• The Exchange will notify applicants if they are ineligible for
government-based healthcare and provide alternative options
for affordable healthcare
• Applicants can appeal adverse eligibility decisions and cost
reimbursement denials from insurance companies through an
internal or external appeal process

27. PAGE 27
APPEAL PROCESS: EMPLOYER
• An employer will be able to appeal an adverse eligibility
determination made by a SHOP
• The SHOP must give the employer 30 days notice to respond to
an eligibility denial and submit the necessary documentation to
the SHOP
• If the SHOP still denies eligibility after receiving documentation
from the employer, the employer may request an external
appeal review by a third party arbitrator

28. PAGE 28
KEY DATES

29. PAGE 29
KEY DATES: EXCHANGE ENROLLMENT
DATE EVENT
January 1, 2013 For 2012 tax year, employers need to include on the employee’s W-2
the cost of employer-sponsored health coverage.
o They must include both employer and employee portions of the cost
of health benefits.
The tax deduction will be eliminated for employers who receive
Medicare Part D retiree drug subsidy payments.
o These payments are a federal subsidy paid to employers who offer
retirement benefits for prescription drugs.
o Employers who receive this payment will have to include the amount
as taxable income.
March 1, 2013 • Employers must provide all employees with a written notice detailing:
- the availability of the healthcare Exchange,
- a description of the services provided,
- contact information for assistance,
- possible tax credit eligibility, and
- information regarding loss of employer sponsored coverage if they
purchase individual coverage in a QHP through the Exchange.

30. PAGE 30
KEY DATES: EXCHANGE ENROLLMENT
DATE EVENT
October 1, 2013 • Open enrollment period begins for the Exchanges
January 1, 2014 ACA Exchanges are in effect
Any U.S. citizen/legal resident who does not have health insurance and
is not exempt will be liable for a tax penalty
Employers that do not provide health insurance coverage will be fined

31. PAGE 31
REED & ASSOCIATES, CPAS
For more information on Reed & Associates, CPAs please
contact us at:
inquire@reedassociatescpas.com
Phone: 860-395-1996
Or visit our website:
reedassociatescpas.com
Quality. Integrity. Experience.