42 U.S.C. § 18082 — Advance determination and payment of

Page 9134 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18082 4 So in original. Probably should be ‘‘on’’. 1 So in original. Probably should be ‘‘employees’’. (3) Limitations on liens and levies The Secretary (or, if applicable, the Attor- ney General of the United States) shall not— (A) file notice of lien with respect to any property of a person by reason of any failure to pay the penalty imposed by this sub- section; or (B) levy on any such property with respect to such failure. (i) Study of administration of employer responsi- bility (1) In general The Secretary of Health and Human Serv- ices shall, in consultation with the Secretary of the Treasury, conduct a study of the proce- dures that are necessary to ensure that in the administration of this title 1 and section 4980H of title 26 (as added by section 1513) 1 that the following rights are protected: (A) The rights of employees to preserve their right to confidentiality of their tax- payer return information and their right to enroll in a qualified health plan through an Exchange if an employer does not provide af- fordable coverage. (B) The rights of employers to adequate due process and access to information nec- essary to accurately determine any payment assessed on employers. (2) Report Not later than January 1, 2013, the Secretary of Health and Human Services shall report the results of the study conducted under para- graph (1), including any recommendations for legislative changes, to the Committees on Fi- nance and Health, Education, Labor and Pen- sions of the Senate and the Committees of 4 Education and Labor and Ways and Means of the House of Representatives. (Pub. L. 111–148, title I, § 1411, Mar. 23, 2010, 124 Stat. 224; Pub. L. 114–255, div. C, title XVIII, § 18001(a)(6)(B), Dec. 13, 2016, 130 Stat. 1342.) Editorial Notes REFERENCES IN TEXT Sections 36B(c)(2)(C) and 5000A(e)(2) of title 26, sec- tion 6103(l)(21) of title 26, and section 5000A of title 26, referred to in subsecs. (a)(3) and (b)(3)(A), (5), were in the original ‘‘sections 36B(c)(2)(C) and 5000A(e)(2)’’, ‘‘section 6103(l)(21)’’, and ‘‘section 5000A’’, respectively, and were translated as if they had been followed by ‘‘of the Internal Revenue Code of 1986’’, to reflect the prob- able intent of Congress. This title, referred to in subsecs. (f)(2)(B) and (i)(1), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and transferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables. Section 1513, referred to in subsec. (i)(1), means sec- tion 1513 of Pub. L. 111–148. AMENDMENTS 2016—Subsec. (b)(3)(B), (C). Pub. L. 114–255 added sub- par. (B) and redesignated former subpar. (B) as (C). Statutory Notes and Related Subsidiaries CHANGE OF NAME Committee on Education and Labor of House of Rep- resentatives changed to Committee on Education and the Workforce of House of Representatives by House Resolution No. 5, One Hundred Eighteenth Congress, Jan. 9, 2023. EFFECTIVE DATE OF 2016 AMENDMENT Amendment by Pub. L. 114–255 applicable to applica- tions for enrollment made after Dec. 31, 2016, see sec- tion 18001(a)(7)(F) of Pub. L. 114–255, set out in a note under section 36B of Title 26, Internal Revenue Code. VERIFICATION OF HOUSEHOLD INCOME AND OTHER QUALIFICATIONS FOR THE PROVISION OF ACA PRE- MIUM AND COST-SHARING SUBSIDIES Pub. L. 113–46, div. B, § 1001, Oct. 17, 2013, 127 Stat. 566, provided that: ‘‘(a) IN GENERAL.—Notwithstanding any other provi- sion of law, the Secretary of Health and Human Serv- ices (referred to in this section as the ‘Secretary’) shall ensure that American Health Benefit Exchanges verify that individuals applying for premium tax credits under section 36B of the Internal Revenue Code of 1986 [26 U.S.C. 36B] and reductions in cost-sharing under section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) are eligible for such credits and cost sharing reductions consistent with the re- quirements of section 1411 of such Act (42 U.S.C. 18081), and, prior to making such credits and reductions avail- able, the Secretary shall certify to the Congress that the Exchanges verify such eligibility consistent with the requirements of such Act [Pub. L. 111–148, see Ta- bles for classification]. ‘‘(b) REPORT BY SECRETARY.—Not later than January 1, 2014, the Secretary shall submit a report to the Con- gress that details the procedures employed by Amer- ican Health Benefit Exchanges to verify eligibility for credits and cost-sharing reductions described in sub- section (a). ‘‘(c) REPORT BY INSPECTOR GENERAL.—Not later than July 1, 2014, the Inspector General of the Department of Health and Human Services shall submit to the Con- gress a report regarding the effectiveness of the proce- dures and safeguards provided under the Patient Pro- tection and Affordable Care Act for preventing the sub- mission of inaccurate or fraudulent information by ap- plicants for enrollment in a qualified health plan of- fered through an American Health Benefit Exchange.’’ § 18082. Advance determination and payment of premium tax credits and cost-sharing reduc- tions (a) In general The Secretary, in consultation with the Sec- retary of the Treasury, shall establish a pro- gram under which— (1) upon request of an Exchange, advance de- terminations are made under section 18081 of this title with respect to the income eligi- bility of individuals enrolling in a qualified health plan in the individual market through the Exchange for the premium tax credit al- lowable under section 36B of title 26 and the cost-sharing reductions under section 18071 of this title; (2) the Secretary notifies— (A) the Exchange and the Secretary of the Treasury of the advance determinations; and (B) the Secretary of the Treasury of the name and employer identification number of each employer with respect to whom 1 or more employee 1 of the employer were deter- Page 9135 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18082 mined to be eligible for the premium tax credit under section 36B of title 26 and the cost-sharing reductions under section 18071 of this title because— (i) the employer did not provide min- imum essential coverage; or (ii) the employer provided such min- imum essential coverage but it was deter- mined under section 36B(c)(2)(C) of title 26 to either be unaffordable to the employee or not provide the required minimum actu- arial value; and (3) the Secretary of the Treasury makes ad- vance payments of such credit or reductions to the issuers of the qualified health plans in order to reduce the premiums payable by indi- viduals eligible for such credit. (b) Advance determinations (1) In general The Secretary shall provide under the pro- gram established under subsection (a) that ad- vance determination of eligibility with respect to any individual shall be made— (A) during the annual open enrollment pe- riod applicable to the individual (or such other enrollment period as may be specified by the Secretary); and (B) on the basis of the individual’s house- hold income for the most recent taxable year for which the Secretary, after consulta- tion with the Secretary of the Treasury, de- termines information is available. (2) Changes in circumstances The Secretary shall provide procedures for making advance determinations on the basis of information other than that described in paragraph (1)(B) in cases where information included with an application form dem- onstrates substantial changes in income, changes in family size or other household cir- cumstances, change in filing status, the filing of an application for unemployment benefits, or other significant changes affecting eligi- bility, including— (A) allowing an individual claiming a de- crease of 20 percent or more in income, or filing an application for unemployment ben- efits, to have eligibility for the credit deter- mined on the basis of household income for a later period or on the basis of the individ- ual’s estimate of such income for the taxable year; and (B) the determination of household income in cases where the taxpayer was not required to file a return of tax imposed by this chap- ter for the second preceding taxable year. (c) Payment of premium tax credits and cost- sharing reductions (1) In general The Secretary shall notify the Secretary of the Treasury and the Exchange through which the individual is enrolling of the advance de- termination under section 18081 of this title. (2) Premium tax credit (A) In general The Secretary of the Treasury shall make the advance payment under this section of any premium tax credit allowed under sec- tion 36B of title 26 to the issuer of a qualified health plan on a monthly basis (or such other periodic basis as the Secretary may provide). (B) Issuer responsibilities An issuer of a qualified health plan receiv- ing an advance payment with respect to an individual enrolled in the plan shall— (i) reduce the premium charged the in- sured for any period by the amount of the advance payment for the period; (ii) notify the Exchange and the Sec- retary of such reduction; (iii) include with each billing statement the amount by which the premium for the plan has been reduced by reason of the ad- vance payment; and (iv) in the case of any nonpayment of premiums by the insured— (I) notify the Secretary of such non- payment; and (II) allow a 3-month grace period for nonpayment of premiums before dis- continuing coverage. (3) Cost-sharing reductions The Secretary shall also notify the Sec- retary of the Treasury and the Exchange under paragraph (1) if an advance payment of the cost-sharing reductions under section 18071 of this title is to be made to the issuer of any qualified health plan with respect to any indi- vidual enrolled in the plan. The Secretary of the Treasury shall make such advance pay- ment at such time and in such amount as the Secretary specifies in the notice. (d) No Federal payments for individuals not law- fully present Nothing in this subtitle or the amendments made by this subtitle allows Federal payments, credits, or cost-sharing reductions for individ- uals who are not lawfully present in the United States. (e) State flexibility Nothing in this subtitle or the amendments made by this subtitle shall be construed to pro- hibit a State from making payments to or on be- half of an individual for coverage under a quali- fied health plan offered through an Exchange that are in addition to any credits or cost-shar- ing reductions allowable to the individual under this subtitle and such amendments. (Pub. L. 111–148, title I, § 1412, Mar. 23, 2010, 124 Stat. 231.) Editorial Notes REFERENCES IN TEXT This subtitle, referred to in subsecs. (d) and (e), is subtitle E (§§ 1401–1421) of title I of Pub. L. 111–148, which enacted this subchapter and sections 36B and 45R of Title 26, Internal Revenue Code, amended section 405 of this title, sections 38, 196, 280C, 6103, and 7213 of Title 26, and section 1324 of Title 31, Money and Finance, and enacted provisions set out as notes under sections 36B and 38 of Title 26. For complete classification of sub- title E to the Code, see Tables. Page 9136 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18083 1 So in original. Probably should be followed by ‘‘of the Social Security Act’’. 2 So in original. Probably should be preceded by ‘‘is’’. § 18083. Streamlining of procedures for enroll- ment through an Exchange and State med- icaid, CHIP, and health subsidy programs (a) In general The Secretary shall establish a system meet- ing the requirements of this section under which residents of each State may apply for enroll- ment in, receive a determination of eligibility for participation in, and continue participation in, applicable State health subsidy programs. Such system shall ensure that if an individual applying to an Exchange is found through screening to be eligible for medical assistance under the State medicaid plan under title XIX 1 [42 U.S.C. 1396 et seq.], or eligible for enrollment under a State children’s health insurance pro- gram (CHIP) under title XXI of such Act [42 U.S.C. 1397aa et seq.], the individual is enrolled for assistance under such plan or program. (b) Requirements relating to forms and notice (1) Requirements relating to forms (A) In general The Secretary shall develop and provide to each State a single, streamlined form that— (i) may be used to apply for all applica- ble State health subsidy programs within the State; (ii) may be filed online, in person, by mail, or by telephone; (iii) may be filed with an Exchange or with State officials operating one of the other applicable State health subsidy pro- grams; and (iv) is structured to maximize an appli- cant’s ability to complete the form satis- factorily, taking into account the charac- teristics of individuals who qualify for ap- plicable State health subsidy programs. (B) State authority to establish form A State may develop and use its own sin- gle, streamlined form as an alternative to the form developed under subparagraph (A) if the alternative form is consistent with standards promulgated by the Secretary under this section. (C) Supplemental eligibility forms The Secretary may allow a State to use a supplemental or alternative form in the case of individuals who apply for eligibility that is not determined on the basis of the house- hold income (as defined in section 36B of title 26). (2) Notice The Secretary shall provide that an appli- cant filing a form under paragraph (1) shall re- ceive notice of eligibility for an applicable State health subsidy program without any need to provide additional information or pa- perwork unless such information or paperwork is specifically required by law when informa- tion provided on the form is inconsistent with data used for the electronic verification under paragraph (3) or is otherwise insufficient to determine eligibility. (c) Requirements relating to eligibility based on data exchanges (1) Development of secure interfaces Each State shall develop for all applicable State health subsidy programs a secure, elec- tronic interface allowing an exchange of data (including information contained in the appli- cation forms described in subsection (b)) that allows a determination of eligibility for all such programs based on a single application. Such interface shall be compatible with the method established for data verification under section 18081(c)(4) of this title. (2) Data matching program Each applicable State health subsidy pro- gram shall participate in a data matching ar- rangement for determining eligibility for par- ticipation in the program under paragraph (3) that— (A) provides access to data described in paragraph (3); (B) applies only to individuals who— (i) receive assistance from an applicable State health subsidy program; or (ii) apply for such assistance— (I) by filing a form described in sub- section (b); or (II) by requesting a determination of eligibility and authorizing disclosure of the information described in paragraph (3) to applicable State health coverage subsidy programs for purposes of deter- mining and establishing eligibility; and (C) consistent 2 with standards promul- gated by the Secretary, including the pri- vacy and data security safeguards described in section 1942 of the Social Security Act [42 U.S.C. 1396w–2] or that are otherwise appli- cable to such programs. (3) Determination of eligibility (A) In general Each applicable State health subsidy pro- gram shall, to the maximum extent prac- ticable— (i) establish, verify, and update eligi- bility for participation in the program using the data matching arrangement under paragraph (2); and (ii) determine such eligibility on the basis of reliable, third party data, includ- ing information described in sections 1137, 453(i), and 1942(a) of the Social Security Act [42 U.S.C. 1320b–7, 653(i), 1396w–2(a)], obtained through such arrangement. (B) Exception This paragraph shall not apply in cir- cumstances with respect to which the Sec- retary determines that the administrative and other costs of use of the data matching arrangement under paragraph (2) outweigh its expected gains in accuracy, efficiency, and program participation. (4) Secretarial standards The Secretary shall, after consultation with persons in possession of the data to be