NEW INFORMATION Please forward to your distribution lists and colleagues:

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1 From: Hillsberg, Bonnie S.(CMS/CMCS) Sent: Tuesday, January 27, :20 AM Subject: RE: New CMS Tribal Fact Sheets: Special Protections for AI ANs and AI AN Trust Income and MAGI NEW INFORMATION Please forward to your distribution lists and colleagues: CMS Tribal Affairs is pleased to announce the release of two new fact sheets. The first fact sheet explains the Protections for American Indians and Alaska Natives (AI ANs) in the Marketplace, Medicaid and CHIP. The second fact sheet describes Modified Adjusted Gross Income (MAGI) and what that means for AI AN Trust Income. These fact sheets support our outreach and education efforts to encourage AI AN enrollment in CMS programs. The fact sheets were developed with input from the CMS Tribal Technical Advisory Group and our federal partners at IHS and HHS IEA. Please feel free to distribute further. The fact sheets will be available for downloading on the CMS AI AN website at: and will be available to be ordered from the CMS warehouse in a few weeks.

2 Health Insurance Marketplace Protections for American Indians and Alaska Natives Marketplace Protections: The Marketplace provides special benefits for AI/ANs, but some are limited to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) corporation shareholders. Special Enrollment Periods (SEP): Tribal members and ANCSA shareholders can enroll in the Health Insurance Marketplace throughout the year, not just during the yearly Open Enrollment period. In Federally Facilitated Marketplace (FFM) states, non-tribal members applying on the same application as a tribal member can take advantage of the SEP. Tribal members and ANCSA shareholders with income at or below 300% of FPL: May be able to enroll in a zero cost sharing plan, which means no copays, deductibles, or coinsurance when receiving care from Indian health care providers or when receiving Essential Health Benefits (EHBs) through a QHP. There is no need for a referral from an Indian health care provider when receiving EHBs through the QHP. Tribal members and ANCSA shareholders with incomes above 300% FPL: Can enroll in a limited cost sharing plan, which means no copays, deductibles, or coinsurance when receiving care from Indian health care providers. Will need a referral from an Indian health care provider to avoid cost sharing when receiving EHBs through a provider outside the Indian health system. Tribal members and ANCSA shareholders can enroll in a zero cost sharing or limited cost sharing plan at any metal level, including less expensive bronze plans. Tribal members and ANCSA shareholders who qualify for cost sharing reductions are not exempt from premiums. However, they may qualify for Advance Premium Tax Credits depending on income. All AI/ANs can apply for an exemption from the shared responsibility payment (tax penalty/fee) that others must pay when they file their taxes if they don t have health insurance. Did you know? The Health Insurance Marketplace benefits American Indians and Alaska Natives (AI/ANs) by providing increased opportunities for affordable health coverage through a Qualified Health Plan (QHP) bought in the Marketplace, through Medicaid, or the Children s Health Insurance Program (CHIP). Medicaid and CHIP Protections: All AI/ANs have the following Medicaid and CHIP protections: Do not have to pay premiums or enrollment fees. If they receive care from an Indian health care provider or through referral to a non-indian provider, they do not have to pay any cost sharing, such as deductibles or copayments.

3 Local Indian health care providers may be able to provide a letter to their beneficiaries to verify eligibility for these protections. Certain types of Indian income and resources are not counted when determining Medicaid or CHIP eligibility. For example: Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties Payments from natural resources, farming, ranching, fishing, leases, or profits from Indian trust land (including reservations and former reservations) Money from selling items that have tribal cultural significance, such as Indian jewelry or beadwork NOTE: Per capita income from Indian gaming is not excluded and should be reported. Indian Exemption: Due to a policy change, all AI/ANs, including individuals who are otherwise eligible for services through an Indian health care provider, can now apply for an exemption from the shared responsibility payment (tax penalty/fee) in two ways. 1. Apply when filing a federal income tax return through self-attestation or by providing an Exemption Certificate Number (ECN). Self-attestation Do not need to submit documentation because an individual can self-attest that they or a member of their tax household are eligible for an exemption Should retain the same documentation as if filing for an exemption through the Marketplace (see Step 5 of the exemption application) Must be able to produce this documentation if audited by IRS Provide an ECN (the number received from the Marketplace contractor) Keep this number, because it will need to be provided every year when filing taxes Because an individual has proven eligibility for an ECN, he or she will not need to produce tribal or eligibility documentation in case of an IRS audit 2. Apply through the Marketplace by completing an exemption application and mailing it with supporting documentation. Must submit documentation of membership in a federally recognized tribe/ancsa corporation, or eligibility for services through an Indian health care provider (see Step 5 of the exemption application) Will receive an ECN. The ECN is valid for a lifetime, but it must be reported if required to file an income tax return to avoid a shared responsibility payment (tax penalty/fee). If an individual does not have an ECN, he or she must file for the Indian exemption when completing his or her federal income tax return every year to avoid the shared responsibility payment (tax penalty/fee). Even if an individual applies for an exemption from the fee, he or she can also apply for QHPs on the Marketplace, or for Medicaid and CHIP programs, and still receive services from an Indian health care provider. Forms to apply for the Indian exemption on the Marketplace are available for downloading at: publications-and-articles/tribal-exemption.pdf For more information, visit: Contact Info:

4 American Indian and Alaska Native Trust Income and MAGI Q: What is Modified Adjusted Gross Income (MAGI)? A: MAGI is your adjusted gross income, as determined for federal income tax purposes, with certain types of income added in and subtracted out. Q: What is the purpose of MAGI? A: MAGI is used to determine an individual s eligibility for premium tax credits and cost sharing reductions for Qualified Health Plans purchased through the Health Insurance Marketplaces. MAGI is also used to determine eligibility for families and children coverage groups in Medicaid and the Children s Health Insurance Program (CHIP). Q: Are there special rules for calculating MAGI for American Indians and Alaska Natives (AI/ANs)? A: Yes. MAGI is based on taxable, adjusted gross income reported to the Internal Revenue Service (IRS). Because some types of income specific to AI/ANs are non-taxable, this income is excluded when determining eligibility for Marketplace tax credits, cost sharing reductions, Medicaid, and CHIP. Certain additional types of AI/AN income are excluded when determining eligibility for Medicaid and CHIP, even though they might be taxable. This means that your MAGI might be slightly higher for the purposes of Marketplace assistance than it is for Medicaid eligibility. Did you know? You may qualify for lower cost health insurance coverage on the Marketplace. When you provide your MAGI, you can find out if you re eligible for premium tax credits and other savings that can lower the cost of health insurance. Learn how MAGI works, the types of income counted and excluded, and the special rules for AI/ANs for the Marketplace, Medicaid, and CHIP. Use of any information from this document is for general information only and does not represent personal tax advice, either express or implied.

5 Q: What types of AI/AN income are generally exempt from MAGI? A: The following categories of income are generally excluded from an AI/AN s MAGI: Distributions from Alaska Native Claims Settlement Act (ANCSA) Corporations and Settlement Trusts Distributions from trust/reservation property Income from property and rights related to hunting, fishing, and natural resources Income from the sale and use of cultural/ subsistence property Student financial assistance provided by the Bureau of Indian Affairs and/or a Tribe Income that falls within the IRS General Welfare Doctrine Any other income that is non-taxable according to federal law or IRS guidance You should contact your Tribe if you are unsure whether a certain type of income is exempt from MAGI. Q: Income exempt under the General Welfare Doctrine is excluded from MAGI. What is the General Welfare Doctrine? A: Payments made under social benefit programs for the promotion of general welfare may be excluded from gross income under a concept known as the general welfare doctrine. This applies only to governmental payments out of a welfare fund based upon the recipient s need, and not as compensation for services. When distributions to tribal members are made equal (per capita) and not based on need, then they do not fall under the general welfare doctrine. Benefits payable regardless of the financial status, health, educational background, or employment status of the recipient may be included in gross income of recipient. Q: Is my tribal gaming per capita payment excluded from MAGI? A: No. Gaming per capita payments are taxable and must be included in your MAGI. Q: The list of AI/AN income includes distributions and payments from activities on trust property. Does that property have to be located on a reservation for the income to be excluded from MAGI? A: No. This income is exempt from MAGI so long as it is derived from property that is held in trust by the federal government, subject to federal restrictions, located on an Indian reservation or within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior.

6 Q: How do I list AI/AN income on the application for Marketplace health insurance, Medicaid, and CHIP? A: When filling out an application for health insurance in the Marketplace, you will be asked to list your taxable income. You should provide the same income that you report to the IRS when you file your federal income tax. Do not include AI/AN income that the IRS exempts from taxation as part of your taxable income. In Appendix B of the Marketplace application, you will be asked to list certain types of AI/AN income that you previously included in Step 2 of your application. Even though this income is taxable, it still may be excluded from MAGI for the purposes of Medicaid and CHIP eligibility. You are asked to list this type of income on Appendix B to make sure that it is not counted toward your MAGI as part of the Medicaid and CHIP eligibility determination. If you don t have these types of income, just put a zero on the application after the questions in Appendix B. If you do have this type of income, list what kind you have and how much of it you receive. Do not list any per capita income from gaming in Appendix B, as it is taxable and included in MAGI. Q: Who should I contact for help when filling out the Marketplace application regarding my exempt AI/AN income? A: You should contact your Tribe or the enrollment assister at your local Indian Health Service, tribe or tribal organization, or urban Indian organization. You can also check with a Navigator or the Help Desk at your State s Marketplace or at Healthcare.gov. If someone helps you prepare your taxes, you can also ask them. Specific Types of AI/AN Exempt Income Below are some specific types of AI/AN income that may be excluded from your MAGI when determining eligibility for Medicaid, CHIP, and the tax credits and cost sharing reductions in the health insurance Marketplace. Please note that these are just examples and that this list is not exhaustive. Distributions from ANCSA Corporations and settlements trusts Cash distributions from an ANCSA corporation or settlement trust Stock or bonds issued by or acquired from an ANCSA Corporation A partnership interest distributed by an ANCSA Corporation, as well as subsequent partnership distributions Land or an interest in land (including land or an interest in land received from an ANCSA Corporation as a dividend or distribution on stock) Per capita payments or distributions from trust/ reservation property Rents from any such lands and any structures on the land (housing, retail facilities, etc.) Royalties or other compensation received from oil and gas production, mineral extraction, timber harvesting, and similar activities Profits or revenues derived from economic activity on the land, such as the operation of motels, retail stores, gas stations, farms and ranches, etc.

7 Grants from the Bureau of Indian Education s Higher Education program Payments from funds held in trust by the Secretary of Interior for an Indian tribe, including interest and investment income accrued while such funds are held in trust and initial purchases made with such funds Income derived from property and rights related to hunting, fishing, and natural resources Profits from the sale, lease, or harvest of mineral, timber, and other such resources Income derived from hunting, fishing, gathering, and harvesting fish, wildlife, and plant resources pursuant to federally protected rights, including off-reservation rights Income from the sale and use of cultural or subsistence property Earnings from ownership interests and usage rights to items that have unique religious, spiritual, traditional, or cultural significance that support subsistence or traditional lifestyle Materials such as the sale of sage or sweetgrass for use in a healing or spiritual ceremony The sale of artwork, pottery, or jewelry with cultural or religious significance Crafts made by AI/ANs from fish and wildlife resources taken for personal or family consumption Proceeds of subsistence fish and game Student financial assistance provided by the Bureau of Indian Affairs Student financial assistance provided under programs in Title IV of the Higher Education Act of 1965 Payments that are exempt from federal income taxation under federal statute Per capita shares distributed to Indians pursuant to the Indian Tribal Judgment Funds Use or Distribution Act (25 U.S.C et seq.), including interest and investment income earned on Judgment Funds while under administration Distributions from certain federal settlements, such as the Cobell v. Salazar class action settlement and some payments under the Keepseagle v. Vilsack settlement Income excluded under the General Welfare Doctrine Housing assistance Education assistance Programs serving elders and individuals with disabilities Cultural and religious programs Transportation programs Disaster relief Payments used to help establish AI/AN-owned businesses on or near a reservation Contact Info: Questions? Give us a call TTY: