Overview This notice is sent to the household contact for an application when an applicant listed on his or her application is found to be enrolled

Transcription

1 Overview This notice is sent to the household contact for an application when an applicant listed on his or her application is found to be enrolled in both Marketplace coverage with Advance Payments of the Premium Tax Credit (APTC) and Medicaid or CHIP coverage that qualifies as minimum essential coverage (MEC). Affected consumers should immediately end Marketplace coverage with APTC for each person who is also enrolled in Medicaid or CHIP benefits to help reduce the possibility that the tax filer(s) will have to pay back premium tax credits when they file their tax return. The notice outlines steps that must be taken if the household contact or others on the application: (1) ARE enrolled in Medicaid or CHIP that qualifies as MEC (i.e., terminate the Marketplace coverage with APTC); or (2) are NOT enrolled in Medicaid or CHIP (i.e., no further action needed). Taglines in multiple languages are located at the end of the notice for those who may require assistance in another language.

2 DEPARTMENT OF HEALTH AND HUMAN SERVICES 465 INDUSTRIAL BOULEVARD LONDON, KENTUCKY $(hh_contact_first_name) $(hh_contact_last_name) $(hh_contact_street_name_1) $(special_address_2_line) $(hh_contact_city_name), $(hh_contact_state_code) $(hh_contact_zip_plus_4_code) $(todays_date) Application date: $(application_submission_date) Application ID: $(application_identifier) Dear $(hh_contact_first_name): You re getting this notice because some people in your household may be enrolled in both a Marketplace health plan and Medicaid or Children s Health Insurance Program (CHIP) and you may need to take action immediately to end Marketplace coverage with advance payments of the premium tax credit. Consumers aren t eligible for a Marketplace plan with the premium tax credit if they were determined eligible for Medicaid or CHIP coverage that qualifies as minimum essential coverage. The Marketplace has information indicating that the following people are enrolled in a Marketplace plan with premium tax credits and [State Medicaid Program Name] (Medicaid) or [State CHIP Program Name] (CHIP): If the people listed above are enrolled in Medicaid or CHIP benefits, they should immediately end their Marketplace coverage with premium tax credits. The tax filer(s) who claim these people as dependents on their income tax return will likely have to pay back all or some of the premium tax credits received for a Marketplace plan during the months the people listed above were also enrolled in Medicaid or CHIP. What should I do next? You should immediately end Marketplace coverage with advance payments of the premium tax credit for each person who is also enrolled in Medicaid or CHIP benefits. This will help reduce the possibility that the tax filer(s) will have to pay back premium tax credits when they file their tax return. There are two ways to do this: Online by following the Cancelling a Marketplace plan when you get Medicaid or CHIP instructions on HealthCare.gov:

3 DEPARTMENT OF HEALTH AND HUMAN SERVICES 465 INDUSTRIAL BOULEVARD LONDON, KENTUCKY OR Over the phone by contacting the Marketplace Call Center at (TTY: ) and telling the call center representative that you want to end a Marketplace plan for someone who is enrolled in Medicaid or CHIP. For each person listed above, if they aren t enrolled in Medicaid or CHIP, you don t need to take any further action. You only need to take action if they re enrolled in Medicaid or CHIP. If you want more information about Medicaid or CHIP, or if you aren t sure whether any of the people listed above are enrolled in Medicaid or CHIP, you can call your state Medicaid or CHIP office. Use the state drop-down menu to get contact information for your state Medicaid office: Visit or call to contact your CHIP office. For more help Visit HealthCare.gov, or call the Marketplace Call Center. You can also make an appointment with an assister who can help you. Information is available at LocalHelp.HealthCare.gov. Get language assistance services. If you need language assistance in a language other than English, you have the right to get help and information in your language at no cost. Information about how to access these language assistance services is included with this notice, as a separate page. You can also call the Marketplace Call Center to get information on these services. Call the Marketplace Call Center to request a reasonable accommodation if you have a disability. These accommodations are available and provided at no cost to you. Sincerely, Health Insurance Marketplace Department of Health and Human Services 465 Industrial Boulevard London, Kentucky Privacy Disclosure: The Health Insurance Marketplace protects the privacy and security of the personally identifiable information (PII) that you have provided (see Healthcare.gov/privacy/). This notice was generated by the Marketplace based on 45 CFR and 45 CFR part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace. The Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on your application. If you have questions about this data, contact the Marketplace at (TTY: ).

4 DEPARTMENT OF HEALTH AND HUMAN SERVICES 465 INDUSTRIAL BOULEVARD LONDON, KENTUCKY According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is

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