42 USC 18082 - Advance determination and payment of premium tax credits and cost-sharing reductions

U.S Code last checked for updates: Apr 29, 2024

§ 18082.

Advance determination and payment of premium tax credits and cost-sharing reductions

(a)

In general

The Secretary, in consultation with the Secretary of the Treasury, shall establish a program under which—

(1)

upon request of an Exchange, advance determinations are made under section 18081 of this title with respect to the income eligibility of individuals enrolling in a qualified health plan in the individual market through the Exchange for the premium tax credit allowable 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

 So in original. Probably should be “employees”.

of the employer were determined 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 minimum essential coverage; or

(ii)

the employer provided such minimum essential coverage but it was determined under section 36B(c)(2)(C) of title 26 to either be unaffordable to the employee or not provide the required minimum actuarial value; and

(3)

the Secretary of the Treasury makes advance payments of such credit or reductions to the issuers of the qualified health plans in order to reduce the premiums payable by individuals eligible for such credit.

(b)

Advance determinations

(1)

In general

The Secretary shall provide under the program established under subsection (a) that advance determination of eligibility with respect to any individual shall be made—

(A)

during the annual open enrollment period 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 household income for the most recent taxable year for which the Secretary, after consultation with the Secretary of the Treasury, determines 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 demonstrates substantial changes in income, changes in family size or other household circumstances, change in filing status, the filing of an application for unemployment benefits, or other significant changes affecting eligibility, including—

(A)

allowing an individual claiming a decrease of 20 percent or more in income, or filing an application for unemployment benefits, to have eligibility for the credit determined on the basis of household income for a later period or on the basis of the individual’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 chapter for the second preceding taxable year.

(c)

Payment of premium tax credits and cost-sharing reductions

(1)

In general

(2)

Premium tax credit

(A)

In general

(B)

Issuer responsibilities

An issuer of a qualified health plan receiving an advance payment with respect to an individual enrolled in the plan shall—

(i)

reduce the premium charged the insured for any period by the amount of the advance payment for the period;

(ii)

notify the Exchange and the Secretary 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 advance payment; and

(iv)

in the case of any nonpayment of premiums by the insured—

(I)

notify the Secretary of such nonpayment; and

(II)

allow a 3-month grace period for nonpayment of premiums before discontinuing coverage.

(3)

Cost-sharing reductions

(d)

No Federal payments for individuals not lawfully present

(e)

State flexibility

(Pub. L. 111–148, title I, § 1412, Mar. 23, 2010, 124 Stat. 231.)

cite as: 42 USC 18082