QHP redetermination when consumers provide or fail to provide verification documents

When consumers apply for coverage through Maryland Health Connection, they may be asked to verify some of their information. Two important pieces of information that must be verified are: 

  1. Citizenship or immigration status
  2. Household income

If the consumer’s attested information does not match electronic sources, a Verification Checklist Item (VCL) is triggered, and QHP consumers are asked to provide a document within 95 days verifying their attestation. If not provided within 95 days, federal regulations stipulate that eligibility must be redetermined, and the consumer may lose their coverage and/or financial assistance as a result.

Note that VCL rules for Medicaid eligibility are different from those for QHPs. Medicaid requires income verification within 30 days of a completed application but allows 95 days for citizenship and immigration status verifications. Unlike a QHP enrollment, a consumer’s Medicaid enrollment will not become active until the consumer satisfies all outstanding VCLs within the allowed time frame.

Maryland Health Connection recently began running these 95-day VCL batches manually, and redetermining coverage when necessary, in order to move closer to compliance with federal regulations. Within the next few months, we anticipate this process will be automated. 

Failure to provide a VCL document

Before a QHP consumer is redetermined for failure to provide a VCL document, they receive a notice at the time of application that a VCL document is needed, a reminder notice at 30 days and a notice at the time of redetermination that the reason for action was due to failure to satisfy the VCL requirement.

All of these notices are sent by mail unless the primary applicant has selected the option to receive “paperless” notices; in that case, the notice is uploaded directly into their account inbox and they receive an email to check their account for important information.  

Failure to provide a VCL document means that eligibility is redetermined based on electronic resources. If the Federal Data Services Hub (FDSH) cannot verify citizenship or lawful presence, the consumer will be disenrolled. If the consumer does not provide an income verification document, APTC will be determined based on the electronic data, which may be quite different than the income attested to, as FDSH information may up to 2 years old. Remember, if no other income document is available, the consumer may be able to verify attested income using this affidavit (PDF).

Steps if the consumer provides a VCL document after the 95-day period

Sometimes consumers do not provide a verification document within the 95-day period but try to provide a document after action has been taken. Once the verification period has expired, consumers may be able to re-enroll or regain financial assistance with the following steps:

  1. For citizenship/immigration status VCLs, if the consumer returns with a valid document within 30 days, they may be reinstated with no gap in coverage. Consumer assistance workers may trigger this by change reporting a loss of MEC in HBX.  If the 15th of the month rule gives next-following-month eligibility, escalate the case to request following-month eligibility. The VCL document should be uploaded on the new application generated by the change report.
  2. For citizenship/immigration status VCLs where the consumer returns with a valid document after 30 days, coverage will follow the 15th of the month rule, and there will be a gap in coverage.
  3. For income VCLs where the redetermination changes any amount of APTC to 0, or changes an existing CSR amount to a different CSR amount, as long as the consumer stays enrolled, he will have a 60-day SEP in which to choose another plan (follows the usual SEP rules for APTC changes). These changes are not retroactive, however, but follow the 15th of the month rule.

Remember, the APTC rules apply only to currently enrolled consumers. If the consumer disenrolls or is terminated for nonpayment, the SEP does not apply. If there is no change in CSR or the change in APTC is in amount only, an SEP will not trigger. If the household is terminated for nonpayment while waiting for APTC to adjust, there will be no additional opportunity to enroll until the next open enrollment period or unless the household has a qualifying life event

About “The Classroom”

“The Classroom” is Maryland Health Connection’s blog for its consumer assistance community, including navigators, authorized brokers, certified application counselors, caseworkers and call center staff. Check here for updates on training, website releases, new tools, and other helpful information as you help get Marylanders covered through the health insurance marketplace.

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