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As the rollout of coverage expansions under the Affordable Care Act (ACA) continues across the country, more Americans are gaining insurance coverage, with all the benefits that that implies in terms of health care access and financial protections. However, if, as President Obama has argued, affordable health care is a cornerstone of economic security for American families, findings from a survey of Massachusetts residents suggest that insurance coverage alone will not be enough.
Since its 2006 health reform initiative, Massachusetts has had the
nation’s highest level of insurance coverage. But though there have been
improvements in access to health care and health care affordability,
insurance coverage has not eliminated the burden of high health care
costs for Massachusetts families. Health care costs are a problem for many insured adults. In 2012, more than one-third (38.7 percent) of Massachusetts adults with
health insurance coverage for all of the past year reported problems
with health care costs, with the level much higher for low-income
insured adults (41.6 percent for those with family income at or below
138 percent of the poverty line—the income eligibility standard for the
Medicaid expansion under the ACA) and middle-income insured adults (49.5
percent for those with income from 139 to 399 percent of poverty—the
income group targeted by the new health insurance Marketplaces). Insured
adults in Massachusetts report going without needed health care,
cutting back on other spending, reducing savings, and taking on debt to
deal with health care costs.
The challenges faced by low-income and middle-income Massachusetts
families are particularly worrisome given that the consumer protections
for out-of-pocket health care costs are generally better in
Massachusetts than those required under the ACA. For individuals with
family income between 100 and 200 percent of poverty who are enrolled in
the state’s subsidized health insurance program, out-of-pocket spending
for covered prescriptions and medical services is limited to $1,000 per benefit year. The ACA allows individuals in this income cohort to have out-of-pocket costs that can sum to more than double this amount ($2,250).
Even with these stronger consumer protections, more than 4 in 10 insured low-income Massachusetts adults
had trouble covering their health care costs in 2012. Nearly a third
(31.6 percent) reported problems related to their spending on health
care (e.g., problems paying medical bills or medical debt), and 23.6
percent reported going without some type of needed health care because
of the cost.
The experience in Massachusetts demonstrates that while expansions in
insurance coverage do lead to improved access to care – as evidenced,
for example, by the higher shares of Massachusetts adults with
preventive care visits and dental visits after reform – having insurance
is not necessarily sufficient to provide protection from the challenge
of health care costs. Taking the next step to address costs. While health insurance
coverage is a necessary component of affordable health care, high
cost-sharing requirements combined with high health care costs can make
access to needed health care services a challenge for many American
families, leading to gaps in health care use, problems paying health
care bills, and medical debt. To achieve the promise of health care
affordability for all, we must consider the implications for families
with limited resources of policy initiatives aimed at reducing health
care costs.
T-minus 14 days until open enrollment closes for ObamaCare. It is
crunch time for thousands as they decide if they want to enroll, and
ultimately how much of a tax credit to accept in order to determine
their first premium payment amount. Much attention has been lavished on
the “positives” of the ACA’s tax credits (also called premium
subsidies). White House press releases often highlight the impact of the
credits while chiding others for not including them when discussing the
new higher premiums under the law. Yet, the new reality of ObamaCare’s
tax credits has left finance reporters to pen
articles warning readers to “take care” when considering a tax credit
and providing strategies for how best to “protect yourself.” So what do
finance reporters know that the White House doesn’t?
By accepting a tax credit, low-income or lower-middle class families
face significant tax ramifications and potential financial risk.
Congress has changed the rules twice on consumers for the credits,
making the income cliffs steeper, and fully equipping the IRS to claw back overpaid subsidies (unlike the individual mandate penalty).
The flip side of the tax credits is almost unknown to the general public.
IRS building. Photo credit: Jim Watson/AFP/Getty Images
Who Exactly Gets The Tax Credits?
The ACA’s tax credits are given directly to the insurance companies,
and are calculated on a sliding scale, based on family size, and in
theory, to those making between 138% and 400% of the federal poverty
level (FPL) in states that have expanded Medicaid eligibility. In states
that have not expanded Medicaid, the tax credits are available to those
making between 100% and 138% FPL.
However, individuals can claim them by estimating that they will make
over 100% FPL even if they end up making 90% FPL in these states,
effectively closing the coverage gap
we have heard Medicaid expansion supporters and the media complain so
loudly about. However, the tax credits are unavailable to those with an
“affordable” offer of employer-based insurance, or for those on other
forms of government-approved coverage like standard Old Medicaid or
Medicare.
Yet, soon to be published research by my colleague Jonathan Ingram
will show that the tax credits phase out quickly for those in the
exchange, and are therefore unavailable for many young people (18-34) in
numerous states making far less than 400% FPL, based on the complex
formula used to calculate the subsidies, and the price of the plans
available on the exchange. This fact is only making the Administration’s
job of convincing young people to sign up even harder.
The credits can only be used in a government-sanctioned ObamaCare
exchange. In other words, individuals purchasing private insurance on
their own must decide if they want to keep their current insurance plan
without a subsidy or drop their coverage to take the tax credit. Since
so many states rejected
the President’s call to renew policies for those facing cancellations,
and the recent extension of that policy, millions of Americans are
facing this exact decision of joining an exchange or buying elsewhere by
March 31st.
All citizens that take the credit must file a tax return to receive
the credits regardless of their income. Failure to do so will result in
them being prohibited from seeking a credit in the future. Married
couples must file a joint return. How You Take The Credit Could Determine Exposure
The initial tax credit calculation will be based on an applicant’s
income tax return from the previous year, or a best estimate of what it
will be next year. The credit can be taken in advance at the beginning
of the year. However, individuals who enroll in the ObamaCare exchange
will run the risk of having to pay back a significant portion of the tax
credit if their life circumstances change (more on this below).
The credit can also be taken on the following year’s return in the
form of a refund. However, individuals who make this decision will be
responsible for coming up with the full cost of the ObamaCare exchange
insurance at the beginning of the year. Individuals and families do have
the option of taking a partial credit. Congress Has Changed ObamaCare’s Tax Credit Rules Twice
Republicans have by and large ignored the tax credit issue unless
talking about the budget implications. Perhaps the silence is due to the
fact that Congress has voted to change ObamaCare twice to increase the
financial risk that families could face when they take the credit.
Since the enactment of ACA, these limits have been amended twice: first under the Medicare and Medicaid Extenders Act of 2010 (P.L. 111-309), and then under the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayment Act of 2011
(P.L. 112-9). Congress changed the payback protection to vanish at the
400% poverty level and increased the payback amounts at 200% and 300%
FPL from what they had been before.
The result will be surprise bills from the IRS in the mail come
tax time 2015, in the order of a couple hundred dollars all the way up
to full value of any subsidy received if a family crosses the 400% FPL
threshold. (This could be $10,000-$12,000 for a family of four, as an
example.) Just a few dollars of extra income could result in thousands
of back taxes to be paid. Life Change Should Be Reported To The Exchange, Requiring A New Application
Our lives are constantly in flux. Lower and middle-class families
rarely find themselves in static work and life environments, but that is
exactly what ObamaCare assumes. Even the most common and mundane life
changes could significantly impact an individual’s financial situation
if he or she decides to take the tax credit. So ObamaCare recommends
that individuals report these changes immediately.
In a recently released presentation
by CMS, it was outlined that individuals will have to submit a new
application to re-determine eligibility, triggering a special enrollment
period and subsequently termination of the old policy.
As reported by Sara Hansard at Bloomberg:
Life events resulting in a special enrollment period eligibility are:
• adding a member, such as a birth or by marriage;
• relocating;
• losing access to other coverage, such as employer coverage;
• being released from incarceration; and
• changing citizenship or immigration status.
…
The presentation also listed life events that don’t result in
special enrollment period eligibility: removing a member as a result of
death or divorce; gaining access to other coverage, such as employer
coverage; becoming pregnant; a change in tax filing status; a change in
status as American Indians, Alaska Natives or tribal status; changes in
disability status; corrections to date or birth or Social Security
number; or some changes in income.
However many of these rules will cause significant confusion as a
death or divorce could change the income of a family significantly,
making some households appear more wealthy as they jump down a family
size level on the FPL scale. Or gaining employer coverage should make an
individual ineligible for a subsidy. 36-40% Of California Exchange Eligible Enrollees Will Owe the IRS Money Next Year
To put a finer point on how many people are likely to be subject to a
life chance significant enough to trigger a payment to the IRS, UC
Berkley’s Ken Jacobs and Dave Graham-Squire, Elise Gould from the
Economic Policy Institute, and Dylan Roby at UCLA wrote an illustrative
piece for Health Affairs. Largely overlooked by the media the article “Large Repayments of Premium Subsidies May Be Owed to the IRS if Family Income Changes are Not Promptly Reported,”
made some important observations about the exchange eligible population
in California that can be extrapolated to most of the rest of the
country. Income Fluctuation Is Very Common In This Population.
Nearly three-quarters (73.3 percent) of the predicted subsidy
recipients were in families with income changes of more than 10 percent
between the two years. Of those recipients, 37.8 percent had large
income increases, while 35.5 percent had large decreases. Thirty percent
of recipients were in families whose income increased more than 20
percent, and 18.9 percent had income increases of more than 40 percent.
To be fair, some will receive even more subsidy as a result of a life change, the Health Affairs
piece estimated that 41% would receive an additional credit. But given
the level of income fluctuation in this population, one bad economic
year (but a good subsidy year) is likely to be followed by a good
economic year (but a bad subsidy year). A Sizable Portion Will Owe The IRS The Entire Value Of The Credit.
We estimate that 9 percent of those who are eligible for a subsidy
at the beginning of 2018 would end the year with an annual income of
more than 400 percent of poverty, requiring them to pay back any subsidy
that they had received. Nineteen percent of those who started with an
annual income of 251-400 percent of poverty would end the year with an
annual income of more than 400 percent of poverty.
Many Will Owe Money Even If They Report All Life Changes.
…if no income changes were reported…38.4 percent of individuals
receiving subsidies would be in families that were predicted to owe
repayments…
If income changes of 10 percent of more were reported and the new
income was used to adjust subsidy levels”…35.8 percent would…” still owe
repayments. Percent of CA Exchange Subsidy Recipients Owing Repayment, 2019, By Scenario
Source: Health Affairs, September 2013 vol. 32 no. 9 1538-1545
Median Payments Are Substantial.
Median repayment amounts with no income changes reported or subsidy adjustments will be close to $900.
Nationally repayment will be a very big deal if we buy the estimates by the Kaiser Family Foundation that 48% of those that purchase individual policies will now qualify for a premium subsidy. Small Raises Could Mean Tens Of Thousands In Back Taxes To The IRS
In a recently released report I co-authored with CPA Jonathan Small, “Too Risky Too Exchange?”
we looked at five very common life events that could dramatically
impact citizens’ life, perhaps most dramatically near the income cliff
found at the 400% FPL of eligibility. But there are income cliffs baked
into ObamaCare around 133%FPL and 250% FPL as well.
If you are interested, even more technical information on this issue can be located in this CRS report, “Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA).” More Education About Exchange Subsidies Could Depress Enrollment
A pull quote from the Health Affairs piece might have hit the nail on the head for why the report was largely ignored by the media.
If there is much media attention to the need for repayments, some people could be dissuaded from participating in the exchanges.
Sadly the media has once again failed, and left millions of American
with only half the information that is needed to make an intelligent
decision about ObamaCare’s tax credits. We can anticipate a flurry of
sad stories of families receiving multi-thousand dollar bills from the
IRS next April, and quotes from the families wondering why no one told
them the truth about the ObamaCare tax credits.
In two weeks, Obamacare’s centerpiece—the individual mandate to purchase government-approved health insurance—kicks in.
Are you “covered,” as the White House keeps asking in its endless
advertising? Because if you don’t have health insurance by March 31, you
will have to pay a penalty on your income tax form next year.
For 2014, the penalty for not purchasing insurance will be either $95
or 1 percent of your annual income (whichever is greater). But as
Heritage expert Alyene Senger explains,
“Very few, if any, people will end up paying just $95, because
individuals with an annual income of only $9,500 or less would likely
qualify for Medicaid or a hardship exemption from the mandate.”
If you don’t make enough income to file a federal tax return, you’re already exempt. Do you think you qualify for a hardship exemption? Check out the application (subject to approval by Health and Human Services) here. For example, did you:
Receive “a shut-off notice from a utility company”?
Recently experience the death of a close family member?
Receive a notice that your health plan was being canceled, and “you consider the other plans available unaffordable”?
At the end of the list, the application form
has the catch-all reason “You experienced another hardship in obtaining
health insurance.” To prove it? “Please submit documentation if
possible.”
Despite all these possible exemptions, The Fiscal Times reports,
“A new study by Bankrate.com shows that about one-third of uninsured
Americans are going to remain without coverage and opt to pay the
penalty.” In fact, more than half of the uninsured are “unaware of the
March 31 deadline.”
If you think the penalty is no big deal right now, Heritage’s Senger warns
that “The mandate increases drastically in coming years, rising to $325
or 2 percent of income in 2015, and $695 or 2.5 percent of income in
2016—whichever is greater.”
The Congressional Budget Office estimates that from 2015 to 2024, the mandate penalty—which the Supreme Court ruled is essentially a tax—is expected to cost Americans $51 billion.
And that was after President Obama promised not to raise taxes on the middle class.
It’s worth mentioning the official name of this tax—because it just
doesn’t get any more Orwellian. Really, it’s the left’s ideal name for
all taxes: the “shared responsibility payment.”
An estimated 1 in 3 Americans report having difficulty
paying their medical bills – that is, they have had problems affording
medical bills within the past year, or they are gradually paying past
bills over time, or they have bills they can’t afford to pay at all.1
Medical debt – and a host of related problems – can result when people
can’t afford to pay their medical bills. While the chances of falling
into medical debt are greater for people who are uninsured, most people
who experience difficulty paying medical bills have health insurance.
Medical debt can arise when people must pay out-of-pocket for care not
covered by health insurance or to which cost-sharing (such as
deductibles) applies. Medical debt might also result from health
insurance premiums that individuals find difficult to afford.2
The consequences of medical debt can be severe. People with
unaffordable medical bills report higher rates of other problems –
including difficulty affording housing and other basic necessities,
credit card debt, bankruptcy, and barriers accessing health care.
This report examines medical debt through case studies of nearly two
dozen people who recently experienced such problems, and reviews their
experiences in light of other studies and surveys about medical debt. It
focuses primarily on problems of medical debt among insured individuals
and families. Most of the case studies feature people who struggled
with medical debt while covered under health plans that would be
considered typical and mainstream today. The report concludes with a
discussion of how provisions of the Affordable Care Act (ACA) may
influence the factors that contribute to medical debt.
Study Approach
In order to gain more detailed insights into the problems and causes
of medical debt, we collaborated with a national, non-profit credit
counseling agency to identify individuals struggling with medical bills
and study their experiences. We partnered with ClearPoint Credit
Counseling Services (ClearPoint),3
a non-profit consumer credit counseling agency based in Atlanta,
Georgia, that provided counseling and debt management services to over
200,000 people nationwide in 2011. Most ClearPoint clients self-refer
when they are in financial distress, for example, when they can no
longer make minimum payments on loans and debts or when they’re
contacted by debt collectors. Others are referred for recommended or
required counseling, for example, when they apply for mortgage
foreclosure relief or file for bankruptcy. In 2011, roughly 12 percent
of ClearPoint clients identified medical bills as the first or second
leading cause of their financial difficulties.
We developed an online screening survey to send to clients who had
recent difficulty paying medical bills and for whom email addresses were
available. The survey requested information not already collected by
ClearPoint, such as insurance status and coverage changes, the total
amount and types of medical bills, and whether illness triggered other
problems, such as job loss or missed rent or mortgage payments. It was
also used to identify individuals with medical debt who were willing to
participate in in-depth interviews. Of the 129 respondents to the
screener survey, 23 completed hour-long interviews providing detailed
information about their medical bills, insurance coverage and financial
status. While neither ClearPoint clients – nor survey respondents or
interview subjects – can be considered representative of the broader
population, their circumstances are consistent with findings of other
studies of medical debt. This report examines the case studies in light
of these other, broader studies.
A brief overview of each case study is displayed in Table 1. Stories
of the 23 people interviewed appear in the Appendix. Several key
characteristics of these individuals and their circumstances are
summarized in Table 2.
Table 1: Case Study Overview
Name *
Age
Occupation
Income (% FPL)
Insurance Source
Amount Bills
Bill Timeline
Whose Bills?
Ben
59
Trucker
$68,000 (590%)
Large employer
$5,000
2012
Self
Kris
56
Construction
$38,000 (330%)
Large employer
$6,000
2011
Self
Kieran
43
Car dealer
$75,000 (240%)
Large employer
$20,000
2007-2011
Spouse, children
Sonya
49
Homemaker
$85,000 (360%)
Large employer
$60,000
1994-2011
Self, son
Stuart
48
Sales manager
$74,000 (315%)
Large employer
$6,000
2010-2011
Spouse
Duncan
45
Teacher
$50,000 (255%)
Large employer
$10,000
2010-present
Spouse
Maisy
51
Librarian
$66,000 (280%)
Large employer
$30,000
2004-2011
Spouse
Richard
36
Financial adviser
$130,000 (550%)
Large employer
$30,000
2007-2011
Self, daughter
Dorothy
59
Teacher
$34,000 (300%)
Large employer
$4,500
2011-2012
Self
Gwen
57
Medical transcriptionist
$22,000 (140%)
Large employer
$40,000
2011
Spouse
Dillon
48
Repairman
$59,000 (529%)
Large employer
$19,000
2003-2010
Self
Jeanne
64
Retired
$24,000 (220%)
Large employer
$2,000
2010-2011
Self
Safiya
22
Restaurant worker
$10,000 (90%)
Large employer
$5,000
2011
Self
Connie
47
Nurse
$50,000 (210%)
Small employer
$36,000
1996-present
Spouse, children
Elsie
37
Writer
$60,000 (310%)
Small employer
$20,000
2007-2009
Self, child
Katherine
46
Customer service rep
$19,200 (167%)
Small employer
$35,000
2006-2009
Self
Morgan
51
Entertainer
$51,000 (220%)
Non-group
$35,000
2008-2012
Self
Millie
52
Realtor
$65,000 (340%)
Non-group
$20,000
2007-present
Self
Louise
58
Unemployed
N/A
Interrupted
$50,000
2005
Self
Gillian
59
Artist
$10,000 (90%)
Interrupted
$10,000
2009-2010
Self
Claire
44
Unemployed
N/A
Uninsured
$50,000
2008-2011
Self
Tanisha
47
Unemployed
N/A
Uninsured
$7,000
2008
Self
Charlene
51
Teller
$38,000 (195%)
Uninsured
$23,000
2010-2011
Self, daughter
* Names and certain other characteristics of individuals
have been changed to protect their identity.* Names and certain other
characteristics of individuals have been changed to protect their
identity.
Table 2: Case Study Highlights
Characteristic
Number of Cases
Age
< 30
1
31-40
2
41-50
9
51-64
11
Amount of medical bills/ medical debt
< $5,000
4
$5,001 – $10,000
5
$10,001 – $20,000
4
$20,001 – $50,000
9
> $50,000
1
Time period bills incurred
< 1 year
6
1-2 years
4
> 2 years
13
Whose bills?
Self or one family member
17
Multiple family members
6
Household income
<$20,000
6
$20,000 – $50,000
7
$51,000 – $75,000
8
$76,000 – $100,000
1
>$100,000
1
Illness triggered income loss?
Yes
18
No
5
Health insurance source
Large employer
13
Small employer
3
Non-group
2
Uninsured
3
Coverage interrupted
2
Health plan deductible (per person)*
<$500
3
$501 – $1,000
5
$1,001 – $2,500
3
>$2,500
6
Significant out-of-network costs*
Yes
7
No
11
Other medical debt impacts
Damaged credit
21
Lost home/home equity
6
Deplete retirement, other savings
13
Other financial deprivation
9
Bankruptcy
15
Access to care barriers
5
* Insured cases only
Key Interview Themes
Together, these cases reveal cross cutting themes and insights into
the problem of medical debt, its causes and potential solutions. Medical debt can affect almost anyone. People we
interviewed ranged in age from 20s to 60s and lived in various states.
Some were single, others headed families. Their annual incomes ranged
from less than $10,000 to more than $100,000. Most were insured
continuously in job-based group plans; a few were covered in non-group
policies. Two others were insured at the outset of illness, and then
lost coverage. Three were uninsured the entire time. For most in our
study, this instance of medical debt was the first time they had
experienced serious financial or credit problems. The onset of an
illness, accident, or pregnancy generated expenses that they did not
anticipate and which they were unprepared to pay. Some faced tens of
thousands of dollars in medical debt. For others, just a few thousand
dollars of bills proved unaffordable, particularly when a chronic
illness meant bills would continue year after year. Among insured individuals, unaffordable medical debts resulted primarily from cost-sharing for care covered by their insurance.
Some insured people faced exceedingly high levels of health plan
cost-sharing (e.g., $10,000 or more per person per year). For most,
though, much smaller amounts proved unaffordable. Some with limited
incomes and/or cash savings had trouble paying even a few thousand
dollars. Others might have been able to handle a single year of
cost-sharing liability for one person, but when treatment spanned two
plan years or when more than one family member made significant claims,
cost-sharing expenses multiplied and became unaffordable. Out-of-network charges also proved burdensome.
Typically health plan coverage is less for care rendered by non-network
providers. Many people inadvertently received non-network care while
hospitalized. Though they had selected a network facility, other
hospital-based professionals whom they did not and could not select –
such as anesthesiologists and emergency physicians – were not in
network. As a result, patients owed much more out-of-pocket than
expected. Coverage limits and exclusions and unaffordable premiums also caused problems.
In some cases, patients were left to pay bills for care their policy
simply didn’t cover. Some also fell into debt trying to pay health
insurance premiums they couldn’t afford. Related problems can often exacerbate medical debt.
Often significant health events triggered loss of income, rendering
unaffordable bills that might otherwise have been manageable. For the
vast majority of those interviewed, the medical event associated with
the debt also left the patient unable to work or prompted a working
family member to quit or reduce hours in order to become a caregiver.
Significant health events can also compromise a person’s ability to
manage the paperwork of medical bills. Nearly all those interviewed
emphasized how the sheer volume of bills during a major health event was
overwhelming. They had trouble tracking what had been paid, what was
owed, and what had been transferred to collections. Their task was made
more difficult by confusing provider bills and insurance company
statements that lacked key information. Most didn’t know where to seek
help, and the burdens of illness made it harder to resolve problems on
their own. Once it starts, medical debt can be hard to stop.
Most of those interviewed struggled for years to climb out of medical
debt, and for some, new debts arose even after prior ones had been
resolved. This was the case for people with chronic health conditions
as well as for people with high medical bills from a single health
event. Fifteen of those interviewed used credit cards to pay at least
some of their outstanding medical bills, and resulting finance charges
increased their debt. Medical debt can trigger other severe consequences.
The economic and personal impact of medical debt can be devastating.
Most of those interviewed ended up declaring bankruptcy as a direct
result of high medical bills. Others depleted retirement or college
savings, lost homes to foreclosure, or did without basics such as home
heat. Almost all suffered damage to their credit rating. Some
eventually bounced back from medical debt problems while others
permanently reduced their standard of living. Some people experienced
barriers to care. Nearly all expressed a strong ethic to pay their
bills and deep regret, even shame, to be in medical debt.
You may qualify for a hardship exemption if you experienced one of the following:
Submit this documentation with your application 1 You were homeless. None
2 You were evicted in the past 6 months or were facing eviction or foreclosure. Copy of eviction or foreclosure notice
3 You received a shut-off notice from a utility - Copy of shut-off notice from a utility company company.
4 You recently experienced domestic violence. None
5 You recently experienced the death of a close family member. Copy of death certificate, copy of death notice from newspaper, or copy of other official notice of death
6 You experienced a fire, flood, or other natural human-caused disaster that caused substantial damage to your property. Copy of police or fire report, insurance claim, or other document from government agency, private entity, or news source documenting event
7 You filed for bankruptcy in the last 6 months. Copy of bankruptcy filing
8 You had medical expenses you couldn’t pay in the last 24 months. Copies of medical bills
9 You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member. Copies of receipts related to care
10 You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and the Children’s Health Insurance Program (CHIP), and another person is required by court order to give medical support to the child. Copy of medical support order AND copies of eligibility notices for Medicaid and CHIP showing that the child has been denied coverage
11 As a result of an eligibility appeals decision, you’re eligible either for: 1) enrollment in a qualified health plan (QHP) through the Marketplace, 2)lower costs on your monthly premiums, or3)cost-sharing reductions for a time period whenyou weren’t enrolled in a QHP through the Marketplace. Copy of notice of appeals decision
12 You were determined ineligible for Medicaid because your state didn’t expand eligibility for Medicaid under the Affordable Care Act. Copy of notice of denial of eligibility for Medicaid
13 You received a notice saying that your current health insurance plan is being cancelled, and you consider the other plans available unaffordable. Copy of notice of cancellation
