Navigator Manual 2017

GetCoveredTennNavigatorManual
GeneralInformation
ContactListandAgencyMap
ProgramStructure
GetCoveredTennGlossary
ProjectLinks
ExpectationsandStandardOperatingProcedures
NavigatorGoalsandGuidelines
NavigatorDosandDonts
ConnectorReporting
Assist Connect Standard Operating Procedures
AppointmentMetricGuidance
WorkingwithVolunteers
HandlingConsumersPII
EligibilityIssues
TennesseeJusticeCenterResources&Toolkit
SpecialEnrollmentPeriodChartfromBeyondtheBasics
IDVerification:HowtocompleteonlineapplicationwhenIDcannotbeverified(screenshots)
PregnantWomenandNewborns:CoverKidsandTennCaretips
BeyondtheBasics:AssistersGuidetoTaxRules
EmployerCoverageFlowChart
TJCIncomeGuide
SEPVCheatSheetandNewRulesCheatSheet
Appendix:FormsandOtherInformation
EssentialHealthBenefitsandNoCostPreventiveServices
CarrierMap
LanguageLineInstructions
EnglishConsentForm
SpanishConsentForm
PhoneConsent
SigninSheetforEvents
MarketplaceAccountInfoSlip
TennCareSlip
ContinuingEducationCertificationforTDCI
GetCoveredTennNavigatorConsortiumUpdatedAugust2017

**PleaseNote:Phonenumbersareforinternaluseonly,notforconsumers**
#1:AMPA:4232326700
Navigators:Lead:TracyPate:Tracy@projectaccesseasttn.org;SarahScott:sarah@projectaccesseasttn.org
#2:Family&ChildrensService:
Navigators:SilviaCalzadilla(bilingualSpanish):scalzadilla@fcsnashville.org;8653842404;EmmaEllisCosigua(bilingualSpanish):
eecosigua@fcsnashville.org;8653618758

Navigators:Lead:KatherlynGeter:kgeter@fcsnashville.org;

#4:THCC
Navigator:BarbMyers:barbara@thcc2.org9313033995

#5:THCCUpperCumberlandNavigator:
Navigator:BarbMyers:barbara@thcc2.org9313033995

#6:FCS:6157241339
Navigators:Lead:SharonBarker:Sharon.barker@fcsnashville.org;AlanHall,partnershipLead:alan.hall@fcsnashville.org;
BilingualNavigators
Amharic:AidaWhitfieldaida.whitfield@fcsnashville.org;
Spanish:EmilieFauchet,Lead:efauchet@fcsnashville.org;PaoloGuazzini(trilingualSpanishandItalian):paolo.guazzini@fcsnashville.org;Angel
Chavez:achavez@fcsnashville.org;TracyZander:tzander@fcsnashville.org
Arabic:MohsenNagiub:(Mohsen.nagiub@fcsnashville.org;SereneHakki:shakki@fcsnashville.org;

#7:THCCEasternSouthCentral
Navigator:AndrewHawkins,Lead:andrew@thcc2.org9314345823

#8:THCCNorthwest
Navigator:ChelseaBrandon:chelsea@thcc2.org
#9:THCCSouthwest
Navigator:MerylRice:meryl@thcc2.org7316093239
DiamondRamirez(bilingualSpanish):dramirez@fcsnashville.org9013665882ext.122
EdithSalazar(bilingualSpanish):esalazar@fcsnashville.org9013665882ext.123
TamikaSmith:tamikan_smith@yahoo.com

MapRevised9/25/17

GetCoveredTNGlossary
ACA:AcronymforthePatientProtectionandAffordableCareAct,withprovisionsincluding
nodenialforpreexistingconditionsandallowingchildrentoremainontheirparents
insuranceuntil26
CMS: TheCentersforMedicare&MedicaidServices,CMS,ispartoftheDepartmentofHealth
andHumanServices(HHS).TheyadministerMedicare,Medicaid,theChildrensHealth
InsuranceProgram(CHIP),andpartsoftheAffordableCareAct(ACA).
CoverKids:
TennesseesSCHIPprogramforchildrenwhoareaboveincomeforTennCare,aswellas
pregnantwomen(includingnoncitizens)whosechildrenwillbeU.S.citizens.This
insuranceisthroughBlueCrossandBlueShieldofTNwithbenefitscomparableto
TennCare.
CSR: CostSharingReductions;oneofthetwotypesoffinancialassistanceavailableonthe
MarketplacewhichresultsinlowerdeductiblesandoutofpocketmaximumsonSilver
plansforthosewhoqualify(100250%)
EPO: ExclusiveProviderOrganization;Atypeofhealthplanwhereservicesareonlycovered
whenprovidedbyaninnetworkprovider.
FPL: FederalPovertyLevel,showninpercentagesi.e.under100%
HMO: HealthMaintenanceOrganization;Atypeofhealthinsuranceplanthatusuallylimits
coveragetocarefromdoctorswhoworkfororcontractwiththeHMO.Itgenerally
won'tcoveroutofnetworkcareexceptinanemergency.
TheMarketplace:
TheHealthInsuranceMarketplaceathealthcare.govor18003182596where
consumerscanapplyforTennCare,Coverkidsandapplyforandenrollinqualifiedhealth
plans.
PII: PersonallyIdentifiableInformation;PIIisanythingthatcouldindividually,orin
combinationwithotherdataelements,identifytheconsumer,suchasaconsumers
name,address,telephonenumber,socialsecuritynumber,MarketplaceapplicationID
orotheridentifier.
PPO: PreferredProviderOrganization;Atypeofhealthplanthatcontractswithmedical
providers,suchashospitalsanddoctors,tocreateanetworkofparticipatingproviders.
Youpaylessifyouuseprovidersthatbelongtotheplansnetwork.Youcanusedoctors,
hospitals,andprovidersoutsideofthenetworkforanadditionalcost.
GetCoveredTennNavigatorConsortiumUpdated03/09/2017
PTCorAPTC:
AdvancedPremiumTaxCredit,alsoreferredtoassimplyataxcreditorsubsidy,one
ofthetwotypesoffinancialassistanceavailableontheMarketplacewhichresultsin
lowermonthlypremiumpaymentsforthosewhoqualify(100400%FPL)
QHP: QualifiedHealthPlan;aninsuranceplanthatiscertifiedbytheHealthInsurance
Marketplace,providesessentialhealthbenefits,followsestablishedlimitsoncost
sharing(likedeductibles,copayments,andoutofpocketmaximumamounts),and
meetsotherrequirements.
TennCarerelated:
Choices:
TennCareCategoryforthosewhomeetnursinghomeadmissioncriteria,butchooseto
getcareathome,insteadofgoingintoanursinghome.
DHS: DepartmentofHumanServices:AgencythatprocessesFamilysFirst/Food
Stampapplications.EachDHSshouldhouseakioskwithacomputerthatconsumerscan
usetoenroll.SomeofficesalsohaveCACsonstaff.
MCO: ManagedCareOrganization.TennCarerecipientsareassignedtooneof4MCOsinthe
state:BlueCare,Amerigroup,AmeriChoice,andTennCareSelect(Childreninstate
custodyorChildrenonSSI).
PCP: PrimaryCarePhysician:ThefamilyDr.inchargeofaTennCarerecipientscare.Theyare
alsoresponsibleforreferralstospecialists.
SpendDown:
TennCarecategoryforpregnantwomenandthoseuptotheageof21,whoareoverthe
incomelimit.TheycanuseunpaidmedicalbillstoSpendDowntheirincometomeet
eligibilityguidelines.
Medicarerelated:
PartA:PaysforHospitalization.AvailabletothosewhopaidintoMedicarewhentheyturned
65or2yearsafterbeingapprovedfordisability.TherearenopremiumsforPartA.
PartB:Pays80%ofDr.visitsandtesting.SameeligibilityguidelinesasPartA.Premiumsfor
PartBare$110permonthandaredeductedfromtherecipientsSocialSecuritycheck
eachmonth.
PartD:PaysforMedication.Therearehundredsofplanstochoosefrom.Recipientsgethelpin
identifyingaplanwithaformularythatcoversthemedicationstheytake.Premiums
rangefrom$0over$100permonth.ThepremiumsaredeductedfromrecipientsSS
check.
AdvantagePlans:
SometimesreferredtoasMedicarePartC.AdvantageplansactasMedicareA,B,andD
combined.Enrolleemustuseprovidersfromtheirlistonly,orriskhighercopays.
TheseplanssometimesofferservicesnottraditionallycoveredbyMedicaresuchas
dentalandvision.Sometimestheyoffertheseservicestogetindividualstoenroll,then
dropthoseservicesfromtheircoverage.
DonutHole:
GapindrugcoveragethatbeginswhenMedicarerecipientmeetstheirMedicarePartD
plansinitialcoveragelimit($2,930in2012)andendswhentheyspendatotalof$4,700
outofpocketonRxsin2012.
SHIP: StateHealthInsuranceAssistanceProgramwhichassistsconsumerswithMedicare
18778010044
QMB:QualifiedMedicareBeneficiary:VerylowincomeMedicarerecipient.Benefits:The
statepays$110PartBdeductibleandupto$34towardaPartDdeductibleeachmonth,
insteadofcomingoutofrecipientsSScheck.QMBalsoactsasasupplementto
Medicare,recipientsareexemptfromthedonuthole,andtheymaychangeplansas
oftenastheyneedto.
SLMB:SpecifiedLowIncomeBeneficiary:NextincomelevelaboveQMBeligibility.SLMBhas
samebenefitsasQMB,exceptsupplementalcoverage.ThosewithSLMBwillpaya
hospitaldeductibleandwillhavetopaythe20%ofDr.visitsthatMedicarePartBdoes
notcover.
NursingHome:
ResidentialfacilityforthosewhoqualifyforSNFcare.Thislongtermcarefacilityoffers
careandroomandboard24hoursaday.Thoseadmittedtonursinghomescannotcare
forthemselves.
AssistedLivingFacility:
Residentialfacilityforpeoplewhocancareforthemselves,butprefernottolivealone
orareinneedofsomeassistancewithActivitiesofDailylivingorhelpwithmedication.
Thesefacilitiestypicallyrequirethattheresidentisambulatory(canwalkontheirown)
andindependentwithmostoftheircare.
GetCoveredTenn
ProjectLinks
CoalitionWebsiteandHotline:
Http://www.getcoveredtenn.org18446445443
FamiliesUSA
http://familiesusa.org/emailsignup
*ParticularlytheWeeklyHealthPolicyDigest
BeyondtheBasicsWebinarsandNewsletters
http://healthreformbeyondthebasics.us10.list
manage.com/subscribe?u=fcb519d4a06d032e8e2bbf63f&id=8ff722d6b6
IntheLoop
http://enrollmentloop.org/
NavigatorGoalsandGuidelines
OpenEnrollmentPeriodGoals(appointments PostOpenEnrollmentGoals
endinginenrollment): (appointmentsendinginenrollment):
Urbanonly:17perweek(11QHP&6Medicaid/CHIP) Urbanonly:8perweek
Ruralonly:12perweek(8QHP&4Medicaid/CHIP) Ruralonly:4perweek
Urban/Ruralschedule:14perweek(9QHP&5 Urban/Ruralschedule:5perweek
Medicaid/CHIP)
TomeettheseGoals,Navigatorscommitto:
MaximizingOutreachandAwarenessintheCommunityandcountiescoveredduringpostOEmonths:
attendHealthFairs,festivals,healthdepartmentevents,schoolevents,etc.Thisisthetimethatisall
aboutawareness,educationandawareness(yesawarenessx2!)thisstrategybringstheeligible
uninsuredtousforassistance.
EveryNavigatorshouldhaveatleast3outreachoreducationeventsoutsidetheofficeeachweek,
withappointmentsintheConnectorforenrollmentsonotherdays.
TargetTennCareandCoverKidsenrollmentsduringpostOEmonths
Workwheneligibleconsumersareavailable,includingnightsandweekendwork,especiallyduringOE.
ForUrban/RuralNavigators,planatleast2enrollmenteventsincountiesoutsidemetroareaduring
OE,thathavesmalleruninsuredpopulations,andatleast3incountiesthathavehigheruninsured
populations.
UpdatetheConnectorandAssistConnect!
Makesureyouhaveplentyofavailableappointmentssotheycanbefilled.
Foranylocationthatyouhaveappointmentsscheduled,alsocreateaneventinAssistConnectto
captureyourworkoutinthecommunity.Ifyouendupnothavingenrollmentsduringyourevent,
thatisokaybecausewecanstillcountitasoutreachifyouleaveflyersoranswerquestionsof
consumers.
MakesuretoenteryourNavigatorIDintoeveryapplicationthatyouassistwithonlineoroverthe
phone.CMSwillbecheckingourreportingagainstthenumberofapplicationswithyourNavigator
IDsentered.
Bepluggedin!!Pleasereademailsdaily!
Youwillmissimportantnotificationsthatletyouknowyoumayhaveanewappointmentthe
followingmorning.
ReportingquestionsmaycomeyourwayonThursdayandFriday.Gettingourquestionsanswered
iscriticalforreportingandmakingsureallworkiscountedandyougetcreditforyourworkis
equallycritical.
Timelyinformation,latebreakingnewsgoesoutalmostweeklyduringOEperiodsfromCMSto
changeswithTennCareandCoverKidsinTN.Manytimes,youllbeunabletogetenrollments
throughwithoutthisinfo.
Callnewappointmentswithin24hours.Whenyoureceiveanemailthatoneofyourappointment
slotshasbeenfilled,itisprotocoltocalltheconsumerandscreenthemrightaway.Iftheyareinthe
gap,dothem,andyourself,afavorandmarkthatintheirinformationandcanceltheappointmentso
someonewhoiseligiblecanfillit!Wecantmaximizeenrollments,ifyourappointmentsarefilledwith
consumerswhoarenoteligible.Also,thiscallhelpstoestablishapersonalrelationshipbetweenthe
NavigatorandtheConsumer,significantlydecreasingthenoshowratesforyourappointments.
Ifyoureceiveareferralbyemail,pleasereplybacktothemwhenyouhavecontactedtheconsumer,
oriftheresareasonyouareunavailable.Consumersoftencallusbackwhentheyhaventheard
fromyouandweneedtoknowifweshouldrefertheclientelsewhere.
DeadlineEnrollments:December15isthelastdayofOpenEnrollment,beflexibleandbeavailableto
worklateforlastminuteconsumers.Thisisthefinalpushandyouwouldbesurprisedbyhowmany
youcanenrollinthefinalhours!
Postenrollmentassistance:ItisoneoftheNavigatorsresponsibilitiestoprovidepostenrollment
assistancetotheconsumer.Duringtheenrollmentappointment,besuretolettheconsumerknow
thatyouareavailabletoassistthemthroughouttheyeariftheyneedtoreportalifechange,need
assistancefindingaprovider,needtosubmitsupportingdocumentstoresolveadatamatching
inconsistencyorneedhelpfollowinguponaTennCareorCoverKidsapplication.
Dont
referconsumerstotheMarketplacecallcenterorTennesseeHealthConnectionwithoutofferingto
callwiththemon3wayorprovideinpersonassistance.Althoughsometimestheconsumermayfeel
comfortablecallingontheirown,alwaysofferguidanceaboutwhattheycanexpectduringthephone
callandurgethemtocontactyoufollowingtophonecalltoensurethatthecallhadtheanticipated
outcome.Also,dontforgettorecordthephonecallasanappointmentintheConnectorsothatyou
cangetcreditfortheenrollmentassistanceyouprovided.
usehealthcare.govasascreeningtool.Byusingourscreeningtools,youcandetermineeligibilityin5
minutesoverthephone,beforeanappointment.ThiseliminateswastingappointmenttimesduringOE
waituntilThursdayeveningtodoALLofyourweeklyreporting.Outreachandappointmentdata
shouldbeentereddaily,butifthatisnotpossible,alldataforFridayWednesdayofeachweekshould
beenteredbyWednesdayevening.Then,dataforThursdaycanbeenteredonThursdaynight.
guessifyouarenotsureoftheanswertogiveaconsumeraskaLeadormanagement.
forgettoaddeventsandappointmentstoyourcalendarastheyarescheduled.Notshowingupfor
anappointmentoraneventreflectspoorlyonusasawhole,andobviouslydoesnotservethe
consumerwell.
stoplearningaftercompletingtheNavigatortraining.Techniquesandpoliciesareconstantlyevolving
andeachNavigatorshouldbeanexpertinthisfieldwhichmeansstayingabreastofanyandall
changes.SigningupforupdatesfromIntheLoopandBeyondtheBasicswillbeveryhelpfulalongwith
readingtheCMSupdatesthatcomeoutweekly.
Missreportingdeadlines!ReportingisEVERYFriday,andhasbeeneveryweekforthepast4years.
Thisisntsomethingnew.IfyoudidntmeettheThursdaynightdeadlineofenteringyourwork,
youreworkDOESNOTEXIST.Notonlyhaveyounotmetyourgoals,itcontributestousnot
meetingthegoalsofourgrant.Reportingyourwork=meetinggoals=GETTINGFUNDED.
WeexpectacutinfundingduetonotmeetingQHPgoals.Weweredownbyaround20%.Halfof
thatamountwasafewnavigatorsmissingThursdaynightdeadlines.Ifyoumissdeadlines,youre
hurtingyourteam.Thisisntnegotiablegoingforward.Revised9/25/17
EnrollmentDosandDonts
Doobtainconsumersconsentatthebeginningofphonecallorenrollmentsession,ifnot
previouslyobtained
DohandleconsumersPIIresponsibly(seeguidelinesunderNavigatorResponsibilities)
Dooffertoassisttheconsumerintheirpreferredlanguage
DonotdiscussaconsumerscasewithanotherNavigatororassisterwithoutaskingthe
consumerfirst
o Avoiddiscussingcaseloudlyduringenrollmenteventwhereotherscanhearyou
Donotchooseaplanonbehalfoftheconsumer
o Answerquestionsandempowerconsumertochoosethebestplanforthemselves
Dodescribeprovidernetworksindetail
DoassisttheconsumerwithcallingtheMarketplace
o AvoiddirectingtheconsumertocalltheMarketplaceontheirown
Donotenterpaymentinformationfortheconsumer
Doprovidetheconsumerwithalloftheirlogininformationfortheiraccountanddetailsofthe
plantheyselected
Doprovidetheconsumerwithacomparisonoftheplanstheyhavenarroweddownto,ifthey
areunabletoselectaplaninitially
Doensurethattheconsumerhasyourcontactinformationandencouragethemtofollowup
withyouiftheyencounteranypostenrollmentissues
Doprovidetheconsumerswithcoveragetocareresources:theCMSbooklets,alistoffree
preventivecareservices,providerdirectory,etc.

ConnectorReporting
2017
CreatingaSchedule
CreateaLocationforYourSchedule
Locations
pageisunder
the Create
Organizations Location
Tab
Includeyour
nameinthe
location
name. Thisisthephonenumber
theconsumerwillreceive
tocontactyoubyifthey
needtochangetheir
appointment.Youshould
useyourcontactnumber
andnotthephonenumber
oftheactuallocation
CreateaSchedule
Schedules
Pageis Createa
underthe
Scheduling new
Tab Schedule
MUSThave
already
createdthe
location.
MUSTincludeyour
namehere.Ifyoudo
not,youwillnotget
appointmentalertsand
willhavedifficulty
findingthe
appointment.
Ifchecked,
schedulewill
notappearon
publicsearch
ScheduleCreated
CreatingAppointments
1st WaytoCreateAppointments
Appointment
PageFound New
Under Appointments
Scheduling
Tab
Appointment
Statusand
Enrollment ClickHereto
Statuscanbe Editalready
editedhere created
appointments
Please
Phone
include
Numberis
ZipCode
Required
Youcanselect
appointmentslot
hereifyouhave
alreadycreated
theschedule
TextReminderwillnot
besenttoconsumerif
thisischecked.Helpful
forappointmentswhich
havealreadytaken
CreateAppointment
place.
2nd WaytoCreateAppointments
Schedulepage
isfoundunder
the
Youcanaddan
Scheduling
appointmentdirectly
Tab.
toaspecificschedule
here.Youcanalso
updateandedityour
schedulefora
particularlocation.
Clickhereto Clickonthe
enterthe availableslot
appointment toaddyour
information. appointment.
UpdatingAppointments
Clickhereto
searchfor
appointments
Cansearchby
the
consumers
name Cansearchby
yournameto
seeallofyour
appointments
Clickhereto
editalready
created
appointments
UpdateStatusof
Appointmentand
EnrollmentStatusof
Consumer
Referto
Appointment
Metric
Guidance
AssistConnect Best Practices and Standard Operating Procedures
Overview
This Standard Operating Procedure is intended as an overview of the AssistConnect system.
AssistConnect is the system for entering Health Insurance Marketplace related outreach. It helps
Marketplace Assisters and CMS manage events and capture required reports in a more efficient and
collaborative manner.
Security in AssistConnect and Passwords

AssistConnect is a cloud-based system that is fully accessible from any computer or mobile device with
an internet connection. The link for AssistConnect is: https://assistconnect.force.com/home/home.jsp
The AssistConnect password is a separate password from other systems. When you receive a license for
AssistConnect, you receive an email with instructions on setting up your account.
Passwords expire and must be reset every 60 days
AssistConnect will automatically log you out after 15 minutes of inactivity. You will be required
to re-authenticate to the system after a logout.
If You Forget Your Password

AssistConnect will disable your account after three failed
login attempts.
Before you get locked out of the system (after second
attempt), click on theForgot your password? link and
follow the on-screen instructions to reset your password.
If your account becomes disabled, contact the
AssistConnect email box at: AssistConnect@cms.hhs.gov
If You Want to Change Your Password
To manage your password, click on your name in upper right corner of AssistConnect and click
MySettings from the drop down menu. From the
screen that appears, click Security Settings and you
will be prompted to choose a new password.
Searching AssistConnect
To get started searching, use the Search Bubble located in
the upper left corner of the AssistConnect screen. You can left click once in the box, and then begin
typing. As soon as you begin typing, the system will suggest records. This is based on records youve
touched previously. If you see what youre searching for among the AssistConnect suggestions, you can
just click directly on the record youre interested in to open it.
If the system doesnt make suggestions, or doesnt make a
suggestion youre interested in, type the word(s) youre
looking for, and click Search to see what it returns.
TIP: Just like with any other search engine, the more general the information you enter, the more likely
you are to return results. Try searching for Address, or sponsor name, as well, if you arent finding
anything by searching for an Event.
TIP: Try using an asterisk (*) after a partially spelled word to search for every variation of the word.
This can help you find records that may have been entered with words spelled differently.
TIP: Once your results display, you can sort them by clicking on a column header (like Event Date or
City). You can also click Show More to expand the list.
AssistConnect Best Practices and Standard Operating Procedures 2

Edited by Get Covered Tenn
Last Updated: August 2017
AssistConnect Event Tracking
AssistConnect is intended to capture two types of records:
Marketplace Events: A Marketplace Event includes any Navigator work performed for outreach,
enrollment, or educational purposes. Marketplace events may include, but are not limited to:
o Providing information and an opportunity for an individual or group of consumers to ask
questions about and apply for enrollment in Marketplace coverage;
o Enrolling consumers in Marketplace coverage;
o Sharing information necessary for a consumer to make a decision to apply for, or enroll
in health coverage through the Marketplace; and/or
o Educating about Marketplace health coverage and how it works.
Marketing/Promotion Activities: A marketing/promotion activity is any work done by the
Navigator organization to raise awareness about the health insurance options available through
the Marketplace and the opportunities for assistance to consumer who need help applying.
Steps for Entering a New Marketplace Outreach Record

After logging in to AssistConnect, you can create a new record in
one of two ways:
1) Click on the Create New button on the left side of the

screen and select Marketplace Outreach
2) OR Click on the Marketplace Outreach tab in the grey
toolbar and click on the Create New Marketplace Outreach
button when it appears.
A screen with two checkboxes will appear. Click on the box of the type of record youre entering
The screen will expand depending on which choice you make. If you make a mistake in your choice, just
re-click the checked box to unselect it, and then click on the correct box.

Entering a Marketplace Event
If you are entering a Marketplace Event, use the definitions below to guide your entry.
HINT: You may be able to turn on Autofill in your internet browser, which will allow your
browser to suggest text based on past entries. This may make entering records easier.
Event Name [Required]: The name of the event you are entering. Especially if an event recurs
throughout the year, use enough description to set it apart from other events, i.e. Delta Lodge
Community Christmas Dinner
Event Date [Required]: A date and time of the event. A space must be left between the date and time
for it to be accepted by the system. A space must also be left between the time and AM/PM for the
entry to be accepted. You can click on the underlined date and time to the right of the field to have the
current date and time inserted.
Event Location Name [Required]: The name of the location where the activity will take place, i.e.,
Houston City Hall
Street Address [Required]: The street number and name where the activity will physically take place.
City [Required]: The city where the activity will physically take place.
State [Required]: The state where the activity will physically take place.
Zip Code [Required]: The zip code where the activity will physically take place.
Population-Based Activities: If your activity primarily serves specific populations, then you will indicate
it here. You can select more than one population as applicable. Note: if your activity is for the general,
do not make any selections. To make a selection, click on the appropriate option under Available, then
select the Right-facing arrow button to move it to Chosen. You can move multiple values and are not
limited to one.
Sponsor/Partner(s): Enter the name of your organization. For example: Tennessee Health Care
Campaign, Family & Childrens Service, South Memphis Alliance or Appalachian Mountain Project
Access

Event Description [Required]: General Inquiries and consumers targeted must be included in this
section using the following format and indicated by GI: for General Inquiries and CT: for
Consumers Targeted (consumers in attendance). It is important to maintain the order of general
inquiries first followed by consumers targeted. If either number is 0 please still list it as, GI:0 and/or
CT:0. Example below:
A brief description of the event that will be useful to people reviewing this event as part of a report
should follow the reporting of the numbers for general inquiries and consumers targeted. This
description should be updated after the activity has occurred to reflect any new information you
learned. This new information includes, but is not limited to, environmental scanning, topics covered,
composition of audience, etc.
POC Name [Required]: Enter the name of the Navigator responsible for the event.
POC Phone [Required]: Enter the phone number of the Navigator for the event.
POC Email [Required]: Enter the email address of the Navigator for the event.
Entering a Marketing/Promotion Activity

If you are entering a Marketing/Promotion Activity, use the definitions below to guide your entry.
Activity Name [Required]: The name of the activity you are undertaking, such as
Activity Date [Required]: A date and time of the activity. A space must be left between the date and
time for it to be accepted by the system. A space must also be left between the time and AM/PM for
the entry to be accepted. You can click on the underlined date and time to the right of the field to have
the current date and time inserted.
Number of Consumers Targeted [Required]: Enter the number of consumers expected to be reached as
part of the activity. Accurate numbers on media reach can be extremely difficult to obtain, so make an
estimate based on the information available to you.

Media Type [Required]: Select the mediums you will be using as part of your activity. You can select
more than one medium, as applicable. To make a selection, click on the appropriate option under
Available, then select the Right-facing arrow button to move it to Chosen. You can move multiple
values and are not limited to one.
Activity Description [Required]: A brief description of the activity that will be useful to people reviewing
this activity as part of a report.
Editing and Deleting Records

Once your entry is Saved, you can Edit or Delete it. Editing will allow you to change any information that
you need to, and Deleting will remove it from the system. Youll find the record either under your
Recent Items list (on the left side of the screen), in your list of Recent Marketplace Events, or by
searching for it. Once you have the record pulled up, simply click Edit to open it in Edit mode. When
youre finishing editing, be sure you click Save to save your changes. To delete it, select the Delete
button.
Cloning Records
AssistConenct allows you to clone a record and take advantage of replicating events so you dont have to
re-enter information. This can be a good option for events that recur at set intervals, like weekly
presentations at a community center. Once an event has been completed, a grey button will appear
labeled Clone. To clone an Event, click the Clone button. The same information from the original record
will appear with the exception of a blank Event Date or Activity Date field, depending on the record
type. Fill in the new start date and update any additional information and click Save to complete your
new record.
When cloning an event, be careful not to leave information from the original event that is
not applicable to the new event, in the record.

Assistance Type Notes How to Count
Not necessarily the tax household, only
those consumers you assisted. For
example: a married couple made up of a
husband on Medicare and a wife who
needs to apply on the MP. If the wife
contacts you for assistance with her
application but does not have any
questions about her husband's Medicare
you would put 1 here. If the wife applies
for the Marketplace and asks you
questions about her husband's Medicare
and you answer her questions and/or
refer him to TJC or SHIP you would put 2 Count only consumers
How many individual consumers fall under this appointment report? here. that you assisted
*ONLY the most general questions-

nothing specific. If this box is checked,
then no other assistance type should be
selected. DO NOT include requests for an
appointment or scheduling an
appointment. This can include inquiries
Addressing general inquiries about health insurance options by telephone and email. *Per Incidence
Formerly "Education only-no

enrollment" includes any assistance with
application that does not result in
enrollment including previewing plans or
answering questions about the
application process that would assist the
consumer with completing the Per Individual consumer
Application Assistance application on their own. on Application
Coverage to Care, understanding health
Health Insurance Literacy insurance terms *Per Incidence
Locating in-network providers for their

Locating Providers QHP and/or TennCare and CoverKids *Per Incidence
billing and payment questions specific to
Billing and Payment questions their situation *Per Incidence
*ONLY choose when the QHP is selected Per Individual Consumer
Enrolling in a QHP during the appointment Enrolling
Choose when MP eligibility says "May be

eligible/Eligible for TennCare/CoverKids"
or when assisting with a newborn
presumptive application or paper Per individual consumer
Applying for Medicaid/CHIP CoverKids application eligible
Per Individual consumer
Referral to Medicaid/CHIP Use for redetermination-include in notes Referred
Enrolling into SHOP *ONLY actual SHOP enrollment Per employee enrolled
Remember to not refer to a specific

agent or broker, but you can provide
Questions about/Referral to Agent/Broker consumers with a list in their area *Per Incidence
Questions about/Referral to Medicare Include SHIP and TJC referrals *Per Incidence
Referrals to safety net, Project Access,
Questions about/Referral to other consumer assistance/health Memphis Plan, sliding scale clinic, charity
insurance programs care program, etc. *Per Incidence
Referrals to issuer (insurance company)

for inquiries about consumers' ID cards,
or if their plan covers a specific service,
Questions about/Referral to issuer medication, etc. *Per Incidence
Questions about/Referral to State deptatment of insurance any referrals to TDCI *Per Incidence
*ONLY assistance with obtaining
Marketplace tax forms: 1095A, 8962, etc.
Marketplace tax form NOT general tax filing advice *Per Incidence
Per Exemption *For

example: If you help a
family of four apply for
one type of exemption,
you would count 1 here; if
you helped a single
assistance with MP application to obtain consumer apply for 2
exemption code and/or filling out the exemptions you would
Filing Marketplace exemptions Marketplace exemption application count 2 here.
assistance with MP and/or TennCare and
Submitting Marketplace or insurance coverage appeals CoverKids appeals *Per incidence
Assistance with either DMI at the time of

application, post-enrollment assistance
with uploading docs and/or Periodic
Data matching issues Data Matching issue assistance *Per Incidence
Assisting consumer with getting an SEP

*NOTE: if the consumers who were
granted SEP also choose a QHP you
would select both "Enrolled in a QHP"
SEP Eligibility and "SEP Eligibility" for each consumer Per individual consumer
Family glitch, employer coverage tool,
Employer-sponsored coverage issues COBRA, etc. Per individual consumer
*ONLY consumers who have an issue
with APTC/CSR and need specific
assistance with resolving that issue
should be counted here NOT standard
enrollment where a consumer receives
APTC/CSR as part of the enrollment
APTC/CSR process Per Individual consumer
Those individuals under 100% of FPL who

Coverage Gap do not fit into a Medicaid category Per individual consumer
*ONLY assistance that does not fit into a
Other category above *Per Incidence
*Assistance types counted as "Per Incidence" will always be counted
as 1 per appointment
GuidanceforWorkingwithVolunteers
CMShasnotreleasedofficialguidanceonworkingwithvolunteers,buttheyhaveprovidedproject
managementwithverbalguidanceonthesubject.
WhenworkingwithNavigatorsvolunteerscan:
Assistinsettingupevents,afterconsultingNavigatorstoensurethereisnotaconflictwiththe
Navigatorsschedule.Ifavolunteersetsupaneventwithoutconsultingthe
subcontractor/Navigator,theNavigatorisnotresponsiblefortheeventorforbeingpresent.
Workeventstoprovidesupport,buttheycannotprovideeducationorenrollmentservices.
Makefollowupcallstoconsumers.
Handoutmaterialsorinformationtoconsumers.
Volunteerscannot:
ProvideenrollmentservicesormarketplaceinformationunlesstheyarecertifiedasaCertified
ApplicationCounselorwiththefederalandstategovernment.
Navigatorsareresponsibleforthiswork,fortheaccountability,andformanagingthegrant
responsibilities.
GetCoveredTennNavigatorConsortium10/25/2015
Best Practices for Handling

Personally Identifiable Information:
Fast Facts for Assisters
Updated February 2015
This Fact Sheet Applies If You:

Are a Navigator, non-Navigator assistance personnel (in-person assister), or certified
application counselor (collectively, an assister) in a state with a Federally-facilitated
Marketplace or State Partnership Marketplace
Have questions about personally identifiable information (PII)
Are looking for best practices and tips on handling PII
Personally Identifiable Information (PII): Overview

As a Navigator, non-Navigator assistance personnel (or in-person assister), or certified
application counselor (CAC) (collectively referred to as an assister) helping consumers who
are applying for health insurance through a Federally-facilitated or State Partnership
Marketplace, you may encounter consumers personally identifiable information (PII). This
document contains suggested measures to take for protecting consumers personally
identifiable information (PII) in the course of performing assister duties. Remember: these
suggestions are not intended to replace your obligation to determine how to follow the specific
privacy and security standards that apply to your work, and the suggestions in this document
might not be necessary in all circumstances, or you might have to do more than what is
suggested here in order to meet the privacy and security standards that apply to your work. The
specific privacy and security standards that apply to your work are contained in your
organizations agreement with CMS or the terms and conditions for your grant or contract with
CMS, as applicable.
PII is anything that could individually, or in combination with other data elements, identify the
consumer, such as a consumers name, address, telephone number, social security number,
Marketplace application ID or other identifier. 1 Consumers must have an opportunity to access,
inspect, and/or correct their PII if they make a request to do so. Only those assisters who need
to access or use PII to carry out required duties should be given access to it, and they should
access or use only the minimum amount of PII necessary in order to carry out required duties.
Examples:
Dont request information about a persons status as a citizen, national, or immigrant if
that person is not seeking coverage for himself or herself on any eligibility application.
Dont request an individuals Social Security Number (SSN) if he or she is not seeking
coverage for himself or herself, unless information about the individuals income is
necessary to determine the applicants household income. (Note: an individual is not
required to provide his or her SSN if he or she is not applying for coverage for himself or
herself, but if the individuals income is included in the applicants household income,
providing this information can help speed up the verification process.)
Dont use someones PII to discriminate against them, such as by refusing to assist
individuals who are older or have significant or complex health care needs. 2
Protecting consumers PII should be routinely discussed and monitored within your organization
and continuing education is strongly encouraged.
See the list below for examples of PII that you may encounter while assisting consumers. This is
not an exhaustive list. If you are a Navigator or certified application counselor, a comprehensive
list of types of PII that you might encounter and that you are authorized to access and use is
provided in the privacy and security standards that apply to your organizations agreement with
CMS or grant terms and conditions, as applicable.
Examples of PII You May Encounter

Name
Birth date
1 According to the privacy and security standards set forth in Navigators grant terms and conditions and certified
application counselor organizations agreements with CMS, PII is defined as information which can be used to
distinguish or trace an individuals identity, such as their name, social security number, biometric records, etc., alone, or
when combined with other personal or identifying information that is linked or linkable to a specific individual, such as
date and place of birth, mothers maiden name, etc. (OMB Memoranda M-07-16 (May 22, 2007)).
2 However, under 45 CFR 155.120(c)(2), CAC organizations that are federally-funded to provide services to a specific
population, such as a Ryan White HIV/AIDS program or an Indian health provider, may continue to limit their services
to that population, as long as they do not discriminate within that specific population. If CACs providing these limited
services are approached by consumers outside of this specific population, they must refer these consumers to
Marketplace-approved resources, such as Navigators or other CACs that can provide assistance.
Social Security number
Alien Registration Number
Home address
Email address
Phone number
Electronic or paper federal tax returns (e.g., 1040, 941, 1099, 1120, and W-2)
Medicaid/CHIP eligibility status
Citizenship or immigration status
Applicant ID
Household income
Qualified health plan (QHP) eligibility status
Advanced payments of the premium tax credit/cost-sharing reduction (APTC/CSR)

eligibility status
Spoken and written language preference
Tobacco usage
One best practice you might want to consider is taking periodic training on the privacy and
security requirements that apply to consumer PII during the year, beyond the CMS-required
training. This could increase your ability to identify PII and reinforce how to keep consumers
information private and secure.
When Assisters Will Encounter PII

PII is needed and used by the Marketplace to determine or assess consumers eligibility for
health coverage and programs to lower their costs through the Marketplace, as well as to
identify available coverage options for all consumers. You might also encounter PII as you help
consumers select among various coverage options and enroll in coverage. As you assist
consumers who are applying for and enrolling in coverage through the Marketplace, youre likely
to encounter PII when assisting consumers with:
Creating a Marketplace account
Completing and submitting an application for health coverage
Assessing options for lowering costs of health coverage
Selecting and enrolling in a qualified health plan (QHP)
Applying for an exemption from the individual shared responsibility payment
Filing an eligibility appeal
Reporting changes to the Marketplace, including those that may qualify the consumer for
a special enrollment period or new eligibility determination
Best Practices related to Obtaining Consumer Authorization (or

Consent)
When providing assister services to a consumer for the first time, you should first explain to the
consumer your role as an assister and the privacy and security practices that you will take to
ensure that the consumers information is kept private and secure. Once you have discussed
this with the consumer, you must obtain the consumers authorization to provide assistance prior
to beginning to obtaining access to the consumers PII. To help assisters comply with this
requirement, CMS has developed a model form that Navigators and CACs may adopt or modify.
A revised draft model form was published in November 2014. Records of consumer
authorization must be appropriately secured and retained for at least six years, in accordance
with federal regulations. Consumers can revoke or limit their authorization at any time.
The following are a few best practices related to the consumer authorization requirement:
Prior to obtaining access to consumers PII, develop and follow standard consumer
authorization procedures that are appropriate for the nature of your work. For example, if
your organization assists individuals over the phone, such procedures might include
developing a verbal script and process to document and retain a consumers oral
authorization. CMS provides a model authorization form template for Navigators and
CACs to adopt or modify, as appropriate.
Develop a checklist for assisters to use when providing assistance to a consumer for the
first time. This will allow you to be sure all consumers provide their authorization (such as
by signing an authorization form or orally consenting) before the session begins.
Develop a standard operating procedure to document instances where a consumer

withdraws or limits their authorization to access their PII.
Provided the consumer has provided a general authorization to permit you to access his
or her PII to provide assistance, as well as his or her preferred contact information, keep
his or her name and contact information to set up appointments or to follow up with the
consumer at later date on application or enrollment issues. We recommend as a best
practice that preferred contact information be documented at the same time that
consumer authorization is obtained, consistent with your organizations standard
consumer authorization procedures.
Best Practices related to Providing Application and Enrollment

Assistance
During consumer appointments, utilize private spaces to ensure privacy. If assisters are
at an event and a private space is not available, create a space that is out of earshot to
discuss private information with potential applicants. Also, use computer screen covers
(that are inexpensive to purchase) which can help protect PII from the view of others.
PII collected from the consumer, including name, email address, telephone number,
application ID number, addresses, or other notes must be stored securely.
o If in hard copy, PII should be stored in locked filing cabinets or within locked
offices where the paper filing system is maintained.
o If in electronic format, PII should be stored securely in a password-

protected file on a password-protected computer to which only authorized
individuals have access.
Do not leave files or documents containing PII or tax return information unsecured and
unattended on desks, printers, personal computers, phones or other electronic devices,
and fax machines.
Do not send or forward e-mails with PII to personal e-mail accounts (e.g., Yahoo, Gmail).
Protect e-mails that contain PII (e.g., encryption).
Do not upload PII to unauthorized websites (e.g., wikis).
Do not use unauthorized mobile devices to access PII.
Lock up portable devices (e.g., laptops, cell phones).
Clear your web browser history to avoid other users accessing PII.
Disable auto-fill settings on your web browser.

Keeping notes might be necessary to perform effective application and enrollment
assistance for that consumer. For example, a consumers case may require you to
research their specific questions and follow up with them at a later appointment. If a
consumer provides a general consent for you to gain access to that consumers PII to
provide assistance, you are permitted to keep notes linked to his or her individual
situation, unless the consumer specifically limits his or her consent to prevent you from
doing so.
If you write down any quick notes for your own reference during the phone call with a
consumer but do not intend to keep those notes, shred the notes as soon as you
complete the call.
All computer equipment, including mobile devices, should have a password-protected

login screen that will not allow access to files without the proper, secure password.
Any time you step away from a computer, you should lock the computer to avoid the
chance that an unauthorized individual gains access to the computer.
Always return originals or copies of official documents that contain a consumers PII to
consumers and only make copies for yourself or others if necessary to carry out required
duties. It can be helpful to have a supply of manila folders to hand to consumers with
their documents inside. This helps them keep track of their documents in one place and
shields the content of the documents from view.
If consumers mistakenly or accidentally leave behind PII at a facility or enrollment event,

store the documents in a safe, locked location, and return PII to consumers as soon as
possible.
Remind consumers that they should keep their PII locked and in a safe place, or if stored
electronically, protected by passwords that they will remember.
What Assisters Need to Know About Breaches and Incidents (this

section is focused on Navigators and CACs and the privacy and
security standards that apply to their work)
A breach is defined by OMB Memorandum M-07-16, Safeguarding and Responding to the
Breach of Personally Identifiable Information (May 22, 2007), as the compromise, unauthorized
disclosure, unauthorized acquisition, unauthorized access, loss of control or any similar term or
phrase that refers to situations where persons other than authorized users or for an other than
authorized purpose have access or potential access to Personally Identifiable Information (PII),
whether physical or electronic. 3
Incident, or security incident, means the act of violating an explicit or implied security policy,
which includes attempts (either failed or successful) to gain unauthorized access to a system or
its data, unwanted disruption or denial of service, the unauthorized use of a system for the
processing or storage of data; and changes to system hardware, firmware, or software
characteristics without the owners knowledge, instruction, or consent.
You and your organization must implement breach and incident handling procedures that are
consistent with CMS Incident and Breach Notification Procedures 4 and memorialized in your
organizations own written policies and procedures. Such policies and procedures would:
Identify your organizations Designated Privacy Official, if applicable, and/or identify other
personnel authorized to access PII and responsible for reporting and managing Incidents
or Breaches to CMS.
Provide details regarding the identification, response, recovery, and follow-up of Incidents
and Breaches; and
Specify adequate procedures by which you can make a reasonable effort to report any
Incident or Breach of PII to the CMS IT Service Desk by telephone at (410) 786-2580 or
1-800-562-1963 or via email notification at cms_it_service_desk@cms.hhs.gov within
one hour of discovery, as required.
Issues you should report include:

Lost, stolen, or misplaced records containing PII
Unauthorized personnel seeing or possessing PII
Lost, stolen, or misplaced electronic devices (e.g., tablets or laptops) that contain
consumer PII
Scenarios
1. Consumer Leaves Behind Documents with PII: Maggie, a 34-year old single mother,
needs help applying for health coverage through the Marketplace. Before she can finish
the application, she gets a call from the schools nurse and has to run out quickly when
she learns that her son has lice. In her rush to leave, Maggie leaves behind a copy of her
3http://www.whitehouse.gov/sites/default/files/omb/memoranda/fy2007/m07-16.pdf
4
Available at http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-
Technology/InformationSecurity/Downloads/RMH_VIII_7-1_Incident_Handling_Standard.pdf
tax return with her Social Security number, home address, and phone numbers on the
assisters desk. What should the assister do?
The assister should follow Maggie out with the tax return, in the hope that she can catch
her and return the papers. In case the assister is unable to find her, the assister should
securely store the tax return in a locked drawer until Maggie is able to return and pick up
her tax return, or the papers are sent to her home address in a secure, opaque envelope.
This would not qualify as a breach of PII, and there is no requirement to notify the
Marketplace.
2. Securing PII: Paul, a 30-year old self-employed carpenter, recently had his credit card
information stolen. He is afraid of being a victim of identity theft again. Before signing up
for insurance, Paul wants to know how you will safeguard his PII. What should you tell
Paul about how PII will be secured?
Before obtaining access to Pauls PII, you should tell Paul how you work to protect his
privacy and the confidentiality of his PII, including telling him what information you might
collect, why you might collect it, and how it will be used, as well as whether the
information will be shared. Then, Paul must authorize you to access his PII. You should
reassure him that you will only access or use the minimum amount of his PII that is
necessary to effectively provide assistance for him, keep his PII private and secure at all
times, and that he may limit or revoke his authorization to share his PII with you at any
time. If Paul brings official documents like his Social Security card that contain his PII
when he meets with you, he should take these documents with him when he leaves.
Additional Resources
For More Information Visit:
Marketplace Privacy and Security Standards
45 CFR 155.260; any applicable privacy and security standards set forth in agreements,
in accordance with 155.26
Minimum Acceptable Risk Standards for Exchanges (MARS-E)

Available at: http://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/index.html#MinimumAcceptableRiskStandards
Internal Revenue Service (IRS): Data Safeguards

IRS Publication 1075 (Jan. 2014), available at: http://www.irs.gov/pub/irs-pdf/p1075.pdf
OIG Fraud Hotline

Available at: https://forms.oig.hhs.gov/hotlineoperations
Federal Trade Commission (FTC): Submission of Fraud Complaint
Available at: https://www.ftccomplaintassistant.gov/
Toolkit for
TennCare
and the
Affordable Care Act
Updated on 3/30/2017: Please check our website for updates at

www.tnjustice.org/trainings
NEW ADDRESS:
Tennessee Justice Center
211 7th Ave N., Suite 100
Nashville, TN 37219
615-255-0331 | www.tnjustice.org
Table of Contents
Counting Household Size for TennCare ............................................................................ 3
TennCare Household Size Chart ...................................................................................... 3
TennCare Household Size Flow Chart ............................................................................ 4
Income: MAGI ............................................................................................................................. 5
TJC Coverage Cheat Sheet ...................................................................................................... 6
Coverage Categories Chart .................................................................................................... 7
TennCare Eligibility Flow Charts ..................................................................................... 12
Children (Ages 0*-21) ....................................................................................................... 12
Pregnant Women ............................................................................................................... 13
Adults ..................................................................................................................................... 14
People with Disabilities or Significant Health Needs ............................................ 15
Buying Plans on the Marketplace .................................................................................... 16
Federal Poverty Level Yearly Amounts ......................................................................... 18
Coverage Gap 20
Appendix A: More Information on TennCare Categories ........................................ 20
Newborns.............................................................................................................................. 20
Pickle...................................................................................................................................... 21
Medically Needy Spend Down ....................................................................................... 22
Appendix B: More Information on Medicare ............................................................... 25
Appendix C: Special Enrollment FAQs ............................................................................ 27
Appendix D: TennCare Delays........................................................................................... 29
Appendix E: Helpful Phone Numbers & Addresses .................................................... 31
Appendix F: CHOICES Appeal ............................................................................................. 32
* Information originally prepared 8/28/02 by: Tennessee Health Care Campaign | P. O. Box 60809 | Nashville,
TN 37206 | 615-277-7500 (Nashville office) | 931-528-8422 (Cookeville office) | www.thcc2.org .
Updated by Legal Aid Society and Tennessee Justice Center.
211 7th Ave N., Suite 100 | Nashville, TN

Updated 3/30/17 615-255-0331 | www.tnjustice.org Page 2
Counting Household Size for
TennCare
TennCare Household Size Chart
How do you read this chart?
Determine who the person is: tax filer, tax dependent, or neither?
1. If they are a tax filer, their household is their filing unit.
2. If they are a tax dependent, check to see if they fall into any of the exceptions.
If they do fall into an exception, follow non-filer rule.
If they do not fall into an exception, their household is their filing unit.
3. If they are a non-filer, follow the non-filer rule.
Notes:
A child counted in the household for MAGI Medicaid if under age 19, or up to age 21 if a
full-time student.
Not everyone counted as a household member will be categorically eligible for Medicaid.
How are Households Determined in MAGI Medicaid?

If an individual expects to be a:
Tax Filer Not Claimed as a
Tax Dependent Non-Filer/ Non-Dependent
Dependent
Individual's household is...
Tax filer and all persons whom The household of the tax filer For adults:
taxpayer expects to claim as a claiming individual as a Household is the individual
tax dependent dependent plus, if living with individual,
Exceptions and special rules: spouse and minor children
For married couples filing Apply the rule for non-filers
jointly, each spouse is for: For children:
considered a tax filer. 1. Tax dependents not a child Household is the child plus
or spouse of the taxpayer minor siblings and parents
Married couples living together 2. Children living with both (including step-parents and
are always in each other's parents not expected to file a step-siblings) living with child
household regardless of how joint return
they file. 3. Children claimed as tax Note: Children for MAGI
dependent by non-custodial Medicaid categories are under
parents age 19, or full-time students
up to age 21.
Note:
A pregnant womans household includes the unborn child(ren).
Or, use the flow chart on the next page.

TennCare Household Size Flow Chart
This is the same information as the previous page, but can be easier to work through. Remember
that not everyone counted as a household member will be categorically eligible for TennCare.
If you are a tax filer not claimed as a dependent, then your household is you,
your spouse, and all claimed dependents for the upcoming year. If you are not a
tax filer, follow the flow chart:
Are you claimed as a

tax dependent?
Yes: The household is the tax

filer(s), and all claimed dependents
for the upcoming year.
UNLESS one of these 3

exceptions apply:
Exception 1: Exception 2: Exception 3: No, not

Individual is not Child lives with Child claimed by claimed as tax
a child/spouse 2 unmarried non-custodial
dependent.
of the taxpayer. parents. parent.
If you are an adult, the household size is the individual plus spouse and minor children if
living together.
If you are a child, the household size is the child plus minor siblings and parents if they live
together.
Notes:
Married couples living together are always in each others household, regardless of how they file.
Children for MAGI Medicaid categories are under age 19, or full-time students under age 21.
A pregnant womans household includes the unborn child(ren).

Income: MAGI

TJC Coverage Cheat Sheet
Note: The 2017 federal poverty level guidelines were published in the spring of 2017.
Federal Poverty Level Guidelines 2017 (Monthly Income)
Potential Coverage Categories FPL Household 2 3 4 5 6 7
size of 1
Parent/Caretaker Relatives* n/a $1018 1329 1611 1867 2102 2320 2524
Minimum Income to Qualify for 100%
Premium Tax Credits
$1005 1353 1702 2050 2398 2747 3095
May be eligible for premium tax credits
Cost-sharing reductions
Child age 6-18** 138% $1387 1868 2348 2829 3310 3790 4271
Child age 1-5** 147% $1477 1989 2501 3014 3526 4038 4550
Cost-Sharing Reductions at 94% 150% $1508 2030 2553 3075 3598 4120 4643
Pregnant, Child <1**;

200% $2010 2707 3403 4100 4797 5493 6190
Cost Sharing Reductions at 87%
Cost Sharing Reductions at 73% 250% $2513 3383 4254 5125 5996 6867 7738
CoverKids** 255% $2563 3451 4339 5228 6116 7004 7892

Maximum Income for Premium
Tax Credits
400% $4020 5413 6807 8200 9593 10,989 12,380
*According to TennCare, the Federally Facilitated Marketplace (FFM) could not program TennCare Caretaker
Relative dollar figure thresholds into its eligibility processing functionality. The numbers above are contained within
the TennCare State Plan. While applications are being processed through the FFM, the income standard for Caretaker
Relatives is 103% of the Federal Poverty Level, beginning April 1st, 2017, until the income standard is revised in 2018.
**Includes 5% FPL disregard.
Note on who is a child: to qualify for TennCare as a
Parent/Caretaker Relative, the child being cared for must be under 18 OR 18 and a full-time student living in the
house with the parent/caretaker-relative.
Child (through TennCare MAGI categories, TennCare Standard, or CoverKids) the child must be under 19
Child through Medically Needy Spend Down, the child must be under 21
Medicare Savings Programs
Program Income Limit Assets What It Pays
QMB (Qualified Medicare 100% FPL or lower (with $20 $7,280/single Part A, B premiums
Beneficiary) disregard) $10,930/couple Part A, B deductibles
$1025/single Full extra help for Part D
$1,373/couple 20% coinsurance
Cost-share for Medicare Advantage
SLMB (Specified Low-Income 120% FPL or lower (with $20 $7,280/single Part B premium
Medicare Beneficiary) disregard) $10,930/couple Full extra help for Part D
$1,226/single
$1,644/couple
QI (Qualified Individual) 135% FPL or lower (with $20 $7,280/single Part B premium
disregard) $10,930/couple Full extra help for Part D
$1,377/single
$1,847/couple
QDWI (Qualified Disabled 200% FPL or lower (with $20 $4,000/ single Part A premium
and Working Individual) disregard) $6,000/ couple
$2,030/ single
$2,727/ couple

Coverage Categories Chart
*Current as of 3/30/17: Income and some resource limits will change at different times for different programs in 2017*
Major Medicaid Eligibility Categories

Brief Monthly Income Resource Where to
Category Comments
Description Limit Limit Apply?
Use MAGI
TennCare for Low income (Family of 1) $1,018 A caretaker relative is a relative
Parents and families with (Family of 2) $1,329 None
to the 5th degree of the child
Marketplace
who makes the day-to-day
Caretaker child(ren) under (Family of 3) $1,611
decisions for the child, and with
Relatives age 18 (Family of 4) $1,867 whom the child lives.
(Family of 5) $2,102
Use MAGI
Infants aged 0-1: 200% 200% FPL: $2010 for family of 1
FPL* $4100 for family of 4
Children under Children aged 1-5: 147%
TennCare for age 19 FPL* 147% FPL: $1477 for family of 1 Marketplace
None
Children Children aged 6-18: $3014 for family of 4
138% FPL*
138% FPL: $1387 for family of 1
*includes 5% FPL $2829 for family of 4
disregard
Go to your
countys health
department to
TennCare for Use MAGI 200% FPL: $2010 for family of 2
get
Low income presumptive
Pregnant pregnant women
200% FPL (includes 5% None $4100 for family of 4
eligibility
(household includes unborn child)
Women FPL disregard) immediately.
Then, apply on
the
Marketplace.
SSI Low income Family of 1
(Supplemental aged, blind,
$755 (single-includes
$2,000; Social Security Administration
and/or disabled Family of 2 (SSA) determines eligibility.
Security individuals
$20 disregard)
$3,000; SSA provides monthly cash
Social Security
Administration
Income) $1,123 (couple-includes
Exclude assistance.
$20 disregard)
homestead
and one car
Received SSI If income would qualify Family of 1 Marketplace
See TJCs Pickle Eligibility
Pickle or and SS income in one for SSI after $2,000;
Chart with table of figures for
and appeal;
same month after deducting all SS cost of Family of 2 Tennessee
Pickle April 1977 & living adjustments $3,000; quick screening and Health
Amendment currently getting (COLA) received since Exclude calculation of Pickle Connection
SS but not last eligible for both SS homestead eligibility. (855-259-
eligible for SSI and SSI in same month and one car www.tnjustice.org/help/pickle 0701)
Lost SSI as result Income without Social

Disabled Adult Family of 1 Marketplace
of turning age 60 Security (Title II) Will remain eligible in this
Widow/ and becoming benefits must be below
$2,000;
category as long as the reason
and appeal;
Tennessee
Widower eligible for Title SSI limit ($755
Family of 2
for not receiving SSI is result Health
$3,000;
(DAW) II benefits including $20 disregard)
Exclude
of getting SS benefits and not Connection
(Social Security or if SSI is lost as result yet entitled to Medicare Part (855-259-
homestead
widow(er) of COLAs, disregard A. 0701)
and one car
benefits). COLA

Category Comments
Family of 1
Must be at least 18 years old Marketplace
$2,000;
with blindness or disability and appeal;
Would be eligible Family of 2
Disabled Adult for SSI but for
Below SSI/FBR limit
$3,000;
that began before age 22. Tennessee
Child eligibility for SSD
excluding total SS
Exclude
DAC can remain eligible for Health
benefits based on a Medicaid/TennCare upon
(DAC) based on a parents
parents work history.
homestead
marriage if married to a SS
Connection
work history. and one car (855-259-
beneficiary who is also 0701)
(Same as
eligible for DAC.
SSI)
Women with Uninsured Women with incomes Offers coverage to individuals
breast or Tennessee women below 250% of the who have no other insurance Screened at
cervical cancer under 65 who have federal poverty level coverage, including Medicare, local health
been determined can obtain free or whose insurance does not department
through the screening from the None cover treatment for breast or then enroll
countys health health department. cervical cancer. Applicants
on the
department to need must be screened by the health
treatment for breast department. Marketplace
or cervical cancer.
Persons in hospital,
residential $2,205
treatment center, (300% of SSI/ full See also
Institutionalized nursing facility, or Federal Benefit Rate)
$2,000
See also CHOICES and/or CHOICES
individuals intermediate care Only the applicants
Exclude car
ECF CHOICES.
and usually and/or ECF
facility for income counts and
homestead CHOICES.
intellectual applicants share of
disabilities for resources.
more than 30 days
$2,205* (300% of SSI/
full Federal Benefit
Rate)
Persons who Area Agency
require care in Only the applicants on Aging and
CHOICES nursing facility or income counts and
$2,000 Disability if
applicants share of Enrollment in CHOICES
who face Exclude car not on
resources. includes Medicaid/TennCare
institutionalization and usually TennCare; if
enrollment.
without home and homestead already on
community based *Applicants with TennCare,
services income over this your MCO
amount may be
eligible with a
Qualified Income
Trust (QIT)
Some individuals
who meet Social In 2017, the income Family of 1
Security disability limit is $39,851*. $2,000; Call SSA if losing SSI and
criteria, are losing Family of 2 TennCare coverage due to
Social Security
1619(b) SSI, but have *Could be even $3,000; work income, or if want to Administration
medical need such higher, depending on Exclude work but afraid will lose
that they need impairment-related homestead TennCare coverage.
TennCare to be work expenses. and one car
able to work.

Category Comments
If already enrolled
in TennCare
Amerigroup 866-
840-4991 or
BlueCare 888-747-
$2,205 (300% of SSI/ 8955.
Persons with
If not enrolled in
Employment intellectual/ full Federal Benefit 1700 applicants will be
TennCare or a United
Rate)
and developmental $2,000 enrolled this year based
MCO member, call
disability who need Exclude car on priority criteria;
Community specialized Only the applicants and usually remaining applicants
DIDD:
First (ECF) services, such as income counts and homestead will be placed on a
West Tennessee
applicants share of Regional Office
CHOICES employment and waiting list.
(866) 372-5709
vocational training. resources.
Middle Tennessee
Regional Office (800)
654-4839
East Tennessee
Regional Office (888)
531-9876
Can use medical
expenses incurred in the
3 months prior to
application (paid or
Individual must either
unpaid). Can use any
have countable
medical bill actually
income no more than
paid in the application
the figures provided
month (no matter how
below OR s/he must
old). Can use medical
have sufficient
bills incurred in
unreimbursed medical
Family of 1 application month.
expenses to spend
$2,000; Can use medical
down to these income
Family of 2 expenses incurred by
Medically limits, depending upon
$3,000; any household member.
Needy Spend Low income
family size:
Add $100 Medical expenses can
Marketplace and
(Family of 1) $241 appeal; Tennessee
Down pregnant woman or
(Family of 2) $258
per include such things as:
Health Connection
child under age 21 additional health insurance
(Family of 3) $317 (855-259-0701)
individual; premiums, doctor,
(Family of 4) $325
Exclude hospital, pharmacy,
homestead medical supply bills,
Spend Down Formula
and car eye glasses, dental bills,
Total HH hearing aids,
Countable Income transportation costs to
Medical Expenses get medical care @ 47
Adjusted income
below spend
per mile.
down level Over the Counter
Medications: can use up
to $10/month per
household member for
OTC meds without
receipt.
A person can have insurance and/or access to health insurance and still qualify in any Medicaid category.

TennCare Standard - Non-Medicaid TennCare Eligibility Category
Brief Monthly Resource Where to
Category Comments
Description Income Limit Limit Apply?
Children under the age Family income must
of 19 who are losing be at or below 211%
TennCare Medicaid of the Federal Children should
eligibility can be Poverty Line (FPL). be
screened for TennCare There is an Eligible children cannot have
automatically
Standard as Medicaid additional 5% FPL other health insurance nor
TennCare Rollovers. can they have access to an
rolled over into
disregard. If the
Standard: Children already child has a employers health plan
this category
you cannot
Uninsured & enrolled in TennCare qualifying medical None (access exception for
apply for it. If
Medically Standard can reenroll condition, the family children grandfathered in in
child not rolled
if they remain eligible. 2005).
Eligible If the familys income
income can be
Children must be recertified
over, contact
above 211% FPL. Tennessee
is above 211% of annually.
poverty, the child must Health
Uses MAGI Connection.
be medically eligible
Household &
to receive TennCare
Standard. Income Counting
Rules.
Medicare Savings Programs

(Information based on POMS HI00815.023 Medicare Savings Program Income Limits)
Category Brief Monthly Resource Comments How to Apply?
Description Income Limit
Limit
QMB Low income To qualify, Family of 1
The state is required to pay Fill out LTSS form and
(Qualified Medicare income at or Medicare Part A and B fax to Tennessee Health
$7,280
Medicare beneficiaries below 100% premiums, deductibles, and Connection (fax number
Family of 2
Beneficiaries) of poverty* coinsurance for these 1-855-315-0669)
$10,930
individuals.
SLMB (Special Low income Between Family of 1 The state is required to pay Fill out LTSS form and
Low Income Medicare 100% and $7,280 Medicare Part B premiums fax to Tennessee Health
Medicare beneficiaries 120% Family of 2 for these individuals. Connection (fax number
Beneficiaries) poverty* $10,930 1-855-315-0669)
QI (Qualifying Low income Between The state is required to pay Fill out LTSS form and
Individuals) Medicare 120% and Medicare Part B premiums fax to Tennessee Health
beneficiaries 135% Family of 1 for these individuals, as long Connection (fax number
poverty* $7,280 as federal funds are available. 1-855-315-0669)
Family of 2 Qualifying Individuals cannot
$10,930 be enrolled in
Medicaid/TennCare.
QDWI Low income The state is required to pay Fill out LTSS form and
(Qualified Medicare Below 200% Family of 1 Medicare Part A premiums fax to Tennessee Health
Disabled and Beneficiaries poverty* $4,000 for these individuals. Connection (fax number
Working who are Family of 2 1-855-315-0669)
Individuals) disabled and $6,000
working
*There is a $20 disregard. There is also an earned income deduction of $65 plus 50% of the remaining earned income.
Reminder: QMB, SLMB and QI beneficiaries should receive full extra help for Part D.

Marketplace Eligibility
Program Eligibility Benefits Pricing
Premiums can only vary
No pre-existing exclusion; no
based on age, whether
annual benefit limit, no lifetime
Individuals can purchase insurance on person smokes,
benefit limit.
the Marketplace by going to geographic area, and
http://www.healthcare.gov or calling family size.
Marketplace Premium assistance for many
1-800-318-2596. If they want help See
individuals between 100-400%
applying, they can go to http://www.healthcare.g
FPL. Cost-sharing reductions for
https://localhelp.healthcare.gov/. ov for premium
individuals between 100% and
information
250% FPL who choose silver plan.
Cover Tennessee Plans

Program Eligibility Benefits Pricing How to Apply?
Provides
comprehensive
Children:
coverage modeled on
Marketplace.
the state employee
Pregnant women:
Children under 19, pregnant health plan. There are
CoverKids women and infants who are at no pre-existing No premiums but does
Local Health
Department, the
or below 255% of the FPL condition clauses. have co-pays, many as
Marketplace, or
(includes 5% FPL disregard). Not a Medicaid low as $5.
paper application
program. No Early
here:
and Periodic
http://www.tn.gov/c
Screening,
overkids/topic/cover
Diagnostic, and
kids-application
Treatment (EPSDT)
protections.
CoverRx Individuals who are under
Application here:
100% FPL and who have no Offers prescription No premiums, but
https://www.tn.gov/
other health insurance can get drug coverage. copayment of $2-$5 per
hcfa/topic/coverrx-
prescription drug coverage prescription drug.
application
through CoverRx.

TennCare Eligibility Flow Charts
Children (Ages 0*-21)
*For more information on newborns, go to page 21.
Was the child in Yes: Consider applying
foster care when No: Is the child disabled? for SSI and ECF
they turned 18? CHOICES. Continue to
see if they are eligible
No: Is the child under 19? other ways.
Yes: Child may be eligible No: Child might be

for TennCare up to age 26. Yes: What is the expected eligible for Medically
MAGI for the family? Needy Spend Down.
<200% FPL** 200%-255% FPL**

>255% FPL**
Child may be eligible for CoverKids. If

Is the family on TennCare the family has expensive medical Apply for coverage on
now and losing coverage? needs, consider Medically Needy the Marketplace.
Spend Down.
Yes: Sign up for that coverage,
for CoverKids, or for Medically
No: How old is the child? Yes: Does child have access Needy Spend Down.
to other insurance coverage?
No: Child may be eligible

for TennCare Standard.
0-1 year 1 -5 years old 6-18 years old
SSI = Supplemental Security Income

Is the familys Is the familys Is the familys
MAGI = Modified Adjusted Gross Income
MAGI below MAGI below MAGI below FPL = Federal Poverty Line
200% FPL**? 147% FPL**? 138% FPL**?
**Includes 5% FPL disregard.
Yes: Child should be eligible for TennCare No: Child may be eligible for CoverKids. If the family has
expensive medical needs, consider Medically Needy Spend Down.

Pregnant Women
Is your income less than 200%

FPL*? (For TennCare, unborn children count
in the household of the pregnant woman only.)
Yes: Go to your countys health No: Is your income less than

department to get presumptive eligibility. 255% FPL*?
Then, apply for TennCare on the
Marketplace. You must apply promptly.
No: Are your resources below

Yes: Apply for CoverKids. If
$3000 (if household of two)?
your family has expensive
(Add $100 per additional
medical needs, continue
individual in household.
with the flowchart to look
Exclude homestead and car.)
at Medically Needy Spend
Down as an option.
Yes: Does the household No: Apply for insurance on

have high medical bills? the Marketplace.
Yes: Apply for Medically No: Does the family need

Needy Spend Down. medical or mental services?
Yes: If you incur medical No: Apply for insurance on

bills, you may be eligible for the Marketplace.
Medically Needy Spend
Down.
FPL = Federal Poverty Line
*Includes 5% FPL disregard.

Adults
Are you under 26 and were in foster care
when you turned 18?
Yes: You may be eligible for No: Are you a parent or caretaker relative of a child
TennCare until you turn 26. under 18 and have a monthly income less than:
$1329 (HH of 2); $1611 (HH of 3); $1867 (HH of 4)?
Yes: You may be eligible for No: Are you pregnant?

TennCare for Parents and
Caretaker Relatives.
Yes: See TennCare for Pregnant No: Do you have a disability?

Women flowchart
Yes: See TennCare for People with No: Do you expect to make
Disabilities flowchart between 100%-400% FPL?
Yes: Do you expect to make No: Are you below 100% FPL?
between 100%-250% FPL?
Yes: You No: You may Yes: You fall into the No: You make
should be be eligible coverage gap created by our >400% FPL. You
eligible for for PTCs on states decision not to expand are not eligible for
both PTCs and the Medicaid. You may be able to assistance on the
CSRs. Marketplace. change how you file your Marketplace, but
taxes to increase your may still use it to
income to 100% FPL or shop for
above to qualify for
insurance.
HH = Household assistance. For more help
FPL = Federal Poverty Line and to tell your story, visit:
PTC = Premium Tax Credit www.tnjustice.org/gap, or
CSR = Cost-Sharing Reduction call 615-900-GAP3 to tell
your story.

People with Disabilities or Significant Health Needs
Are you under Yes: Go to

Children flowchart.
18 years old?
*If you are under 21, you may also want to go
to the Children flowchart to see if you are
No*: Is your eligible for Medically Needy Spend Down.
income less than
$753/month?
Yes: Are your
resources less than No: Are your resources less than
$2000 ($3000 for a $2000 ($3000 for a couple)?
couple)?
Yes: You may be No: Without Medicaid Expansion, you will Yes: Did you ever
eligible for SSI. not be eligible for TennCare. You can apply get SSI in the past?
Call Social for SSDI through Social Security, which will
Security. give you Medicare after 2 years.
Yes: Did you get an SSI check after age 18 and

have a disability before age 22?
OR
Are you a widow who received SSI before age 60?
No: Do you
need help
with
Yes: Did you lose SSI because you No: Did you ever receive Activities of
started drawing SSDI based on a SSI and Social Security in Daily Living?
parent or SS benefits from a the same month?
deceased spouses work history?
Yes: You might be Yes: You might Yes: You might No: You can go to the
eligible for TennCare be eligible for be able to get Marketplace if you are
as a Disabled Adult Pickle. Look at CHOICES. Call over 100% FPL. You
Child or Disabled Adult the Pickle chart. Area Agency on can also apply for SSDI
Widow(er). Aging and through Social Security.
Disability. If approved, you may
SSI = Supplemental Security Income
be able to get Medicare.
SSDI = Social Security Disability Insurance
SS = Social Security

Buying Plans on the Marketplace
ACA Cheat Sheet
Premium Tax Credits
Tax credits are calculated using an applicants benchmark plan costs and expected premium
contribution.
Applicants benchmark plan = Second lowest cost silver plan that covers applicant (and
family, if applicable).
Applicants expected premium contribution = See table below.
Note: The expected premium contribution may not be the actual amount of the
individuals tax credit, or the individuals premium.
Applicants Expected Premium Contribution (Monthly) % of

FPL 1 2 3 4 5 6 7 income
300-400% 288-384 388-518 488-651 588-784 688-917 788-1050 888-1184 9.56%
250-300% 204-288 274-388 345-488 415-588 486-688 556-788 627-888 8.1-9.56%
200-250% 127-204 172-274 216-345 260-415 304-486 348-556 392-627 6.34-8.1%
150-200% 61-127 82-172 103-216 124-260 145-304 166-348 187-392 4.02-6.34%
133-150% 40-61 54-82 68-103 82-124 96-145 110-166 124-187 3.01-4.02%
<133% <27 <36 <45 <55 <64 <73 <83 2.01%
Calculating Premium Tax Credit Amount

Step 1: Find the cost of the benchmark plan on the Marketplace (i.e., second cheapest silver
plan).
Step 2: Determine the applicants expected premium contribution.
Step 3: Subtract the applicants expected premium contribution from the cost of the
benchmark plan to find the tax credit amount.
Tax credit amount = cost of benchmark plan MINUS applicants expected premium
contribution
Example: Joe is a 29 year-old single adult earning $1,507 per month (150% FPL). On the Marketplace, his
second cheapest silver plan option costs $351 per month; this is his benchmark plan. His expected
premium contribution is $61 (see table above). To find his premium tax credit amount, subtract his
expected premium contribution from the benchmark plan cost ($351-$61= $290). His premium tax credit
amount is $290 per month.
Offers of Employer Coverage

Many people with offers of employer coverage cannot get premium tax credits. But, if the
coverage is unaffordable or inadequate, then the employee does not have minimum essential
coverage and is eligible for PTC, if income is between 100-400% FPL.
Unaffordable: Coverage is unaffordable if employee contribution for self-only coverage is
> 9.56% of household income.
Inadequate: Plan is inadequate if its minimum value is determined by the Marketplace to
be below a certain threshold. (The majority of employer plans are adequate.)
o The application has an appendix for applicant and employer to complete. Based
on this appendix, the Marketplace will then determine whether the plan is
adequate.

Metal Tiers
Marketplace plans are in tiers based on actuarial value (AV). AV tells you what percentage of a
typical populations costs the plan pays; AV does not tell you what the plan will pay for any
particular individual.
Plan Tier Actuarial Value

Platinum 90%
Gold 80%
Silver 70%
Bronze 60%
Cost-sharing reductions
People below 250% of FPL eligible for cost-sharing reductions (CSR) ONLY if they buy a
silver plan.
On Average, the Insurance Company Will Pay This Percentage:

Standard Silver CSR Plan up to CSR Plan for 151- CSR Plan for 201-
No CSR 150% FPL 200% FPL 250% FPL
Actuarial Value 70% 94% 87% 73%
Caps on Repayment of Advanced Premium Tax Credits

At the end of the year, there is a cap to how much people may have to pay
Income as Percentage of Federal Cap for Single Taxpayer Cap for Family
Poverty Level
Less than 200% FPL $300 $600
At least 200% but less than 300% $750 $1,500
At least 300% but less than 400% $1,275 $2,550
400% and above Full repayment of APTC Full repayment of APTC
Household Size Rules for Purpose of Premium Tax Credits

When counting household for the purpose of buying health insurance and getting PTCs,
the household size is the tax unit*.
Filer + Spouse +Qualifying Children** + Qualifying Relatives***

*Medicaid household counting exceptions do not apply.
**US Citizen or resident of US, Canada, or Mexico; lives with filer for more than half the year; under 19 at
end of year or under 21 if a student; child doesnt provide more than half of his or her own support.
***US Citizen or resident of US, Canada, or Mexico; filer provides more than half of his or her support;
must be related to the filer OR live in the home all year; earned less than $4,050 in 2016.

Federal Poverty Level Yearly Amounts
*For monthly income amounts, refer to TJC Coverage Cheat Sheet.
2017 Federal Poverty Level Guidelines

Percentage of Federal Poverty Level
Household Size
1 2 3 4 5 6 7 8
100% $12,060 $16,240 $20,420 $24,600 $28,780 $32,960 $37,140 $41,320
138% $16,643 $22,411 $28,180 $33,948 $39,716 $45,485 $51,253 $57,022

(Insure
TN limit)
150% $18,090 $24,360 $30,630 $36,900 $43,170 $49,440 $55,710 $61,980
200% $24,120 $32,480 $40,840 $49,200 $57,560 $65,920 $74,280 $82,640
250% $20,150 $40,600 $51,050 $61,500 $71950 $82,400 $92,850 $103,300
400% $48,240 $64,960 $81,680 $98,400 $115,120 $131,840 $148,560 $165,280
2017 Federal Poverty Level Guidelines

2017 Federal Poverty Limit Guidelines
Family Size 100% 138% 147% 150% 155% 200% 250% 400%
1 12,060 16,643 17,728 18,090 18,693 24,120 30,150 48,240
2 16,240 22,411 23,873 24,360 25,172 32,480 40,600 64,960
3 20,420 28,180 30,017 30,630 31,651 40,840 51,050 81,680
4 24,600 33,948 36,162 36,900 38,130 49,200 61,500 98,400
5 28,780 39,716 42,307 43,170 44,609 57,560 71,950 115,120
6 32,960 45,485 48,451 49,440 51,088 65,920 82,400 131,840
7 37,140 51,253 54,596 55,710 57,567 74,280 92,850 148,560
8 41,320 57,022 60,740 61,980 64,046 82,640 103,300 165,280
each add'l
4,180 5,768 6,145 6,270 6,479 8,360 10,450 16,720
person add
The creation of this document was supported by Funding Opportunity Number CA-NAV-13-001 from the U.S. Department of Health and Human Services,
Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the Tennessee Primary Care Association and do not
necessarily represent the official views of HHS or any of its agencies. Prepared by: Tennessee Primary Care Association, February 2014

Closing the Heath Care Coverage Gap:
Helping Our Neighbors, Our Economy, and Our Health Care System
Tennessee currently has over 280,000 Tennesseans in the coverage gap. People who are in the
coverage gap cant get affordable health insurance. They dont fall into a TennCare category, and
they dont make enough money to buy health insurance through Obamacare on healthcare.gov.
Governor Haslam proposed Insure Tennessee as a way to solve this problem, but the legislature
failed to pass it. Now, a task force has come up with the Three Star Healthy Plan, which would
potentially close the gap in 2018. Closing the gap is about even more than helping our neighbors.
Truly closing the gap would bring our federal tax dollars home, boost our economy, and keep our
health care system healthy.
Closing the Gap Helps Closing the Gap Helps Our Closing the Gap Helps
our Neighbors Economy our Hospitals
280,000 Tennesseans are Closing the gap would bring Without closing the gap,
in the coverage gap, over $1 billion of our federal our hospitals are at risk
including 24,000 tax dollars back to our state. of closing or cutting their
veterans. Weve already paid the taxes, services because of high
More than 1/2 of these but right now, our money is rates of uncompensated
Tennesseans are working: staying in DC instead of care.
they are servers, cooks, coming back down to our Since 2014, 7 rural
janitors, maintenance state. hospitals have already
workers, and other service A plan to close the gap can be closed, leaving 4 counties
workers. fully paid for by the federal without a hospital.
Others have had to leave government and the hospitals, Across the state, 31% of
the workforce because they and would not cost Tennessee patients in 2013 were
are sick or injured, and taxpayers an extra dime. It admitted to a hospital that
they need health care would create about 15,000 was at risk of closing or
coverage to get better. jobs, and prevent lay-offs in cutting their services.
hospitals across the state.
What can we do?
Right now, there are two vital things that you can do:
Call your legislators. Your state senator and state representative need to hear from you,
and they need to know that you support closing the coverage gap as soon as possible, and
expect them to support it, too. You can connect with your legislators by calling 615-763-
4773: enter your zip code, and youll be connected with your senator and representative.
Talk to your community. Help get the word out! Our legislators need to hear from all of us,
and you can help make that happen. Find resources and more information at
www.tnjustice.org/gap, and bring handouts to your church, your garden club, the rotary
club or anywhere else you have the opportunity to spread information.
Together, we can ensure that all Tennesseans have access to health care coverage but it will take
all of us. Take action now to help close the coverage gap!

Appendix A: More Information on
TennCare Categories
Newborns
There are some options for newborns that could help them get coverage right away.
If the mother was on TennCare at the time of birth, have the parents
call Tennessee Health Connection.
o The newborn will be covered for one year from the date of birth.
o The newborns coverage dates back to date of birth.
o Typically, TennCare will assign the newborn to the same MCO
(Managed Care Organization) as the mother.
If the mother was on CoverKids at the time of birth, have the parents call CoverKids.
CoverKids will determine whether the baby is eligible for TennCare or CoverKids and will
facilitate the newborns enrollment in either of these programs.
o If the newborn is determined eligible for CoverKids, he/she will receive one year of
coverage starting from when the mom got on CoverKids (during pregnancy).
o If the newborn is determined eligible for TennCare, he/she will receive one year of
coverage starting on the date of birth.
o For both cases, coverage will date back to date of birth.
If the mother had private insurance or was uninsured at the time of birth, but
would have been income-eligible for TennCare, call Tennessee Health Connection and ask to
apply for Newborn Presumptive Eligibility (NPE). Or, contact a participating hospital to file a
Newborn Presumptive Eligibility (NPE) application.
o The newborns coverage will date back to the date of NPE application.
o Babies enrolled through NPE must complete an application on the
Marketplace before the end of the following month.
If the family completes a Marketplace application within this time, the babys
NPE will not end until he/she receives a full Medicaid determination. If the
family does not complete a Marketplace application by the end of the following
month, the babys NPE will end.
See the FAQs on Newborn Presumptive Eligibility for more information, and to stay updated as
changes happen. The FAQs can be found at http://www.tenncaretopics.com/pregnant-women-
eligibility/
Phone Numbers:
Tennessee Health Connection 1-855-259-0701
CoverKids 1-866-620-8864

Pickle

Medically Needy Spend Down
Note: Very few medical costs can be used for a child who is on TennCare. TennCare is supposed to
pay for all medically necessary care for a child enrolled in TennCare, including many over the counter
drugs.
Remember: You can use only the part of medical costs that you will owe. You cannot use the
part that insurance covers. Do not count the part of the insurance premium paid by an
employer.
Keep a list of any medical costs that dont seem to fit in the chartor ones youre just not sure
about. Maybe they will still help you meet Spend Down.

Medical Costs Incurred Incurred Last Incurred 2 Incurred 3 Old bill, amount
for all family Application Calendar Month Months ago Months ago paid in
members Month (from (from (from application
application application application month
month) month) month)
Health insurance
monthly premium
Over the counter
(non-
prescription)
drugs, including
up to $10/month
per household
member without a
receipt
Ex: vitamins, cold
drugs
Drugs doctor
ordered
Dental costs
(includes braces
dentures, and
orthodontia)
Doctor costs
Hospital costs
Eyeglasses,
contact lenses,
hearing aids &
walking aids (not
a complete list)

Medical Costs Incurred Incurred Last Incurred 2 Incurred 3 Old bill, amount
for all family Application Calendar Month Months ago Months ago paid in
members Month (from (from (from application
application application application month
month) month) month)
Guide dogs
School fees for
medical care
Nursing home
costs
Nursing services
Prosthetic devices
Psychiatric care
Special education
costs for mentally
and/ or physically
handicapped child
Substance abuse
treatment
Transportation for
medical/remedial
care: to and from
doctors offices
and drug store to
get medicines
(47 cents/mile -
include parking
fees and tolls)
Organ transplant
expenses
(including kidney)
Acupuncture
services
Bed hold at long-
term care facility
TOTALS
*Calendar month means the full month. For example, it would mean the month of April or July, not
March 15 to April 15 or June 22 to July 22.

Appendix B: More Information on
Medicare
Who is eligible for Medicare?
Medicare is health insurance for people 65 and older. People under 65 with certain
disabilities might also be eligible for Medicare. People with End-Stage Renal Disease are
eligible for Medicare if they are already receiving SS or railroad benefits, have worked long
enough to be eligible for benefits (how long depends upon age) or are a spouse or dependent
child of someone who is eligib le for Medicare . You must be a citizen or lawfully present in
the U.S. to be eligible for Medicare.
For information on Medicare open enrollment periods and other questions, call SHIP at
1-877-801-0044.
Medicare Part A
What is Part A?
Medicare Part A is your hospital insurance. Part A helps cover inpatient care in hospitals,
inpatient care in a skilled nursing facility (not custodial or long -term care), hospice care,
home health care, and inpatient care in a religious nonmedical health care institutio n.
How much does Part A cost?

Most people do not pay a monthly Part A premium, because they or a spouse has at least 40
quarters (or about 10 years) of Medicare -covered employment. People with 30 -39 quarters of
employment history have to pay $227 per month. People with less than 30 quarters of
employment history have to pay $413 per month.
Does Part A have cost-sharing?

Yes, you may have copayments, coins urance, or deductibles for Part A services. Visit
Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) for cost information.
Medicare Part B
What is Part B?
Medicare Part B is your medical insurance. Part B helps cover medically necessary doctors
services, outpatient care, home health services, durable medical equipment, and other
medical services. Part B also covers many preventive services. To see if Medicare covers a
service visit Medicare.gov/coverage or call 1 -800-MEDICARE.
How much does Part B cost?

For most people, the m onthly Part B premium is $134 . There are some exceptions. If your
monthly income is above $7,084 (individual) or $14,167 (couple), then your monthly
premium may be higher than $134 . If your monthly income is lower than $1,377 (individual)
or $1,847 (couple) and your resources are below $7,2 80 (individual) or $10,930 (couple),
then the state might pay your Part B premium. (See page 12 of the toolkit for more
information on Medicare Savings Programs.)
Does Part B have cost-sharing?

Yes. Part B has a $183 yearly deductible. You must pay all costs until you meet the deductible
before Medicare begins to pay its share. After you meet the deductible, you typically pay 20%
of the amount of the service. For most preventive services, you pay nothing, as long as your
doctor accepts Medicare. You may have to pay a deductible, coinsurance, or both for some
preventive services.

Medicare Part C
What is Part C?
Medicare Part C is also called an Advantage Plan. It is another way to get your Medicare
coverage. Part C is offered by private insurance companies that Medicare approves. Through
an Advantage Plan, you get Medicare parts A and B. Part C usually includes Medicare
prescription drug coverage (Part D) as p art of the plan, too. It may also offer extra coverage,
like vision, hearing, dental, and other health and wellness programs.
How much does Part C cost?
You still have to pay your Part B premium when you have Part C. In addition, you might have
to pay another monthly premium for Part C. It depends on the Advantage Plan you choose.
Does Part C have cost-sharing?
Yes. Your out-of-pocket costs depend on your plan. If you want information about a specific
Advantage Plan, call the plan provider and request a su mmary of benefits. Contact SHIP for
help comparing plans at 1-877-801-0044.
Medicare Part D
What is Part D?
Medicare Part D is your prescription drug coverage. Part D is offered to everyone with
Medicare. To get Part D, you must join a plan run by an insur ance company or other private
company approved by Medicare.
How much does Part D cost?
Each Part D plan can vary in cost , cost-sharing, and specific drugs covered.

Appendix C: Special Enrollment FAQs
What triggers a Special Enrollment Period (SEP)?
An SEP can be triggered for anyone by:
life changes: marriage, birth, adoption, placement in
foster care, becoming a citizen, release from incarceration,
or a permanent move
involuntary loss of minimum essential coverage:
employer coverage, kids covered by parents who turn 26,
TennCare/CoverKids, or COBRA if it runs out
special circumstances: error, misrepresentation or
inaction by the Marketplace or by enrollment assisters;
misconduct by a broker or application assister; QHP significantly violates their contract;
or other hardships that prevented participation in enrollment
An SEP can also be triggered for someone not currently enrolled in a qualified health plan due
to:
increased income: Applies to consumers in Medicaid non-expansion states whose
incomes rise to or above 100% FPL making them newly eligible for APTCs. Effective on
April 28, 2015.
tax penalty: Applies to individuals and families who did not have health coverage in
2014, did not know about or understand the individual mandate, and had to pay a fine
when they filed their 2014 taxes. Effective from March 15, 2015 to April 30, 2015.
delayed Medicaid or CHIP denial: Applies to consumers who dont receive
Medicaid denials until after open enrollment.
What do I do once I think I should have an SEP?

If you want to apply online, go to healthcare.gov, create an account, and go through the
application. Your eligibility letter will tell you if you have an SEP. You can also apply over the
phone, and your eligibility results will be read to you and will let you know if you have an SEP.
How long is the SEP?

The SEP is 60 days from the qualifying event. So if you get married or lose your job, you have 60
days to go on the Marketplace.
When will my coverage start once I enroll?

For most cases, it will be the same as it was during open enrollment. If you sign up for coverage
between the 1st-15th, your coverage will start on the 1st of the next month. If you sign up between
the 16th and the last day of the month, your coverage will start on the 1st of the month following
the next month (so if you apply on June 20th, your coverage will start August 1st).
The exceptions to this schedule are life changes (birth, marriage, adoption, becoming a citizen,
or permanent move). For these, the coverage will default to start on the 1st day of the next
month, but you have the option to make it retroactive to the day of event.
For example: Roxanne gets married on July 20th, and has 60 days to choose a plan on the
Marketplace. She chooses a plan on August 25th. That plan will start on September 1st. Roxanne
now has two options: she can either have her plan start on September 1 st, or she can have it
backdate to July 20th. If she chooses to backdate it, she will have to pay those back premiums,
but she will be able to bill her new insurance company for any bills incurred in that time.

If I know I am going to have an SEP coming up because I am quitting my job or
getting married, can I choose a plan before that happens?
Yes. You can start your SEP up to 60 days before the qualifying event, and have your insurance
set up to start the day you need it to avoid a longer gap in coverage.
If I switch my health plan, will the money Ive already paid towards my
deductible roll over?
No. Unfortunately, the money that you have paid towards your deductible in your old plan will
not roll over, and you will have to start from scratch with your new plan.
If I get above 100% of the federal poverty line and I am newly eligible for
premium tax credits, will I be able to enroll?
Yes. If you were previously ineligible for APTCs solely due to income below 100% FPL and you
experience an increase in income at or above 100% FPL, then you could be newly eligible for
APTCs and a SEP. This SEP applies only to consumers who live in Medicaid non-expansion
states.
To get this SEP, you must call the Marketplace at 1-800-318-2596. All you have to do is attest
that you were previously ineligible for Medicaid. If you qualify for the SEP, you will then have 60
days to enroll in a qualified health plan.
Do I have to try to enroll to qualify for the hardship to avoid paying the penalty?
If you are below the tax filing threshold ($10,150 for a single individual in 2015), then you are
automatically exempt from paying the penalty, even if you file for taxes anyway.
But, if you are between the tax filing threshold and 138% federal poverty level, you have to
apply for coverage and get a hardship exemption, in order to be exempt from the penalty.
How else could I be exempt from the penalty?
A full list of exemptions can be found at https://www.healthcare.gov/exemptions/.
What if I need help figuring out if I qualify for a SEP?
CMSs SEP screening tool can be found at https://www.healthcare.gov/screener/.

Appendix D: TennCare Delays
Note: this information changes very often. Please keep checking our website for updates:
www.tnjustice.org/tenncare-suit/.
Whats the problem?
Since January 2014, many Tennesseans who have tried applying for TennCare have not heard
back about whether or not they are eligible. Newborns, pregnant women, children, parents, and
people with disabilities have been waiting for months for TennCare to tell them whether they
can get health insurance. Hospitals have been unable to obtain Emergency Medicaid to pay for
emergency treatment provided to immigrants.
On July 23, 2014, three non-profit law firms filed Wilson v. Gordon against TennCare for these
delays.
On September 2, 2014, a judge ruled that everyone who has been waiting for a decision from
TennCare for more than 45 days (or 90 days for CHOICES applications) has the right to a fair
hearing within 45 days (or 90 days for CHOICES) of asking for one.
Who has the right to a hearing?
All class members have a right to a fair hearing. A class member is anyone who:
Applied for TennCare or a Medicare Savings Program (QMB, SLMB, or QI) and has been
waiting more than 45 days for a decision, OR
Applied for CHOICES (TennCares long-term care program) and has been waiting more
than 90 days for a decision.
Even if someone is not eligible for these programs, they are still a class member if they have
applied and are waiting beyond the 45/90 days. The delay in getting a denial from TennCare
may be preventing them from qualifying for a premium tax credit or CoverKids.
What will this hearing get for the class members?
The court indicated that the purpose of the hearing process is to help people get a prompt
decision on their application.
The state has said that they hope to resolve most cases without having to go to a hearing. This
means that they will attempt to determine whether or not someone is eligible before the hearing
happens, so that the hearing will be unnecessary. Please check www.tnjustice.org/tenncare-suit
for updates.
What can I do to help class members?
Once you have identified someone as a class member, take these steps to help him/her:
1. Explain that he/she has a right to appeal. Call Tennessee Health Connection at 1-855-
259-0701, and ask for an appeal over the phone. Be sure to write down the date and time
of the phone call, and who you spoke to. OR fax TennCares Request for Processing
Delay Hearing form with proof of application to Tennessee Health Connection at 1-855-
315-0669. Save a copy of the fax receipt.
2. TennCare may be able to determine someones eligibility without needing more
information. However, they may send a letter asking either for proof of application date,
or for proof of income. They will ask the class member to send this information within 10

days. Try to have this information ready to be sent, so that the class member can do it
immediately, if they do get that letter.
o An applicant can prove their application date with any written correspondence
from the Marketplace that shows the date of application.
Note: If the class member applied on the Marketplace by phone, they may
be able to create an account online, and gain access to their eligibility
letter with their application number.
3. Have the class member call their local Legal Aid office if they are in Middle or East
Tennessee to ask if they can get help with their appeal.
4. Be encouraging! We dont want anyone to be intimidated by the process. TennCare
has indicated that they hope to resolve most cases before they go to a hearing, so it is
possible that many people will not have to actually have a hearing.
Fast Enrollment Options (Presumptive Eligibility)
There are some people that might be able to get coverage right away. These groups should
always file an application through the Marketplace in addition to filing for Presumptive
Eligibility:
Pregnant woman, tell her to go to her local health department to get presumptive
eligibility, which will give her TennCare. As long as the class member then promptly files
a regular TennCare application through the Marketplace, her presumptive eligibility
should not end while that application is pending. If a pregnant woman loses her
presumptive eligibility because she did not apply on the Marketplace, she cannot get
another presumptive eligibility for that pregnancy.
Newborn, and
o the mother was on TennCare at the time of birth, have the parents call Tennessee
Health Connection (1-855-259-0701) to get the newborn covered for one year from
the date of birth. The newborns coverage dates back to date of birth.
o the mother was on CoverKids at the time of birth, have the parents call
CoverKids (1-866-620-8864) to get the newborn on CoverKids for one year from
when the mom got on CoverKids. The newborns coverage also dates back to date of
birth. CoverKids will determine whether the child should be on TennCare or
CoverKids, and will facilitate the enrollment in either category.
o the mother had private insurance or was uninsured at the time of birth,
but would have been eligible for TennCare, contact a participating hospital to
file a Presumptive Eligibility for Newborns application. The newborns coverage will
date back to the date of application. Or, call Tennessee Health Connection and ask
to get Newborn Presumptive Eligibility.
Breast or cervical cancer, tell the class member to go to their local health
department to file a Presumptive Eligibility for a Breast/Cervical Cancer screening to get
presumptive eligibility. If she then promptly files a regular TennCare application through
the Marketplace, her presumptive eligibility should not end while that application is
pending.

Appendix E: Helpful Phone Numbers &
Addresses
Area Agencies on Aging and Disabilities (AAAD) 1-866-836-6678
AmeriGroup 1-800-600-4441
BlueCare 1-800-468-9698
Blue Cross Blue Shield TN 1-877-942-2144
Cigna 1-800-997-1654
Community Health Alliance 1-888-415-3332
CoverKids 1-866-620-8864
CoverRx 1-800-424-5815
Department of Intellectual & Developmental Disabilities 1-615-532-6530
Family Assistance Service Center 1-866-311-4287 or 615-743-2000
Get Covered Hotline 1-844-644-5443
Health Assist 1-800-269-4038
Humana 1-615-221-2155
Marketplace Hotline 1-800-318-2596
Medicare 1-800-633-4227
Mental Health Crisis Line (Statewide) 1-800-809-9957
QMB (Qualified Medicare Beneficiary) Hotline 1-800-624-5547
SHIP (State Health Insurance Assistance Program) 1-877-801-0044 or 1-866-836-7677
Social Security Administration 1-800-772-1213
TennCare Bureau 1-800-342-3145 or 615-507-6000
TennCare Advocacy Program 1-800-758-1638
TennCare Fraud and Abuse Line 1-800-433-3982
(TennCarefraud@state.tn.us) Fax: 615-256-3852
TennCare Long-Term Care and Services 1-877-224-0219
TennCare Select 1-800-263-5479
TennCare Solutions Unit (TSU) 1-800-878-3192
TennCare Spanish-speaking Information Line 1-800-254-7568
TennCare TTY for persons with speech and hearing 1-800-779-3101 or 615-313-9240
impairments
Tennessee Health Connection Hotline 1-855-259-0701
Fax: 1-855-315-0669
Tennessee Justice Center 1-877-608-1009 or 615-255-0331
United HealthCare Community Plan 1-800-414-9025
HCFA (Eligibility Delay Appeals) Tennessee Health Connections

P.O. Box 23650, Nashville, TN 37202-3650. P.O. Box 305240
Fax: 1-844-563-1728. Nashville, TN 37230-5240
Fax: 1-855-315-0669
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061

Appendix F: CHOICES Appeal
Did TennCare say you cant get CHOICES?
You Can Appeal!
TO APPEAL: You can fill out this form and answer the questions on the back. OR you can write a letter that has
the information they ask for on your denial letter. Attach copies of any documents you have that show your need
for care with the form/letter.
Mail the form/letter and documents to: TennCare Long-Term Services and Supports
c/o CHOICES Appeals
310 Great Circle Road
Nashville, TN 37243
OR Fax the form/letter and documents to: 1-615-734-5411
Keep a copy of your appeal and (if you faxed it) the page saying the fax went through.
Who is appealing? Fill this section out with the information of the person who wants to appeal.
Full Name: ________________________________________________ Date of Birth:___/___/_____
Social Security Number: _______-_______-___________
PAE Number (Find this at the top of page 1 of your denial letter): _______________________________
Telephone Number: (______)_______-_____________
Current Mailing Address: ______________________________________________________________
_______________________________________________________________
City:______________________________________ State:______________ Zip: ____________
Who filled out this form? Fill this section out only if you are helping someone file the appeal.
Name: ________________________Daytime phone number: (_____) ______ - _____________
Are you a: ___ Parent, relative or friend ___ Advocate or attorney ____ Doctor or health care provider
Why are you appealing? Tell us what decision by CHOICES you are appealing.
__ I was told I cannot get CHOICES at all.
__ I was told I can only get CHOICES 3, but I need more help at home or care in a nursing home.
__ I was on CHOICES but they are ending my coverage.
__ I am on CHOICES but my services are being reduced.
__ I was told my PAE has only been approved for less than a year.
Why should you be on CHOICES? Tell us why you think you should be on CHOICES. Include any mistakes you
think TennCare made. Send copies of any papers or records you have that will help show your problem and your
medical need for CHOICES. If you have more you want to say simply write it on another sheet of paper and attach
it to this one!
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
NEXT: You can (but you dont have to!) answer the questions on the next page about your health and daily living.
You must sign and date on the other side of this page at the bottom.

OPTIONAL - PLEASE ANSWER THE QUESTIONS BELOW ABOUT YOUR HEALTH
AND DAILY LIVING:
Do you ever have trouble walking or moving around? YES / NO
If Yes please explain the problems you have:_______________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Do you ever have problems eating by yourself? YES / NO

________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Do you ever have trouble using the toilet or cleaning up after toileting accidents? YES / NO
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Do you ever lose your sense of direction or dont know where you are? YES / NO
If Yes please write a little about this:______________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Do you struggle to tell other people your needs? Do you find people cant understand you when you
tell them your needs and feelings? YES / NO
If Yes please write a little about this:______________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Do you have medicines that you need but cant take by yourself? YES / NO
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Are your family and loved ones concerned about how you act? Do they have to take care of you when
you act in strange or upsetting ways? YES / NO
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________
Signature: ___________________________ Date:_________________________

(Person appealing or authorized person who signs
for them).

Special Enrollment Period Reference Chart
A Guide to Special Enrollment Period Triggers and Timing
The Marketplace open enrollment period is the time each year when people can newly enroll in a plan or change to a different plan through the Marketplace (also known
as the exchange). But certain events that occur during the year can trigger a special enrollment period (SEP), when a person may be able to newly enroll in a Marketplace
plan or change to a different plan outside of the open enrollment period.
This chart lists the various events that can trigger an SEP in the Marketplace, the timing for when people can access these SEPs, and when coverage through a particular
SEP becomes effective. In using this chart, its important to note the following:
The events in the chart that trigger SEPs apply in all states regardless of whether the states Marketplace is operated by the federal government or the state itself.
The chart lays out all the SEPs available under the Affordable Care Act (ACA), but focuses on how SEPs are implemented in states that have a Federally-Facilitated
Marketplace (FFM) or rely on the Healthcare.gov platform. State-Based Marketplaces (SBMs) may have additional special enrollment opportunities not listed in the
chart, and in general, states can establish their own rules as long as they are more protective of consumers.
Although the chart focuses on Marketplace coverage, most of the events listed in the chart also trigger an SEP in the individual health insurance market outside of the
Marketplace. The exceptions are those related to immigration status, incarceration, American Indian and Alaska Natives (AI/AN), plan display errors, resolution of data-
matching issues, and exceptional circumstances.
Many SEPs are triggered when either an individual or a member of the individuals family experiences a qualifying event. Once an SEP is triggered, generally all family
members are eligible to enroll in coverage or to change plans. (A recent change in federal rules limits the plans those currently enrolled in Marketplace coverage can
choose during an SEP. The chart notes when this limitation applies.)
Consumers attest that information they provide in their applications about their eligibility for a SEP is true. A new pre-enrollment verification process beginning in
June 2017 requires that most people newly enrolling in Marketplace coverage in states using Healthcare.gov submit proof of the event that triggers certain SEPs
before their coverage becomes effective. People can pick a plan prior to submitting proof, but their enrollment is pended until SEP eligibility is verified. Once
eligibility is verified, the person must pay the first months premium and coverage will generally be effective based on when the person selected his or her plan. Note
that a person cannot pay the first months premium until eligibility for the SEP is verified. The new process starts on June 23, 2017, for SEPs related to loss of other
coverage and a permanent move. In August 2017, pre-enrollment verification is scheduled to begin for SEPs for marriage, adoption and placement in foster care, and
denial of Medicaid or the Childrens Health Insurance Program (CHIP). At this time, federal rules require pre-enrollment verification only in states using the Healthcare.
gov platform. People in SBMs should check with the Marketplace in their state for information about its SEP verification procedures.
i | SEP Reference Chart, Updated June 2017

Key Terms for SEP Reference Chart
QUALIFIED INDIVIDUAL: A person who meets the criteria to enroll through the Marketplace specifically a person who is not incarcerated, has a lawfully present
immigration status, and resides in the state where the Marketplace operates including individuals who are already enrolled in a qualified health plan (QHP) through the
Marketplace. (A qualified individual does not have to be the application filer.)
DEPENDENT (for SEP purposes): A person eligible to enroll in a health plan with a qualified individual under the terms of the health plan. This can include a spouse, child, or
other family member, and does not necessarily have to be a tax dependent.
ENROLLEE: Someone enrolled in a qualified health plan.
QUALIFIED HEALTH PLAN (QHP): A plan offered in the individual market that is certified by the Marketplace and meets certain benefit and cost-sharing standards
established under the ACA. All plans sold in the Marketplace are QHPs.
MINIMUM ESSENTIAL COVERAGE (MEC): Any health coverage that meets certain benefit and cost-sharing standards and satisfies the requirement that people maintain
health coverage or pay a penalty. Most insurance, such as coverage provided by employers, Medicare, and most Medicaid, is MEC and all QHPs are MEC. For more
information, see the Beyond the Basics MEC Reference Chart.
REQUIREMENT OF PRIOR COVERAGE: Eligibility for certain SEPs require that the person experiencing a qualifying event be enrolled in MEC prior to the qualifying event
in order to trigger the SEP. Some SEPs require that the person be enrolled in MEC for at least one day in the 60 days prior to the qualifying event in order to be eligible for
the SEP. Other SEPs are only triggered by people currently enrolled in a QHP. Not every SEP has a requirement of prior coverage, and the chart outlines the specific prior
coverage requirements, if any, for each SEP.
ADVANCE AVAILABILITY: For certain qualifying events, an individual who is eligible to enroll in or change plans through an SEP is allowed 60 days prior to a qualifying event
to select a plan (in addition to having the usual 60 days after the qualifying event to select a plan). This can help people set up health coverage in advance when they know a
change is going to occur so they dont experience a gap in coverage.
REGULAR COVERAGE EFFECTIVE DATES: For SEPs with regular coverage effective dates, coverage is effective the first day of the following month if a plan is selected
between the 1st and 15th, or the first day of the second following month if a plan is selected between the 16th and the last day of the month.
EXCHANGE OPTION: The chart lays out all the SEP available under the ACA, but focuses on how Healthcare.gov is implementing these rules, and notes where there is an
exchange option that allows state Marketplaces to vary how they implement the rules. States using Healthcare.gov cannot implement these variations. People in SBMs should
check with the Marketplace in their state on whether they have implemented exchange options.
PLAN SELECTION LIMITATIONS FOR CURRENT MARKETPLACE ENROLLEES: Beginning June 19, 2017, a person already enrolled in Marketplace coverage can only use
an SEP to change plans within the same metal level as his or her current plan (unless there are no other plans available within the same metal level in that case, a person
will be allowed to enroll in an adjacent metal level plan). If a current Marketplace enrollee gains a dependent or gets married, he or she can either add the new dependent or
spouse to his or her current Marketplace plan, or enroll the new dependent in a separate plan. (In rare cases where an enrollees current plan does not cover dependents, the
enrollee and dependent can choose to enroll in a new plan together within the same metal level as the enrollees current plan.) These restrictions do not apply to certain SEPs
as noted on the chart, and do not apply in the individual market outside of the Marketplace. SBMs may take additional time to implement these limitations. People in SBMs
should check with the Marketplace in their state for information about plan selection limitations for current enrollees.
SEP GENERALLY GRANTED BY: Most SEPs are granted by answering certain questions directly on the Marketplace application, but certain SEPs can only be granted by
a representative from the Marketplace Call Center or by a caseworker from the Centers for Medicare and Medicaid Services (CMS). Assistance from caseworkers can be
requested through the Call Center. The chart notes whether an SEP is available through the Marketplace application in Healthcare.gov, or if the SEP needs to be granted by
the Call Center or a caseworker. People in SBMs should check with the Marketplace in their state about which SEPs are available through the states Marketplace application.
ii | SEP Reference Chart, Updated June 2017

SEP REFERENCE CHART PAGE 1 OF 8
Requirement of Plan Selection SEP Generally

Type
Qualifying Event Prior Coverage Timing Coverage Effective Dates Limitations Granted By
LOSS OF MINIMUM ESSENTIAL COVERAGE (MEC) YES: Only applies if: advance availability YES: Current Marketplace Marketplace
Loss of other qualifying coverage
Qualified individual, enrollee, or a dependent: Losing other Up to 60 days if plan selected before loss: 1st day enrollees can only use Application
coverage in next BEFORE loss of of month following loss of previous SEP to:
Loses employer coverage due to, for example:
60 days coverage coverage Change plans within
Loss of a job
Lost other same metal level as
Voluntarily quitting a job current plan
coverage in past
Reduction in work hours that causes loss of eligibility 60 days Up to 60 days if plan selected after loss: 1st day of
for employer plan AFTER loss month following plan selection
Discontinuation of employer plan
Loses eligibility for Medicaid or CHIP
COBRA coverage expires
Non-group plan is canceled
Loses eligibility for student health plan
Loses coverage due to a divorce or legal separation
Loses coverage because no longer a dependent
Loses eligibility for coverage under a parents plan
Loses coverage due to a death of another person in the
family
Current QHP is decertified
No longer living, working, or residing in the area of the
plan
notes: Loss of MEC does not include voluntarily dropping
coverage or termination by the insurer due to nonpayment of
premiums.
LOSS OF PREGNANCY-RELATED MEDICAID COVERAGE YES: Only applies if: advance availability YES: Current Marketplace Marketplace
Qualified individual or a dependent: Losing other Up to 60 days if plan selected before loss: 1st day enrollees can only use Application
Loses coverage for pregnancy-related services through
Medicaid 60 days coverage coverage Change plans within
Lost other same metal level as
notes: SEP applies regardless of whether the pregnancy-related current plan
coverage in past
coverage qualifies as MEC Up to 60 days if plan selected after loss: 1st day of
60 days
AFTER loss month following plan selection
1 | SEP Reference Chart, Updated June 2017


Type
LOSS OF MEDICAID FOR THE MEDICALLY NEEDY YES: Only applies if: advance availability YES: Current Marketplace Marketplace
Loss of other qualifying coverage (cont.)
Qualified individual or a dependent: Losing other Up to 60 days if plan selected before loss: 1st day enrollees can only use Application
Loses Medicaid coverage for the medically needy (may
be referred to as Medicaid with a spenddown or share 60 days coverage coverage Change plans within
of cost Medicaid) Lost other same metal level as
coverage in past current plan
Loses coverage until a new spenddown amount is met, if Up to 60 days if plan selected after loss: 1st day of
enrolled in medically needy coverage with a spenddown 60 days
AFTER loss month following plan selection
notes: SEP applies regardless of whether the medically needy
coverage qualifies as MEC.
EXPIRATION OF NON-CALENDAR YEAR PLAN YES: Only applies if: advance availability n/a Marketplace
Qualified individual or a dependent: Enrolled in non- Up to 60 days if plan selected before last day: 1st Application
Is enrolled in a plan in the individual (non-group) or group calendar year plan BEFORE last day of day of month following loss of previous
market that comes to the end of the plan year in a month that is ending its plan year coverage
other than December plan year
notes: SEP applies even if there is an option to renew the non- Up to 60 days if plan selected after last day: 1st
calendar year plan. AFTER last day of day of month following plan selection
plan year
MARRIAGE YES: Only applies if Up to 60 days 1st day of month following plan YES: Current Marketplace Marketplace
Change in household size
Qualified individual or enrollee: at least one spouse: AFTER marriage selection enrollees can only use Application
Enrolled in MEC at SEP to:
Gets married
least 1 day in the Add new spouse to
60 days before current plan
marriage Enroll the spouse in a
Lived abroad for separate plan
1 or more days
in the 60 days
before marriage
Is an American
Indian or Alaska
Native (AI/AN)


Type
BIRTH, ADOPTION, PLACEMENT FOR ADOPTION OR FOSTER CARE, NO Up to 60 days Date of birth, adoption or placement, or YES: Enrollees can only Marketplace
Change in household size (cont.)
OR COURT ORDER AFTER birth, effective date of court order use SEP to: Application
Qualified individual or enrollee: adoption, note: Marketplace may allow consumers Add new dependent to
placement, or to choose effective date of 1st day of month current plan
Has a baby (including parents not physically giving birth)
court order after date of birth, adoption, placement, etc. Enroll the dependent in
Adopts a child, or is adopted
a separate plan
Gains or becomes a dependent through placement for
foster care
Gains or becomes a dependent through a child support
order or other court order
EXCHANGE OPTION (NOT AVAILABLE IN FFM)
DEATH YES: Only applies if: Up to 60 days 1st day of month following plan n/a n/a
Enrollee or a dependent: Currently enrolled AFTER death selection
Dies in Marketplace
coverage
notes: If the enrollee dies, an SEP is triggered for the enrollees
dependents. NOT available in FFM at this time.
EXCHANGE OPTION (NOT AVAILABLE IN FFM)
DIVORCE OR LEGAL SEPARATION YES: Only applies if: Up to 60 days Regular coverage effective dates n/a n/a
Enrollee: Currently enrolled AFTER divorce or
in Marketplace legal separation
Gets divorced or legally separated
coverage
Loses a dependent due to divorce or legal separation
Loses a dependent through a child support order or other
court order
notes: NOT available in FFM at this time.


Type
PERMANENT MOVE YES: Only applies if: Up to 60 days Regular coverage effective dates YES: Current Marketplace Marketplace
Change in primary place of living
Qualified individual, enrollee, or a dependent: Enrolled in MEC at AFTER move enrollees can only use Application
least 1 day in the SEP to:
Gains access to new QHPs as a result of a permanent
60 days before exchange option: advance availability Change plans within
move due to, for example:
move Up to 60 days if plan selected before move: 1st day of same metal level as
Moving within the same city, county, or state, as long
Moving from BEFORE move month following move current plan
as there is a different set of QHPs available
abroad
Moving to another state
An AI/AN
A child or other dependent moving back to parents
home
A student moving to or from where he or she
attends school
Moving for seasonal employment, but maintaining
another home elsewhere (such as a seasonal
farmworker)
Moving to or from a shelter or other transitional
housing
Moves permanently to the U.S. after living outside the
country or in a U.S. territory
notes: A short-term or temporary move for medical treatment or
vacation is not considered a permanent move (see FAQs on the
permanent move).
NEWLY ELIGIBLE OR INELIGIBLE FOR PREMIUM TAX CREDITS (PTC) YES: Only applies if: Up to 60 days Regular coverage effective dates YES: Current Marketplace Marketplace
Change in eligibility for financial help
Enrollee or a dependent enrolled in same qhp: Currently enrolled AFTER eligibility enrollees can only use Application
in Marketplace determination SEP to
Experiences a change in income or household size that
makes household newly eligible or ineligible for PTC coverage Change plans within
same metal level as
current plan
CHANGE IN COST-SHARING REDUCTION (CSR) ELIGIBILITY YES: Only applies if: Up to 60 days Regular coverage effective dates YES: Current Marketplace Marketplace
Enrollee or a dependent enrolled in same qhp: Currently enrolled AFTER eligibility enrollees can only use Application
in Marketplace determination SEP to:
Experiences a change in income or household size that
changes eligibility for cost-sharing reductions coverage Change to a silver plan
if not already enrolled
notes: Change in eligibility includes moving between CSR levels in one
and losing or gaining eligibility for CSRs.
Change plans within
same metal level as
current plan


Type
CURRENT EMPLOYER PLAN NO LONGER CONSIDERED QUALIFYING YES: Only applies if: advance availability n/a Marketplace
Change in eligibility for financial help (cont.)
EMPLOYER COVERAGE Enrolled in Up to 60 days if plan selected before change to Application

Qualified individual or a dependent enrolled in affected employer BEFORE change to coverage: 1st day of month following
employer plan: plan coverage change
Becomes newly eligible for PTC due to a change in
employer-sponsored plan resulting in the plan no longer
being considered qualifying coverage (i.e. the plan Up to 60 days if plan selected after change: 1st day
changes benefits so it longer qualifies as adequate AFTER change of month following plan selection
coverage, or the cost of employee coverage is no longer
considered affordable). Examples include:
Employer plan benefits or cost-sharing protections
are scaled back, causing the plan to no longer meet
the minimum value standard
Termination of employer contributions to employees
health coverage
notes: Need to terminate employer coverage prior to effective
date of the new plan.
MOVING OUT OF THE MEDICAID COVERAGE GAP NO Up to 60 days Regular coverage effective dates YES: Current Marketplace CMS Caseworker
Qualified individual: AFTER change in enrollees can only use
income or move to SEP to:
Was previously ineligible for Medicaid due to a states
new state Change plans within
decision not to expand Medicaid and had income below
100% of the poverty line. And either: same metal level as
exchange option: advance availability
current plan
Experiences an increase in income or a change in
If moving to a if plan selected before move: 1st day of
household size that brings household income to a
new state, 60 days month following move
level above 100% of the poverty line, making him or
BEFORE date of move
her newly eligible for PTC, OR
Moves to a new state (including a state that has
expanded Medicaid) and becomes newly eligible for
PTC
notes: SEP applies even if the individual did not previously apply
for Marketplace coverage or Medicaid.
NEWLY GAINING ELIGIBLE IMMIGRATION STATUS NO Up to 60 days Regular coverage effective dates n/a Marketplace
Qualified individual or a dependent: AFTER gaining Application
status
Becomes newly eligible for Marketplace coverage as a
result of gaining a lawfully present immigration status.
notes: SEP does not apply if the individual already had an eligible
immigration status. For more information, see Healthcare.govs list
of lawfully present immigration statuses eligible for Marketplace
coverage.


Type
AMERICAN INDIAN OR ALASKA NATIVE (AI/AN) NO May enroll in or Regular coverage effective dates NO Marketplace
Change in eligibility for financial help (cont.)
Qualified individual or enrollee: change QHPs one Application

time per month
Is or becomes a member of a federally-recognized Native
American tribe or an Alaska Native Claims Settlement Act
Corporation Shareholder
A dependent:
Is or becomes a dependent of someone who is an AI/AN
and is enrolled or enrolling in same QHP as AI/AN
RELEASED FROM INCARCERATION NO Up to 60 days Regular coverage effective dates n/a Marketplace
Qualified individual or a dependent: AFTER release Application
Becomes newly eligible for Marketplace coverage as a exchange option: advance availability
result of being released from incarceration (detention,
jail, or prison) Up to 60 days if plan selected before release: 1st day of
BEFORE release month following release
notes: For more information on the definition of incarceration, see
this FAQ on incarceration and Marketplace eligibility.
ERROR / MISREPRESENTATION / INACTION / MISCONDUCT NO Up to 60 Effective date appropriate to NO Marketplace Call
Enrollment or plan error
Qualified individual, enrollee, or a dependent: days AFTER circumstances Center

Marketplace
Was not enrolled in a plan, enrolled in the wrong plan,
determination of
or did not receive PTC or cost-sharing reductions
eligibility for SEP
for which he or she was eligible due to the error,
misrepresentation, misconduct or inaction by the
Marketplace or HHS, its instrumentalities, or other
entities providing enrollment assistance (e.g., assisters,
navigators, insurers, brokers, Call Center reps)
Experienced a technical error when applying for
coverage that either:
Prevented enrollment in a plan, OR
Prevented insurer from receiving enrollment
information
PLAN OR BENEFIT DISPLAY ERROR NO Up to 60 Effective date appropriate to YES: Current Marketplace Marketplace Call
Qualified individual, enrollee, or a dependent: days AFTER circumstances enrollees can only use Center
determination of SEP to:
Experienced an error related to plan benefits, service
eligibility for SEP Change plans within
area, or premium displayed on a Marketplace website at
the time of plan selection which influenced the decision same metal level as
to select (or not select) a QHP current plan
HEALTH PLAN VIOLATION YES: Only applies if: Up to 60 Effective date appropriate to YES: Current Marketplace CMS Caseworker
Enrollee or a dependent: Currently enrolled days AFTER circumstances enrollees can only use
in Marketplace determination of SEP to:
Demonstrates to the Marketplace that QHP substantially
coverage eligibility for SEP Change plans within
violated a material provision of its contract
same metal level as
current plan


Type
BEING DETERMINED INELIGIBLE FOR MEDICAID OR CHIP: NO Up to 60 days Effective date appropriate to n/a Marketplace
Other less common circumstances
Qualified individual or a dependent: AFTER being circumstances Application

determined (For more info,
Applied for Medicaid or CHIP coverage during open
ineligible for see the following
enrollment (or during an SEP) and the state Medicaid
Medicaid or CHIP Healthcare.
agency determined the individual or his or her dependent
ineligible for Medicaid or CHIP after the enrollment gov links: state
period ended transfers help
and updated
notes: SEP applies regardless of whether applied directly through application help)
state Medicaid agency or applied through Marketplace and
information was transferred to state Medicaid agency.
RESOLVING A DATA-MATCHING ISSUE (DMI) NO Up to 60 days Effective date appropriate to n/a Marketplace Call
Qualified individual: AFTER DMI is circumstances Center
resolved
Resolves a data-matching issue after initial inconsistency
period ended and the Marketplace terminated coverage
Has income under 100% FPL and did not enroll in
coverage while waiting for the Marketplace to verify that
the individual was eligible for PTC based on immigration
status
EXCEPTIONAL CIRCUMSTANCES NO Up to 60 Effective date appropriate to NO CMS Caseworker
Qualified individual, enrollee, or a dependent: days AFTER circumstances / Marketplace Call
determination of Center
Demonstrates to the Marketplace exceptional
eligibility for SEP
circumstances prevented enrollment in coverage during
open enrollment, such as:
A serious medical condition (e.g., unexpected
hospitalization or temporary cognitive disability)
A natural disaster (e.g., an earthquake, hurricane, or
massive flooding)
Wins a Marketplace appeal that an incorrect eligibility
determination or incorrect coverage effective date was
received at the time of application
Starts or ends AmeriCorps service


Type
SURVIVORS OF DOMESTIC VIOLENCE OR ABUSE OR SPOUSAL YES: Only applies if: Up to 60 days Regular coverage effective dates NO CMS Caseworker
Other less common circumstances (cont.)
ABANDONMENT Currently enrolled AFTER requesting / Marketplace Call

Qualified individual or enrollee: in MEC SEP Center
Experiences domestic abuse or violence, is enrolled in
MEC, and wants to enroll in health plan separate from
abuser (who could be an intimate partner, a parent, or
another relative)
Experiences spousal abandonment, is enrolled in MEC,
and wants to enroll in a health plan separate from spouse
A dependent on the same application:
Is a dependent of a person experiencing domestic abuse
or violence or spousal abandonment
Sources:
45 CFR 155.420: Special Enrollment Periods
HHS Market Stabilization Rule, April 18,2017; www.federalregister.gov/documents/2017/04/18/2017-07712/patient-protection-and-affordable-care-act-market-stabilization
HHS Notice of Benefit and Payment Parameters for 2018, December 22, 2016; www.federalregister.gov/documents/2016/12/22/2016-30433/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2018
CMS fact sheet: Special Enrollment Periods for the Health Insurance Marketplace; marketplace.cms.gov/outreach-and-education/special-enrollment-periods-available-to-consumers.pdf
CMS FFM and FF-SHOP Enrollment Manual, Section 5: Special Enrollment Periods, July 19, 2016; www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/ENR-FFM-SHOP-
Manual-071916.pdf

Hit submit, then if still unsuccessful, it will give you one
more try and resubmit
1.
This is the screen it will take you to after unsuccessfully

resubmitting
2.
Dont need to upload

documents for CoverKids
or TennCare application
Select return to My
Profile to start
application without
3. having to verify identity
4.
5.
You will then be directed to begin the application,

but it will quickly direct you to verify identity yet
again
6.
After submitting once, you
will still have to try one
more time in order to get
back into the application
7.
8.
Select continue to your application

9. to finally start the application
Finally! Carry on with application as you do for
consumers whose identity has been verified:
10.
The application ID is created
early on during the application.
Have it easily accessible if you
need to call the Marketplace
and offer to reference it first with
the state you are calling from.
Then STOP. Do not press Save and continue.
Read and explain the agreement
statements to the consumer
before calling the Marketplace
to avoid confusion and to keep
consumer prepared and
informed
Ifyouseethisscreen,youvegonetoofar
Pregnancy = TennCare: income no greater than 200% FPL for given household size*
= CoverKids: income no greater than 255% FPL for given household size*
immigrantsnotsubjectto5year
bar Complete
Refer consumerto
AND Marketplace
healthdepartment
UScitizens applicationand
forpresumptive
AND ensureresultisfor
immigrantssubjectto5yearbar eligibility
TennCare
legally presentfor5+years
* I N C O M E D I V I D E (not applicable for undocumented and unqualified under 5 years)
Immigrantssubjecttothe5year
barandlegallypresentforless Complete
than5years
Marketplace
AND FollowupwithBlue
applicationand
Undocumentedconsumers Cross BlueShield
ensureresultisfor
AND
CoverKids
US citizens
CoverKids
Onlyusepaperapplicationifpatient
isaminororifthereareproblems
withhealthcare.gov
Besuretoincludethesignedcover
sheetinthefax
Faxapplicationondateof
completiontoensureaccurate
effectivedate
KnowledgeCheck
Patientstatessheispregnantandneedstoapplyforhealth
insurance.Shehasanemployerauthorizationcard(EAC)anda
socialsecuritynumberandstatesthatherotherchildrenhave
TennCare.SheshowsyouherEAC.Whatwillshebeeligiblefor?
Knowledgecheckcontinued
C33isDACA
(sample card)
Canpatientgotothehealthdepartmentto
applyforpresumptiveeligibilitywhilewaiting
forapplicationtobeprocessed?
PresumptiveEligibilityisonlyforTennCare
eligiblepatients
CoverKids processingforpregnantwomen
Cardsaremailedbetween23weeksonceapplicationissubmitted
Specificpolicies/subscriberIDsareprocessedwithin34daysafter
application
PatientcancallBlueCrossBlueShieldandaskforhersubscriberID
anytime:8883258386
ThesubscriberIDisidenticaltotheoneonthecardandwillbe
processedlikethecardintheclinic,hospital,pharmacy,etc.
SUBSCRIBER ID: ZXK_______________
GROUP ID: 119002
Infants(within12months)
CallCoverKids memberservicesto
reportbabysbirth.CoverKids will
Yes facilitate enrollmenttoTennCare ifthe
babyiseligibleorCoverKids ifincome
isaboveTennCare limits
No.Did themomhaveCoverKids atthe

timeofbirth?
CompleteMarketplace applicationfor
baby.IfTennCare eligible,call
No TennesseeHealthConnectionto
completenewbornpresumptive
DidthemomhaveTennCare attimeof eligibility.
birth?
CallTennesseeHealthConnectionand
asktodonewbornpresumptive
eligibility.Willhavetofaxcopiesof
Yes
socialsecuritycardandbirthcertificate
toTNHC.Marketplace applicationnot
needed.
The Health Care Assisters
Guide to Tax Rules
Determining Income & Households for Medicaid and
Premium Tax Credits
Center on Budget and Policy Priorities

Authors
January Angeles and Tara Straw
Acknowledgements
The Center on Budget and Policy Priorities is grateful to
The California Endowment and The Annie E. Casey Foundation
for funding the development of this guide.
The authors are also grateful for the valuable contributions of our
colleagues Jeannie Biniek, Judy Solomon, Michele Vaughn, Rob Cady,
and Halley Cloud at the Center on Budget and Policy Priorities
who helped review, edit and design this guide.
Updated October 2015

Table of Contents
Introduction .............................................................................................................................................. 1
Tax-Related Elements of the Marketplace Application..................................................................... 2
Who is a Tax Filer? ................................................................................................................................ 2
Who Must File Taxes? ........................................................................................................................... 3
Who Can Be in a Tax Household? ...................................................................................................... 5
Single ................................................................................................................................................... 6
Married Filing Jointly .......................................................................................................................... 6
Married Filing Separately .................................................................................................................. 8
Head of Household ............................................................................................................................ 8
Qualifying Widow(er) With Dependent Child(ren) ...................................................................... 10
Who Can Be Claimed as a Dependent on a Tax Return? ............................................................ 12
Rules for All Dependents ............................................................................................................... 12
Rules for Claiming a Qualifying Child ........................................................................................... 12
Rules for Claiming a Qualifying Relative ..................................................................................... 14
The Difficulty of Projecting Tax Dependency .............................................................................. 15
How Does Medicaid Determine Households? ................................................................................ 17
Medicaid Household Rules for Tax Filers .................................................................................... 17
Special Rules ................................................................................................................................... 18
State Options ................................................................................................................................... 18
How do Premium Tax Credit and Medicaid Household Rules Compare? ................................. 23
What Income Counts for Medicaid and Premium Tax Credit Eligibility? .................................... 25
What Is Gross Income? .................................................................................................................. 27
What Adjustments (Deductions) Can Be Made From Gross Income? ................................... 29
When Should a Tax Dependents Income Be Counted? .......................................................... 30
Introduction
The health reform law ushered in revised Medicaid eligibility rules that align with the new rules for
premium tax credits, which are used to defray the premium cost of health insurance purchased in
the marketplace. Both programs use definitions of income and household that are based on the
Internal Revenue Code. The use of tax rules to define what is counted as income and who is in a
household is a significant change for people who are familiar with the previous Medicaid rules.
Unlike the standard application of tax rules, which are applied based on actual income and
household composition for the previous tax year, applicants for premium tax credits must apply
these rules prospectively to estimate their income and household size in the coming year. This
projection is unique to the administration of premium tax credits. Complications can arise with both
the initial estimate of household members and income and with mid-year changes that may affect
eligibility.
Household rules define whose income to count in determining eligibility and how many people are
in a persons family for the purpose of Medicaid and premium tax credit eligibility. Premium tax
credits follow tax rules in determining households; a premium tax credit household is the same as
the tax unit. Medicaid, on the other hand, uses a persons status as a tax filer, tax dependent, or
non-filer to determine who is in an individuals household and whose income is counted when
making an eligibility decision. Both Medicaid and premium tax credits determine eligibility based on
income in relation to the federal poverty line, which is dependent on household size.
Income rules determine which types of income are considered in eligibility determinations and
which income can be excluded. Medicaid considers current monthly income, while premium tax
credits are determined based on projected annual income. For Medicaid, one only needs to know
whether a persons income is above or below the threshold for eligibility. Premium tax credits, on the
other hand, are based on a sliding income scale which means the amount of the credit is sensitive to
changes in income. Even small increases in the amount of income that is projected will lead to a
reduction of the premium tax credit; if the income changes are unreported, a consumer may need to
pay back all or part of their tax credit when filing their taxes the following year. Income decreases
can make a consumer eligible for a larger premium tax credit and reduce their monthly premium
payment.
This guide is designed to familiarize people who are assisting consumers with the health care
affordability program application with the tax rules that are applied in determining eligibility for these
programs. A basic understanding of these rules can help guide discussions with applicants,
especially those with complicated family situations or multiple sources of income, or who are
unfamiliar with filing taxes. This is not a comprehensive tax guide, a substitute for seeking tax
advice, or sufficient training to enable assisters to provide tax advice.
1
Tax-Related Elements of the Marketplace Application
State-Based Marketplaces and the Federally-Facilitated Marketplace use applications that gather
information to determine eligibility for Medicaid, the Childrens Health Insurance Program (CHIP), and
premium tax credits. The information includes:
Whether the applicant files taxes: People who receive premium tax credits must agree to file
taxes for the year they receive advance payments of the credit to help pay their premiums. Filing
taxes is not an eligibility factor for Medicaid, but whether an applicant files taxes makes a
difference in determining who is in an applicants household.
Who is in the applicants household: The size of an applicants household will determine the
familys income compared to the federal poverty line, and their options for health insurance
coverage. Determining who is in a household requires knowledge of the filing status a person
will use on her tax return, and understanding how to determine the number of dependents she
can claim.
What is the applicants household income: Eligibility is based on Modified Adjusted Gross
Income (MAGI), which is Adjusted Gross Income plus excluded foreign income, tax-exempt
interest, and non-taxable Social Security benefits. A households total income is the MAGI of
everyone in the household with a tax filing requirement, including any dependents who are
required to file taxes.
Who is a Tax Filer?

The Federally-Facilitated Marketplace application begins with this question: Does [applicant] plan
to file a federal income tax return for the calendar year in which coverage is being sought This
question is important for two reasons. First, the answer triggers other questions in the dynamic
application that will determine whether the applicant is a tax filer, tax dependent, or neither for the
purposes of composing the applicants Medicaid household. Second, answering that the applicant
will not file taxes bars a person from consideration for premium tax credits because people who
receive premium tax credits must agree to file taxes for the year they receive advance payments of
the credits.
When asked whether he or she plans to file taxes, an applicant should answer YES if he or she:
Expects to have a tax filing requirement and will file;
Does not expect to have a tax filing requirement but will file anyway, for any reason (such as, to
get a refund of federal income tax withheld or to claim the earned income credit); or
Does not have a tax filing requirement or is unsure about whether tax filing will be required but
would file in order to qualify for a premium tax credit.
People who indicate that they will not file taxes will continue the application process to assess
their eligibility for Medicaid, CHIP, and to purchase private insurance in the marketplace at full cost,
but they will not be considered for premium tax credits.
2
Who Must File Taxes?
The IRS requires certain people to file taxes. Table 1 indicates who needs to file a tax return
based on filing status, age, and income for the tax year.
In some cases, a person who will be claimed as a dependent must file taxes. The factors that
determine whether a dependent has to file a return include the amount of the dependents earned
and unearned income, and whether the dependent is married, age 65 or older, or blind. Table 2
shows when dependents need to file a return based on these factors.
Some dependents may have to file a return even if their income is below the thresholds in Table 2.
Dependents who have at least $400 in net earnings from self-employment must file a return and
some dependents with unreported tip income may also have to file. For a complete list, see IRS
publication 17.
Table 1:
Minimum Income Requirements to File a 2015 Federal Tax Return
AND age at the end of 2015 THEN required to file a return if
IF filing status is...
was...* gross income was at least...**
Single under 65 $10,300
65 or older $11,850
Head of Household under 65 $13,250
65 or older $14,800
Married, Filing Jointly*** under 65 (both spouses) $20,600
65 or older (one spouse) $21,850
65 or older (both spouses) $23,100
Married, Filing Separately any age $4,000
Qualifying Widow(er) with under 65 $16,600
Dependent Child(ren) 65 or older $17,850
* Individuals born before January 1, 1951 are considered to be 65 or older at the end of 2015.
** Gross income means all income received in the form of money, goods, property, and services that is not exempt from
tax, including any income from sources outside the United States or from the sale of a persons main home (even if part
or all of it can be excluded). Gross income does not include any Social Security benefits unless (a) the person is married
filing a separate return and lived with the spouse at any time during 2015 or (b) one-half of the persons Social Security
benefits plus other gross income and any tax-exempt interest is more than $25,000 ($32,000 if married filing jointly). If
(a) or (b) applies, see the Form 1040 instructions to figure the taxable part of Social Security benefits that must be
included in gross income. Gross income includes gains, but not losses, reported on Form 8949 or Schedule D. Gross
income from a business means, for example, the amount on Schedule C, line 7, or Schedule F, line 9. But in figuring
gross income, income is not reduced by any losses, including any loss on Schedule C, line 7, or Schedule F, line 9.
*** If the person did not live with the spouse at the end of 2015 (or on the date the spouse died) and gross income was
at least $4,000, then a return must be filed regardless of age.
3
Table 2:
Minimum Income Requirements for Dependents to File a 2015 Federal Tax Return
THEN required to file a return if
AND at the
IF marital Unearned Earned
end of 2015
status is... income was at income was Gross income was at least...****
was...*
least** at least***
Single under 65 $1,050 $6,300 the larger of $1,050

years old AND OR
not blind earned income (up to $5,950) plus $350
aged 65 or $2,600 $7,850 the larger of $2,600

older OR OR
blind earned income (up to $5,950) plus $1,900
aged 65 or $4,150 $9,400 the larger of $4,150

older AND OR
blind earned income (up to $5,950) plus $3,450
Married under 65 $1,050 $6,300 $5 and spouse files a separate return and
years old AND itemizes deductions
not blind OR
the larger of $1,050 or earned income
(up to $5,950) plus $350
aged 65 or $2,300 $7,550 $5 and spouse files a separate return and

older OR itemizes deductions
blind OR
(up to $5,950) plus $1,600
aged 65 or $3,550 $8,800 $5 and spouse files a separate return and

older AND itemizes deductions
blind OR
(up to $5,950) plus $2,850
* Individuals born before January 1, 1951 are considered to be 65 or older at the end of 2015.
** Unearned income includes investment-type income such as taxable interest, ordinary dividends, and capital gain
distributions. It also includes unemployment compensation, taxable Social Security benefits, pensions, annuities,
cancellation of debt, and distributions of unearned income from a trust.
*** Earned income includes salaries, wages, tips, and professional fees. It also includes taxable scholarship and
fellowship grants.
****Gross income is the sum of earned and unearned income.
4
Who Can Be in a Tax Household?
Determinations of eligibility for Medicaid and premium tax credits are based on the number of
people in the applicants household and the income of household members. For premium tax
credits, the household is defined using tax rules that determine filing status and dependency. This
means that people who file their taxes as a single household will always be considered as a single
household for the purpose of determining their eligibility for premium tax credits and the amount of
the credits they will receive. Medicaid uses tax filing information to determine who is in a household,
but uses different rules that sometimes result in a different outcome than for premium tax credits
(for a lengthier discussion of the Medicaid household rules, see the How Does Medicaid Determine
Households? section).
The tax household is determined based on marital status, relationship, age, residency, and
support in paying for living expenses. When people complete their tax returns, these factors are
considered based on the calendar year that just ended. However, in the health care context, these
factors must be applied prospectively to determine who is in a persons household.
Marital status determines which tax filing status an individual can use. Understanding tax filing
status is important when applying for coverage because people who are married cannot receive
premium tax credits if they file their taxes using the status of Married Filing Separately. There are
five filing status options, which are illustrated in Figure 1, and discussed in more detail in the
following sections.
Figure 1:
Tax Filing Status Options and Requirements
5
Single
A person is Single if on the last day of the tax year he
or she is unmarried, legally separated or divorced, as ASSISTERS TIP
defined by state law. Some considerations for people What should an assister tell a
who are filing as Single include the following: consumer whose marital status will
change during the year?
Living apart: Married people cannot claim to be
Single if they are still married, even if they have Under IRS rules, a persons marital status
been living apart from their spouse for a long time for the entire year is determined by
whether he is single, married, legally
or their spouse is in another country.
separated, or divorced on the last day of
Legal separation: Some states do not recognize the calendar year for which the person is
legal separation (or decree of separate filing a tax return. While the IRS
determines tax filing status as of the last
maintenance), meaning that separated spouses
day of the year, CMS has said that
must file as married (either jointly or separately) applicants for premium tax credits and
until their divorce is finalized. Medicaid should provide their current
filing status on their application. For
Divorce: A divorce decree must be final in order for example, a person who anticipates being
the tax filer to be considered Single. An divorced by the end of the year would be
interlocutory decree a temporary court judgment considered married when applying for
is not final and does not qualify a person to be coverage, but should update his marital
Single. status with the marketplace when the
divorce is finalized.
Married Filing Jointly
A couple can file as Married Filing Jointly if they are legally married in their state, whether they live
together or apart. Joint filing means joint responsibility for any tax, interest, or penalty due on the
return. This includes joint responsibility for the premium tax credit, even if only one spouse qualifies
for the credit. For example, if one spouse receives more advance premium tax credit than they were
eligible to receive, both spouses may be liable for any resulting repayment of the credit. Some
considerations for people who are Married Filing Jointly include the following:
Common law marriage: Common law marriage a marriage established when a couple
presents themselves as married but does not have a marriage license is recognized by only
about one-quarter of states. In some cases it is only recognized for certain purposes or is only
valid if established before a specific date. (At least four states have enacted laws to end
recognition of common law marriage and will only recognize marriages established prior to the
change in law.) Assisters should consult state law to find out whether common law marriage is
recognized in their state and, if so, how someone qualifies.
In a state that recognizes common law marriage, a couple is considered married for federal tax
purposes and should acknowledge their marriage in the health care application. Once
established, their married status continues to be valid, even if they move to a state that does
not recognize common law marriage. (Note that once a common law marriage is established, a
couple that wishes to end their relationship and be considered no longer married must usually
file for divorce.)
In a state that does not recognize common law marriage, a couple cannot be considered
married without a marriage license, no matter how long they have lived together.
6
Same-sex marriage: A same-sex couple is
considered married for federal tax purposes if ASSISTERS TIP
their marriage is legally recognized in the What should an assister tell a consumer who
state or foreign country of their union. is married but wont file taxes with his or her
However, states that do not permit same-sex spouse?
marriage under their own laws may or may not
An assister should give the consumer all the
recognize marriages sanctioned by other
information needed to make an accurate
states in determining eligibility for Medicaid. prediction of his or her tax filing status and the
Its possible that a couple could be consequences of mistakenly claiming to be
considered married for federal tax purposes, eligible for premium tax credits.
and thus premium tax credit eligibility, but First, remember that tax filing is not a
unmarried for Medicaid. In states where factor in determining Medicaid eligibility
same-sex marriage is not legal, assisters and people filing as Married Filing
should check with the state Medicaid agency Separately can still qualify for Medicaid.
to determine how same-sex marriages will be Second, make the consumer aware that
treated. except for circumstances involving
domestic abuse or spousal abandonment,
Widow/widower: If a spouse dies during the filing taxes as Married Filing Separately
tax year, the surviving spouse is considered to disqualifies him from premium tax credits.
be married for the entire tax year and can file Knowing this, the consumer and his spouse
jointly or separately from their deceased may choose to file jointly. Also, remember
that people may have tax reasons for filing
spouse. Note that if the surviving spouse files separately from a spouse receipt of
as Married Filing Separately, he or she will not premium tax credits may not be the only
be eligible for premium tax credits. consideration.
Non-resident aliens: In general, a couple Third, discuss with the client whether they
cannot file jointly if one spouse is a non- can qualify as Head of Household. Walk
through each step of the test to determine
resident for any portion of the year. However, if the person will live separately from his
they can choose to file jointly if one spouse is spouse in the last six months of the tax
a U.S. citizen or resident and the non-resident year, will pay more than half the cost of
spouse agrees to be treated as a U.S. resident keeping up the home, and will claim his
for the year; in that case, both spouses would child as a dependent.
be taxed on worldwide income. Finally, inform the consumer that he should
update his account information if his
Note that the IRS generally refers to non- expected filing status changes. If a
citizens as resident aliens or non-resident married person is denied premium tax
aliens, rather than using terms more common credits because they wont file taxes with
in immigration or public benefits, like lawful their spouse but then divorces, he may be
permanent resident or lawfully present. newly eligible for premium tax credits for
(Another term used by the IRS, U.S. national, the year. (However, divorce alone does not
qualify a person for a Special Enrollment
refers to people who are not citizens but owe Period; the consumer must already be
their allegiance to the United States; these enrolled in a qualified health plan or will
include American Samoans and Northern need another qualifying event to enroll in
Mariana Islanders.) For more on the tax marketplace coverage.)
treatment of aliens, see IRS Publication 519.
In general, a person is a resident alien if he or she is a green card holder or meets the
substantial presence test, which is based on the length of time an individual is present in the
United States. Anyone who does not qualify as a resident alien (and is not a citizen or a U.S.
7
national) is a non-resident. Non-residents have different tax obligations. (The tests used by the
IRS in determining whether someone is a non-resident alien are different than the tests used in
determining whether an individuals immigration status qualifies him or her for Medicaid or
premium tax credits.)
Married Filing Separately

Some married people do not or cannot file a tax return jointly with their spouse. This might
happen because one spouse is not available to sign the return, the couple is separated and unwilling
to file taxes jointly, or the couple is together but they dont want to be held jointly liable for each
others taxes. Married people who file separately face several disadvantages: a higher tax rate than
couples filing jointly, fewer income deductions are available to them and deductions are phased out
at a lower income level, and certain tax credits including the premium tax credit are not allowed.
A person who files taxes as Married Filing Separately cannot claim a premium tax credit,
regardless of their reason for filing separately. There are two exceptions. The exceptions can be
claimed for no more than three consecutive years.
Survivors of domestic violence: A taxpayer who lives apart from his or her spouse and is unable
or unwilling to file a joint tax return due to domestic violence will be deemed to satisfy the joint
filing requirement by making an attestation on his or her tax return. Under this IRS rule,
taxpayers may qualify for premium tax credits despite having the tax filing requirement of
married filing separately. Domestic abuse is defined as physical, psychological, sexual, or
emotional abuse, including efforts to control, isolate, humiliate, and intimidate, or to undermine
the victims ability to reason independently. The effects of drug or alcohol abuse by the victims
spouse may be considered. Depending on a familys particular circumstances, the abuse of the
victims child or another family member living in the home may constitute abuse of the victim.
Abandoned spouses: A taxpayer is still eligible for premium tax credits if he or she has been
abandoned by a spouse and certifies on the tax return that they are unable to locate the spouse
after reasonable diligence.
Head of Household
A person who is married but does not plan to file jointly with a spouse can sometimes qualify as
Head of Household, a filing status that allows a person to be eligible for premium tax credits, rather
than Married Filing Separately, which does not.
In general, a person can be Head of Household if he or she is unmarried or considered unmarried
for tax purposes and pays more than half of the costs of keeping up the home for a qualifying person
whom he or she will claim as a dependent. The definition of qualifying person varies based on
whether the tax filer is actually single or is married but considered unmarried for tax purposes.
For purposes of the health care application, its not necessary to decide whether a single person is
eligible to file as Head of Household since both of the available filing options Single and Head of
Household are qualifying statuses for premium tax credits. For this reason, the test for Head of
Household as a single person, which uses a broader definition of qualifying person, is not
discussed here. But for someone who is married and not filing a joint return, the ability to file as
Head of Household rather than Married Filing Separately is important because it makes the person
eligible for premium tax credits.
8
A married person qualifies as Head of Household if he or she is considered unmarried. This
means that the taxpayer is married but will live apart from their spouse in the last six months of the
tax year. The person must pay more than half the cost of keeping up the home, and that home must
be the main residence of a child, stepchild, or foster child who will be claimed as a dependent (with
one exception explained below). Considerations for people filing as Head of Household include the
following:
Living apart: A spouse is considered to live in the home if he or she is temporarily absent from
the home. This includes absences due to military service, business, vacation, education, illness
or similar circumstances when the spouse is expected to return to the home after the absence.
Last six months of the tax year (July 1 to December 31): The couple must live apart for the last
six months of the tax year in which premium tax credits will be claimed. In some cases, this can
be very difficult to predict. However, if a person using the Head of Household status in prior tax
years has been separated for a long time, they may be able to reasonably anticipate that they
will be living apart for the last six months of the year.
Cost of keeping up the home: To qualify as Head of Household, the taxpayer must pay more
than half the cost of keeping up his or her home. These costs include rent, mortgage, real
estate taxes, insurance on the home, utilities, repairs and food eaten in the home. Any
expenses that are paid with TANF or other public assistance are not considered expenses paid
by the taxpayer. The costs of medical care, clothing, education, or transportation are not
included in the cost of keeping up the home.
ASSISTERS TIP
When Can a Married Person File as Head of Household?
A married person is considered unmarried and is eligible to file as Head of Household if he or she
can answer YES to each of the following questions:
Will you file taxes separately from your spouse? Yes No

Will you live separately from your spouse from July 1 to December Yes No
31?
Will you pay more than half of the cost of keeping up your home? Yes No
Will your child, stepchild, or foster child (of any age) live with you for Yes No
more than half the year?
Will either you or the childs other parent claim the child as a Yes No
dependent?
If all answers are yes, the applicant is considered unmarried and can file as Head of Household. If
the answer to any of these questions is No, the applicant cannot file as Head of Household.
9
Qualifying person: A taxpayer must have a
qualifying person in order to be Head of ASSISTERS TIP
Household. For a married person to be considered Are there any exceptions to the
unmarried, his or her home must be the main requirement for a married person to
home for his or her child, stepchild, or foster child file jointly or as Head of Household in
for more than half the year. The child can be of any order to receive premium tax credits?
age. (For a single person to be Head of Household,
Yes, a person who is a survivor of
a broader range of people can be the qualifying domestic violence or has been
person, including any related person who lives abandoned by their spouse may qualify
with the taxpayer and is a dependent and parents for premium tax credits, even if he or she
who are dependents even if they do not live with does not file jointly with the spouse.
the taxpayer.)
Exception to dependency requirement: In general, the taxpayers child must be his or her
dependent in order to claim Head of Household filing status. There is an exception if the child is
claimed by the noncustodial parent. For example, if a child lives with her mother for more than
half the year, and the parents agree that the childs father can claim her dependency exemption,
the mother is still eligible to file as Head of Household.
Non-resident alien spouse: A person can be Head of Household while living with their spouse if
the spouse is a non-resident alien for any part of the year and all other tests for Head of
Household are met. However, if the taxpayer elects to treat a non-resident spouse as a resident
for tax purposes, the couple is considered married and neither will qualify for Head of Household
status.
Qualifying Widow(er) With Dependent Child(ren)

A person whose spouse died in the two previous tax years and who has a child who meets the
definition of a Qualifying Child can qualify for this tax filing status. For example, if a taxpayers wife
died in 2014, the taxpayer has not remarried, and he will claim his 14-year-old son as a dependent,
the surviving spouse may file as a Qualifying Widower in 2015 and 2016. (In 2014, he would have
filed as Married Filing Jointly.) This filing status has no impact on eligibility for premium tax credits.
If a person qualifies for this tax filing status, he or she should indicate a marital status of Single on
the application.
10
TEST YOUR KNOWLEDGE
How Does Tax Filing Status Affect Eligibility for Premium Tax Credits?
SCENARIO 1: Sherita is married and has a son, Eddie, who is 9 years old. Sheritas husband moves out
in December 2015. They do not expect to reconcile, but they dont expect to divorce in
2016. Sherita is applying for health insurance during open enrollment for 2016. Since her
husband left, Sherita pays more than half the cost of keeping up the home. She does not
have an offer of insurance through her job, and her income is too high for Medicaid. Does
Sheritas projected filing status for 2016 allow her to qualify for premium tax credits?
ANSWER: She may qualify for premium tax credits, depending on her filing status. Sherita has a few
options:
She could file jointly with her husband if they are still legally married by the end of
2016 and they mutually agree to file together.
Sherita also appears to qualify as Head of Household if her son, Eddie, will live with her
at least half the year, she (or her husband) will claim Eddie as a dependent, she
continues to pay more than half the cost of keeping up her home, and her husband is
not living in the home during the last six months of the year (July 1 December 31).
Filing as Married Filing Jointly or as Head of Household will allow her to claim premium tax
credits. If she files as Married Filing Separately, however, she will be ineligible for premium
tax credits.
SCENARIO 2: Same facts as in Scenario 1 except Sheritas son, Eddie, is 29 years old. Eddie lost his job
and is living with his mother. He will qualify as her dependent. Does Sherita qualify for
premium tax credits?
ANSWER: Sherita can still file as Head of Household (and therefore receive premium tax credits)
because Eddie is her child and her dependent, even though he isnt a minor.
SCENARIO 3: Same facts as in Scenario 1 except Sheritas husband pays the entire mortgage, mortgage
interest, and real estate taxes. Does Sherita qualify for premium tax credits?
ANSWER: Probably not. If Sheritas husband is paying more than half the cost of keeping up the
home, then Sherita cannot be Head of Household. She will have to file as Married Filing
Separately, unless she and her husband agree to file jointly.
SCENARIO 4: Same facts as in Scenario 1 except Sheritas husband moves back into the home in June
and July of 2016 when they attempt to reconcile. He moves out again in August. Does
Sherita qualify for premium tax credits?
ANSWER: Probably not. Because Sherita and her husband didnt live apart for the last six months of
the year, Sherita does not qualify as Head of Household. This is true even though they lived
apart for the majority of the year. Shell have to file as Married Filing Separately, unless she
and her husband agree to file jointly. If Sherita received advance premium tax credits
because she expected to file as Head of Household, she should contact the marketplace to
report that she will file as Married Filing Separately. She is no longer eligible for premium
tax credits and will have to repay the advance premium tax credits she already received, up
to the repayment cap.
11
Who Can Be Claimed as a Dependent on a Tax Return?
The marketplace application asks for the number of dependents an applicant will claim for tax
purposes. This information helps determine the household size and whose income to include in
determining the Modified Adjusted Gross Income (MAGI) for the family. In many cases, it will be
obvious who can be claimed as a dependent, but in others, the assister may need to ask more
questions to help the applicant decide how many dependents, and which dependents, to include on
the application.
There are three threshold tests that must be met to claim someone as a dependent. If these tests
are satisfied, the prospective dependent must meet additional criteria to be either a Qualifying Child
or Qualifying Relative. For the purpose of the health care affordability programs, it isnt necessary to
identify which category of dependent someone falls into, but it may be helpful for an assister to
understand the rules for dependency to help an applicant who is trying to accurately project
household size.
Rules for All Dependents

To be a dependent, three tests must be met:
1. The person claiming the dependent cannot be a dependent of another taxpayer. (For example,
a 21-year-old college student with a 2-year-old child, both of whom are supported entirely by
the students parents, cannot claim her child as a dependent because she is a dependent.)
2. If the prospective dependent is married, he or she can still be claimed as a dependent.
However, if the married dependent files a joint return with his or her spouse, the return must
be filed only to claim a refund of taxes paid during the year through wage withholding.
3. The prospective dependent must be a U.S. citizen, resident, or national or must be a resident
of Mexico or Canada. (Note that although residents of Canada and Mexico can be claimed as
dependents on a tax return, they cannot qualify for health care affordability programs.)
Rules for Claiming a Qualifying Child

To be a Qualifying Child, the person must meet the following tests, which are also summarized in
Figure 2:
1. Relationship The child must be a:
Biological, adopted, foster, or stepchild of the taxpayer
Brother or sister (including half- and step-siblings) of the taxpayer
Niece, nephew, or grandchild of the taxpayer
2. Age At the end of the tax year, the child must be:
Under age 19 and younger than the taxpayer
Under age 24, if a full-time student for at least five months of the year, and younger than
the taxpayer
Any age if permanently and totally disabled
12
Figure 2:
Who Can Be Claimed as a Qualifying Child?
Notes: You cannot claim a dependent if you or your spouse are or could be a dependent. There are special rules for a
married person who may be claimed as a dependent and for adopted children.
See IRS Publication 17 for more information.
3. Residence The child must live with the taxpayer for more than half the year.
Temporary absences, such as a child who attends college and is living away from home,
are considered time in the parents home.
There are exemptions for children of divorced or separated parents or parents who live
apart. In that case, the parents may agree that the noncustodial parent will claim the
child, even if the child lived with the custodial parent for the majority of the year. The
custodial parent must agree and must sign a tax form to allow the noncustodial parent to
claim the child; the noncustodial parent cannot independently decide to claim the child.
4. Support The child must not provide more than half of his or her own support.
Total support includes rent or fair rental value of the home, food, utilities, and home
repairs for the household, with costs equally divided between family members to decide
the childs portion. Expenses related to the childs clothing, education, medical, travel
and other expenses are included. State benefits based on need, such as TANF (welfare),
housing, or food support are not included.
Support the child paid includes all of the childs taxable and nontaxable income, such as
wages, Social Security benefits, and other income. This amount also includes student
loans that the student is responsible to pay, but does not include scholarships the child
receives.
13
Only funds that are actually used for the childs support are included. If the child works
part-time and receives $400 per month but puts that money into a savings account, that
money is not included as support paid by the child.
Sometimes a child meets the test to be a Qualifying Child for more than one person. For example,
a child may be the qualifying child of both her mother and her grandmother if they all live in the
same house. In that case, the IRS has a series of tiebreaker rules that apply to decide who can take
the childs dependency exemption. In general, parents are favored over other relatives. If a parent
does not claim the child, the dependency exemption can be claimed by another eligible relative
(grandparent or aunt/uncle) with the higher income. (See IRS Publication 501 for more information.)
Rules for Claiming a Qualifying Relative

If the prospective dependent does not qualify as the taxpayers Qualifying Child, they may qualify
as a Qualifying Relative. To be a Qualifying Relative, the prospective dependent must meet the
following tests, which are also summarized in Figure 3:
1. Not a Qualifying Child The prospective dependent cannot be the Qualifying Child of any
taxpayer. However, if the person who could claim the prospective dependent as a Qualifying
Child is not required to file a tax return and either does not file a tax return or files a tax return
only to claim a refund, the prospective dependent is not considered to be that persons
Qualifying Child.
2. Relationship The prospective dependent must either be related to the taxpayer or live in the
taxpayers home for the entire year.
Relatives: The person can be the taxpayers child, grandchild, sibling, niece/nephew,
parent, aunt/uncle. This does not include cousins.
Members of the household: A person who is not related to the taxpayer in one of the ways
above can be a dependent if they live with the taxpayer for the entire year.
3. Income The prospective dependent must not have gross income greater than $3,950 (in
2014).
Gross income includes all taxable income. It does not include tax-exempt income, such
as the non-taxable portion of Social Security benefits.
4. Support The taxpayer must pay more than half the support of the prospective dependent.
Support is calculated in the same way as for a Qualifying Child, but the test is different: to be a
Qualifying Child, the child must not be paying more than half of his or her own support, but for a
Qualifying Relative, the taxpayer must pay more than half of the dependents support.
Note that there is no test for age or residence (other than for people who are unrelated to the
taxpayer.) A Qualifying Relative can be of any age and is not required to live with the taxpayer if
related to the taxpayer in one of the ways specified.
14
Figure 3:
Who Can Be Claimed as a Qualifying Relative?
Notes: You cannot claim a dependent if you or your spouse are or could be a dependent. There are special rules for a
married person who may be claimed as a dependent and for adopted children.
See IRS Publication 17 for more information.
The Difficulty of Projecting Tax Dependency

Its important to know who an applicants dependents are because this will influence the
determination of who is in the applicants household, and the applicants poverty level income for
the purposes of determining Medicaid and premium tax credit eligibility. In some cases, however,
dependency can be difficult to predict. For example, consider Katie, who is graduating from college
in May 2016. She has always been her parents Qualifying Child. But what will happen in 2016? If
Katie does not get a job and her parents continue to support her, she may still be her parents
dependent. However, if Katie gets a job, she may end up providing more than half of her own
support and no longer be a dependent. The applicant will need to decide the most likely year-end
scenario for his or her family and alert the marketplace right away if things change.
15
TEST YOUR KNOWLEDGE
Who Can Be Claimed as a Tax Dependent?
SCENARIO 1: Rachel and her son, Jason (age 9), live with Rachels boyfriend, Sam, who is not Jasons
father. Rachel and Sam both work and file their taxes separately. Who can claim Jason as
a dependent?
ANSWER: Only Rachel can claim Jason as a dependent. Jason meets the test to be her Qualifying
Child. (Jason is not Sams Qualifying Child because he isnt Sams child.) Because Jason is
Rachels Qualifying Child, he cannot be Sams Qualifying Relative.
SCENARIO 2: The same facts as in Scenario 1, except Rachel has no income and is supported by Sam.
Who can Sam claim as a dependent?
ANSWER: Jason cannot be Sams Qualifying Child because he is not Sams son. However, Jason may
be Sams Qualifying Relative. In many cases, Jason could not be Sams Qualifying Relative
because he is Rachels Qualifying Child; however, Rachel doesnt have income and will not
file taxes, so Sam is not prevented from claiming Jason as a dependent if all other tests are
met. In addition, since Jason is unrelated to Sam, Jason must have lived with Sam for the
entire year in order to be Sams Qualifying Relative. Rachel may also be Sams dependent
as a Qualifying Relative, if all the tests are met.
SCENARIO 3: The same facts as in Scenario 1, except Rachel has income of $5,000 per year. Who can
Sam claim as a dependent?
ANSWER: Rachel has no tax filing requirement. As long as she does not file or files only to claim a
refund of her income tax withholding, Sam is not barred from claiming Jason as a
dependent. For the same reasons as in Scenario 2, Jason may be Sams Qualifying
Relative. However, Rachel has exceeded the income limits for a Qualifying Relative so Sam
cannot claim her as his dependent.
SCENARIO 4: The same facts as in Scenario 1, except Rachels son Jason is 19 years old and not a full-
time student. Jason has no income. Who can claim Jasons exemption?
ANSWER: Jason is not Rachels Qualifying Child because he is too old. However, he may be her
Qualifying Relative, if Rachel provided more than half of Jasons support and all other tests
are met. (This is true even if Jason didnt live with Rachel.) On the other hand, if Sam paid
more than half of Jasons support and Jason lived with Sam for the entire year, Sam could
claim Jason as a dependent.
16
How Does Medicaid Determine Households?
While premium tax credit household rules are based purely on tax relationships, Medicaid
households are determined based on a persons family and tax relationships, as well as their living
arrangements. How people file taxes and who is in their tax unit does not always determine who is in
their Medicaid household, but it does determine which Medicaid household rules apply in making the
household determination.
The most important difference between Premium Tax Credit and Medicaid households is that for
premium tax credits, members of a tax unit are always treated as a household in determining their
eligibility but for Medicaid, household size and composition are determined separately for each
member of the household. This means that each member of a premium tax credit household that
files its taxes together will have the same household size. However, for Medicaid, household size
may differ for family members even when they are in the same tax filing household. Thus, it is
possible that for Medicaid, a family of three filing its taxes together may have two members with a
household size of three and the third member of the family may be a household of one.
Another important thing to note is that because premium tax credits are a federal benefit, the
rules are established at the federal level and are consistent across states. Medicaid, on the other
hand, provides states with several options on how to define households, so its always important for
assisters to check their states Medicaid rules regarding these options.
In general, there are three sets of household rules that Medicaid applies that depend on whether
someone is:
a tax filer
a tax dependent
neither a tax-filer nor a dependent
Medicaid Household Rules for Tax Filers

The Medicaid household is constructed based on an individuals plan to file a federal income tax
return, regardless of whether or not he or she ultimately files a return at the end of the year or is
claimed as a tax dependent. Its not necessary to have filed a federal income tax return in previous
years.
The general rules for constructing a Medicaid household are listed below. Figure 4 summarizes
the Medicaid household rules and Figure 5 depicts how these rules would be applied:
Tax filers claiming their own exemption and not being claimed as a tax dependent. The
household is the tax filer, the spouse filing jointly, and everyone whom the tax filer claims as a
tax dependent.
Tax dependents. The household is the same as the household of the tax filer claiming the
individual as a tax dependent. However, there are three exceptions to this rule, when the rule
for non-filers is applied. These exceptions are:
o Individuals who expect to be claimed as a dependent by someone other than a parent;
o Children (under 19) living with both parents, whose parents do not expect to file a joint tax
return; and
17
o Children (under 19) who expect to be claimed as a dependent by a non-custodial
parent
Individuals who neither file a tax return nor are claimed as a tax dependent. The household
rules for people in this category differ based on whether the individual is an adult or child.
o If the individual is an adult, the household includes the individual plus, if living with the
individual, his or her spouse and children who are under 19 years old
o If the individual is a child under 19 years old, the household includes the child and any
siblings under 19 years old and parents who live with the child
Special Rules
In addition to the rules for how to construct a Medicaid household based on an individuals
expected filing status, a few special rules apply in all situations.
Married couples who live together are always counted in each others household regardless of
whether they file a joint or separate return. In addition, as noted earlier in this guide, in contrast
to the premium tax credit rules, using the Married Filing Separately filing status is not a
disqualifying factor for Medicaid.
Family size adjustments need to be made if the individual is pregnant. In determining the
household of a pregnant woman, she is counted as herself plus the number of children she is
expected to deliver.
State Options
States also have some flexibility in the following areas:
In determining the family size of other individuals who have a pregnant woman in their
household, states have the option to count the pregnant woman as herself, herself plus 1, or
herself plus the number of children she is expected to deliver.
Whenever an age limit is imposed on whether an individual can be defined as a child (e.g., a
child under 19 years old), states have the option to extend the age limit to include children
under 21 years old who are full-time students.
18
Figure 4:
Summary of Medicaid Household Rules
19
Figure 5:
How to Determine An Individuals Medicaid Household
20
TEST YOUR KNOWLEDGE
How Does Medicaid Determine Households?
SCENARIO 1: Mark and Denise are married and have a son, Joe. Denises mother, Laura, lives with
them. Mark and Denise file jointly and claim Joe as their Qualifying Child. Laura files
taxes on her own. What is the Medicaid household for each member of the family?
ANSWER: Mark and Denise are considered tax filers. Using the rule for tax filers, their household
includes themselves and everyone else in their tax filing unit, so they each have a
household of three. Joe is a tax dependent who is the child of the tax filer. Using the tax
dependent rule, Joes household is the household of the tax filer claiming him, so he has a
household of three. Laura is a tax filer, so her household includes just herself.
Tax Filing Status Medicaid Household Medicaid Rule to Apply

Mark Tax Filer 3 (self, Denise, Joe) Tax filer rule
Denise Tax Filer 3 (self, Mark, Joe) Tax filer rule
Joe Tax Dependent 3 (self, Mark, Denise) Tax dependent rule
Laura Tax Filer 1 (self) Tax filer rule
SCENARIO 2: The same facts as in Scenario 1, except that Mark and Denise claim Laura as a Qualifying
Relative. What is each individuals Medicaid household?
ANSWER: The same rules applied in Scenario 1 still apply to Mark, Denise, and Joe, except that their
tax household is increased to four because it now includes Laura. Laura is now a tax
dependent, however, she falls under the exception to the tax dependent rule because she
is not a child of the tax filer. Therefore, Medicaid uses the non-filer rule to determine her
household, which includes just herself.

Mark Tax Filer 4 (self, Denise, Joe, Laura) Tax filer rule
Denise Tax Filer 4 (self, Mark, Joe, Laura) Tax filer rule
Joe Tax Dependent 4 (self, Mark, Denise, Laura) Tax dependent rule
Laura Tax Dependent 1 (self) Non-filer rule
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TEST YOUR KNOWLEDGE
SCENARIO 3: The same facts as in Scenario 1, except that Mark and Denise file taxes separately. Mark
claims Joe as his tax dependent. What is each individuals Medicaid household?
ANSWER: Even though Mark and Denise are not filing jointly, Medicaid requires that spouses who
live together always be included in each others household. Marks household includes the
people in his tax unit which is himself and Joe and Denise. Denises Medicaid
household includes herself and Mark. Lauras household includes herself.

Mark Tax Filer 3 (self, Denise, Joe) Tax filer rule
Denise Tax Filer 2 (self, Mark) Tax filer rule
Joe Tax Dependent 3 (self, Mark, Denise) Tax dependent rule
SCENARIO 4: Mark and Denise divorce. Denise now lives with Joe and Laura, and Mark lives on his own.
Denise files as Head of Household and claims Joe as her Qualifying Child. Mark files as
Single. Laura files on her own. What is each persons Medicaid household?
ANSWER: Because Denise claims Joe on her tax return, her household includes herself and Joe.
Joes household is the same as Denises household. Marks household includes himself.
Lauras household includes herself.

Mark Tax Filer 1 (self) Tax filer rule
Denise Tax Filer 2 (self, Joe) Tax filer rule
Joe Tax Dependent 2 (self, Denise) Tax dependent rule
SCENARIO 5: The same facts as in Scenario 4, except that Mark claims Joe as a dependent on his tax
return. Denise still files as Head of Household since Joe lives with her. What is each
individuals Medicaid household?
ANSWER: Using the tax filer rule, Denises household includes herself. Joe is not in her Medicaid
household even though he lives with her because Mark will claim Joe as a dependent. Joe
is a tax dependent, but he falls under the exception to the tax dependent rule since hes
being claimed as a dependent by a non-custodial parent. Therefore, Medicaid applies the
non-filer rule, and Joes household includes himself and Denise. Marks household
includes himself and Joe, whom he claims as a dependent. Lauras household includes
herself.

Mark Tax Filer 2 (self, Joe) Tax filer rule
Denise Tax Filer 1 (self) Tax filer rule
Joe Tax Dependent 2 (self, Denise) Non-filer rule
22
How do Premium Tax Credit and Medicaid Household Rules
Compare?
As noted previously, premium tax credit households are defined solely by how people file taxes
while Medicaid households take into account peoples tax filing situation, their living arrangements,
and relationships with members of the household. In many instances, the premium tax credit
household will be the same as the Medicaid household, but there will be times when the two
programs will calculate different household compositions for the same family. Programmatic
differences in how to determine households most commonly arise in cases involving:
Children being claimed as a tax dependent by a non-custodial parent
A tax filer who is claiming a person as a Qualifying Relative
Parents who live together with their child and are unmarried
Married people who live together and file separate tax returns
In such cases, its important to remember that the marketplace will always determine Medicaid
eligibility first, since eligibility for Medicaid will disqualify someone from premium tax credit eligibility.
23
TEST YOUR KNOWLEDGE
How Do the Medicaid and Premium Tax Credit Household Rules Compare?
SCENARIO 1: Janet has a 4-year-old son, Jeremy, who lives with her. However, Janets ex-husband, Carl,
claims Jeremy as a dependent on his tax return. What are the Medicaid and premium tax
credit households for each member of the family?
ANSWER: For Medicaid, Janet and Carl are considered tax filers, so their Medicaid household
includes themselves and everyone else in their tax filing unit. This means Janet has a
household of one and Carl has a household of two. Jeremy is a tax dependent, but he is
being claimed as a tax dependent by his non-custodial dad. Therefore, Medicaid will apply
the non-filer rule which means Jeremys household includes himself and Janet.
For premium tax credits, the households follow the tax unit. Janets household includes
herself. Jeremy and Carl have a household of two, which include themselves. Note that
while Jeremys Medicaid and premium tax credit household size is the same, the people
who are included in those households are different.
Medicaid Premium Tax Credit

Tax Filing Status Household Medicaid Rule to Apply Household
Janet Tax Filer 1 (self) Tax filer rule 1 (self)
Jeremy Tax Dependent 2 (self, Janet) Non-filer rule (exception to 2 (self, Carl)
tax dependent rule)
Carl Tax Filer 2 (self, Jeremy) Tax filer rule 2 (self, Jeremy)
SCENARIO 2: Alex and his wife, Rosa, file taxes jointly. They live with and support Alexs mom, Anita,
whom they claim as a dependent on their tax return. What are the Medicaid and premium
tax credit households for each member of the family?
ANSWER: Alex and Rosa are tax filers, so their Medicaid household includes themselves and
everyone else in their tax filing unit. Anita is a tax dependent, but she is not a child of the
tax filer so Medicaid will apply the non-filer rule. Anitas household includes herself.
For premium tax credits, Alex, Rosa and Anita are all in the same household.

Alex Tax filer 3 (self, Rosa, and Tax filer rule 3 (self, Rosa, Anita)
Anita)
Rosa Tax filer 3 (self, Alex, and Tax filer rule 3 (self, Alex, Anita)
Anita)
Anita Tax dependent 1 (self) Non-filer rule (exception to 3 (self, Alex, Rosa)
tax dependent rule)
24
TEST YOUR KNOWLEDGE
SCENARIO 3: Mary and David live together and have a son, Jack. They are not married, so they cant file
a joint tax return. Mary files as Single. David files as Head of Household and claims Jack
as a dependent. What are the Medicaid and premium tax credit households for each
member of the family?
ANSWER: Using the rule for tax filers, Marys Medicaid household includes only herself and Davids
household includes himself and Jack. Jack is a tax dependent but he falls under one of
the exceptions because he lives with both his parents who do not file a joint return. Using
the non-filer rule, Jacks Medicaid household includes himself and both parents with whom
he lives.
For premium tax credits, Mary and Davids household remains the same. Jacks premium
credit household will be based on his tax filing unit, which includes himself and David.

Mary Tax filer 1 (self) Tax filer rule 1 (self)
David Tax filer 2 (self, Jack) Tax filer rule 2 (self, Jack)
Jack Tax dependent 3 (self, Mary, Non-filer rule (exception to 2 (self, David)
David) tax dependent rule)
SCENARIO 4: Franz and Helga are married and live together, but they keep their finances separate and
they file separate tax returns. What are the Medicaid and premium tax credit households
for each member of the family?
ANSWER: Based on the tax filer rules, Franz and Helgas household includes themselves and
everyone else in their tax filing unit. Even though they file taxes separately, Medicaid rules
require that married people be included in each others household regardless of how they
file taxes. Therefore, they both have a household of two.

Franz N/A ineligible due
Tax filer 2 (self, Helga) Tax filer rule*
to filing status
Helga N/A ineligible due
Tax filer 2 (self, Helga) Tax filer rule*
to filing status
* Medicaid rules also dictate that married people who live together are always counted in each others
household, regardless of whether or not they file a joint tax return.
25
What Income Counts for Medicaid and Premium Tax Credit
Eligibility?
Modified Adjusted Gross Income (MAGI) is the methodology used by all states and the federal
government to measure income for most children and non-disabled, non-elderly adults in Medicaid
and for all recipients of premium tax credits. The states previous non-MAGI rules continue to apply
to people who are aged or disabled and children in foster care.
While MAGI is used to determine eligibility for both premium tax credits and Medicaid, there are
differences in the time period used to count income. Premium tax credit eligibility is based on an
annual projection of income, while Medicaid eligibility is based on current monthly income. Figure 6
describes the formula for calculating MAGI. In addition to this calculation, Medicaid excludes from
income certain scholarships, awards or fellowship grants used for education purposes and not for
living expenses, and certain American Indian and Alaska Native income.
A households MAGI is the sum of the MAGIs of each family member with a tax filing requirement.
If a dependent has a tax filing requirement, the dependents MAGI is calculated and added to the
taxpayers MAGI to determine the MAGI for the household.
Figure 6:
Formula for Calculating Modified Adjusted Gross Income (MAGI)
Note: An applicants most recent tax return can be useful in estimating income if their income has not changed. If a tax
return is not available, or if income is different for any reason, the tax return can still be a useful list of what income
and adjustments to include.
26
What Is Gross Income?
All income is taxable, unless its specifically excluded from taxation. Gross income is all income
(earned and unearned) that a person receives during the year before accounting for deductions,
exemptions and credits to reduce taxable income and total tax. These income items are listed on
the first page of IRS Form 1040. See Tables 3 and 4, based on the IRS Income Quick Reference
Guide, for examples of taxable and non-taxable income. For more details on what is taxable versus
non-taxable income, consult IRS Publication 17 and IRS Publication 525.
Table 3:
Examples of Taxable Income
Wages, salaries, bonuses, commissions IRA distributions
Alimony Jury duty fees
Annuities Military pay (not exempt from taxation)
Awards Military pension
Back pay Notary fees
Breach of contract Partnership, Estate and S-Corporation income
Business income/Self-employment income Pensions
Compensation for personal services Prizes
Debts forgiven Punitive damage
Directors fees Railroad retirementTier I (portion may be taxable)
Disability benefits (employer-funded) Railroad retirementTier II
Discounts Refund of state taxes2
Dividends Rents (gross rent)
Employee awards Rewards
Employee bonuses Royalties
Estate and trust income Severance pay
Farm income Self-employment
Fees Non-employee compensation
Gains from sale of property or securities Social Security benefits (portion may be taxable)
Gambling winnings Supplemental unemployment benefits
Hobby income Taxable scholarships and grants
Interest Tips and gratuities
Interest on life insurance dividends Unemployment compensation
27
Table 4:
Examples of Non-Taxable Income
Aid to Families with Dependent Children (AFDC) Meals and lodging for the convenience of employer
Child support Payments to the beneficiary of a deceased employee
Damages for physical injury (other than punitive) Relocation payments
Death payments Payments in lieu of workers compensation
Dividends on life insurance Rental allowance of clergyman
Federal Employees Compensation Act payments Sickness and injury payments
Federal income tax refunds Social Security benefits (portion may not be taxable)
Gifts Supplemental Security Income (SSI)
Inheritance or bequest Temporary Assistance for Needy Families (TANF)
Insurance proceeds (Accident, Casualty, Health, Life) Veterans benefits
Interest on tax-free securities Welfare payments (including TANF) and food stamps
Interest on EE/I bonds redeemed for qualified Workers compensation and similar payments
higher education expenses
Some key things to note in determining income include:

Cash income: Income from work is taxable and must be included in MAGI. A person who
receives cash for performing a service is required to track the amount of income they have
earned, even if the payer doesnt provide a W-2 or other tax statement. Money earned from
temporary, occasional, or small jobs, for performing personal services, and cash tips are all
included in gross income, such as child care, mowing lawns, cutting hair, shoveling snow, or
other work. This income is generally considered business income, which means that expenses
incurred in performing this work can be subtracted before determining gross income. (Expenses
cannot be subtracted from wages reported on a W-2.)
Projecting and verifying income: Because the amount of the premium credit is based on a
sliding scale, it is important to be as accurate as possible when predicting income in order to get
the right amount of credit. Income projections will be simple if a person expects to be in the
same job and earning roughly the same amount of money in the year of coverage as he or she
did in the previous year. In other situations, such as people who are self-employed and those
between jobs, the projecting income will be harder.
The marketplace will verify income that applicants report by checking IRS and Social Security
databases and other wage databases to which it has access. The IRS will provide income from
the applicants last tax filing, which means that often the marketplace is comparing income
reported on the application with income that is a few years old. For people whose income has
changed or who are selfemployed, these numbers are less likely to match the data on file. In
some cases, such as people who have not filed taxes in the past, including young adults just
entering the work force, the marketplace may not have any information on file. When the
income reported on the application does not match the IRS and other information or no
information is available, the applicant may be asked to provide additional information to verify
his or her income. While this information is being provided, advance payments of the premium
credit will be granted based on the applicants attestation.
Pre-tax deductions: MAGI excludes tax-deferred deductions, such as retirement savings
accounts (401(k), 403(b), 457 plans), and pre-tax deductions, such as the employees share of
employer-sponsored health insurance, flexible spending accounts for health care or dependent
28
care, and public transportation or parking benefits. If applicants projected income and
deductions are similar to the previous year, Box 1 of their most recent W-2 or their wages
reported on Line 7 of the Form 1040 should be used to determine the amount of their earnings
that should be included.
Business income: People who earn money from work that is not reported on a W-2 often must
report this income as business income, whether or not they consider themselves to be
business owners. This includes people who are paid as independent contractors (reported on a
Form 1099 MISC), are self-employed, or receive cash income.
Projecting future business income may be challenging. If income is highly uncertain, it is useful
to ask the applicant whether the previous years income is an accurate starting point for the
projection and then consider any likely changes to that income. Its important that applicants
know what income they projected and that they must track their earnings throughout the year to
determine whether they are on target to meet their projections; if not, they should report
changes in their income to the marketplace.
People with business income may deduct certain business expenses, such as supplies, mileage
(not including commuting expenses), rent, professional licensing fees, and travel.
What Adjustments (Deductions) Can Be Made From Gross Income?

Allowable income adjustments are those listed on the bottom half of the first page of Form 1040.
Some adjustments are rare or have very low dollar limits. For example, unreimbursed classroom
expenses paid by a teacher (educator expenses) may be deducted but the deduction is limited to
$250 per teacher per year. 1
Among the most common adjustments are:
Moving expenses: Moving expenses may only be
deducted if the taxpayer moved due to a change of ASSISTERS TIP
employment or business location or to start a new
business. There are also requirements for the When in doubt, leave it out!
distance and timing of the move relative to starting Some adjustments, like alimony paid or
the new job. contributions to a traditional IRA, may be
safe adjustments if those items were
IRA contributions: A contribution to a traditional properly claimed in the past. Others,
IRA (not a Roth IRA) may be deductible depending such as work-related moving expenses,
on household income and whether the taxpayer or are not as easy to predict. Unless a
his or her spouse was offered coverage under an taxpayer is very confident he or she will
have such a deduction, consider not
employer retirement plan. In any case, the
projecting adjustments. By not factoring
maximum IRA deduction is $5,500 ($6,500 if over in adjustments, the taxpayer will slightly
age 50), or twice that amount if Married Filing over-estimate income; while this results in
Jointly. Consult IRS Publication 17, Tables 17-1 a lower advance credit, it also provides a
and 17-2 for more information about income limits margin for error in the income projection.
for this deduction.
1 At this time, this tax benefit has expired. The deduction for educator expenses (line 23) and the tuition and
fees deduction (line 34) are shown as Reserved in case Congress extends these tax benefits for 2015.
29
Student loan interest: The deduction of student loan interest is capped at $2,500 per year. It
phases out based on income, but the phase out occurs at income that is generally above 400
percent of the federal poverty level, so the phase-out is irrelevant for calculation of MAGI.
Tuition and fees2: Generally, this deduction is available for taxpayers who paid tuition and other
required fees for attending college or any post-secondary school for themselves, their spouse, or
their dependents. The maximum amount of the tuition and fees deduction that can be claimed
is $4,000 per year. This deduction is not available for married couples who file separate tax
returns. Note that many taxpayers with tuition expenses choose to take either the American
Opportunity or Lifetime Learning credits instead of this deduction because in many cases, a tax
credit may be more valuable. Therefore, an assister should not assume that every family with
tuition expenses should take an adjustment to income. For more details on this deduction, see
IRS Publication 970.
As noted, most of the adjustments are capped or are available only to taxpayers within certain
income limits. Consult IRS Publication 17 for specific information on qualifications for these
adjustments.
When Should a Tax Dependents Income Be Counted?

Premium tax credit and Medicaid rules require a tax dependents income to be included in the
household income if the tax dependent is required to file a tax return. Sometimes, a dependent files
a tax return even though he or she is not required to do so for example, to get a refund of taxes
withheld from his or her paycheck. In this situation, the dependents income would not be counted.
A dependents income is counted only when he or she is required to file a tax return. See Table 2 to
review when a dependent is required to file a tax return.
In general, individuals claimed as dependents on someone elses tax return must file taxes if they
receive at least $6,300 in earned or $1,050 in unearned income (for 2015 tax year). Note that
Supplemental Security Income and the non-taxable portion of Social Security benefits are not
counted for the purposes of determining whether a dependent will be required to file a tax return.
However, if the dependent does have a tax filing requirement, then all Social Security benefits will be
counted toward the households MAGI.
2 At this time, this tax benefit has expired. The deduction for educator expenses (line 23) and the tuition and
fees deduction (line 34) are shown as Reserved in case Congress extends these tax benefits for 2015.
30
TEST YOUR KNOWLEDGE
What Sources of Income Are Counted for Premium Tax Credits and Medicaid
SCENARIO 1: Meg files taxes and claims her 17-year-old daughter, Christine, as a tax dependent. Megs
annual income is $30,000. She also receives $12,000 in child support from her ex-
husband. Christine has a part-time job and makes $3,000 a year. What is Meg and
Christines MAGI?
ANSWER: Meg and Christines MAGI is $30,000. The child support that Meg receives is not taxable,
and therefore not counted as income under MAGI rules. Christine doesnt have a tax filing
requirement and therefore her income isnt included in the households MAGI.
SCENARIO 2: The same facts as in Scenario 1, except that Christine also receives $1,100 in dividends
from an investment account that her grandparents set up for her. What is Meg and
Christines MAGI?
ANSWER: Meg and Christines MAGI is $34,100. The child support that Meg receives is still not
taxable, and therefore not counted. Because Christine received more than $1,050 in
unearned income, she is now required to file a tax return. That means that the $3,000 that
she earns from her job, and the $1,100 that she received in dividends will be added to the
$30,000 that Meg earns in determining the household MAGI.
SCENARIO 3: The same facts as in Scenario 1, except that instead of child support, Christine receives
$10,000 in Social Security survivors benefits. What is Meg and Christines MAGI?
ANSWER: Meg and Christines MAGI is $30,000. Social Security benefits in the childs name are not
counted in determining whether Christine has a tax filing requirement. Her income from her
part-time job is not enough to trigger a tax filing requirement. Since she doesnt have to file
taxes, none of her income is counted toward the households MAGI.
SCENARIO 4: The same facts as in Scenario 1, except that instead of child support, Christine receives
$10,000 in Social Security survivors benefits. In addition, Christine receives $1,100 in
dividends from an investment account that her grandparents set up for her.
What is Meg and Christines MAGI?
ANSWER: Meg and Christines MAGI is $44,100. All income received by both Meg and Christine is
counted toward their households MAGI. Because Christine receives more than $1,050 in
unearned income, she now has a tax filing requirement. And because she has a tax filing
requirement, her Social Security benefits are now counted toward her MAGI.
1
Istheapplicantofferedhealthinsurancebytheiroraspousesemployer?
IsenrollmentforEmployer
basedplancurrentlyopen? YES
NO
Isemployeesshareofpremium NO
YESORNO affordable?<9.5%ofgrossincome?
YES Maybeeligiblefor
CSRand/orPTCif
othercriteriaare
Noteligiblefor Doesemployerofferedplanmeet met
NO
CSRand/orPTC, minimumvaluestandard?
canstillpurchase
planonMPatfull
cost
YES
INCOME GUIDE
NEW Address:
2117th
Avenue North, Suite 100
Nashville, TN 37219
615-255-0331
Contents
What is Modified Adjusted Gross Income (MAGI)? ...................................................................................... 2
Whose TennCare eligibility is based on MAGI? ........................................................................................ 2
Wages............................................................................................................................................................ 3
Self-Employment and Business Income ........................................................................................................ 3
Self-employment/Proprietor .................................................................................................................... 3
Farm Income & Farm Rental Income ........................................................................................................ 4
Rental Income ........................................................................................................................................... 5
NON-Government Employment Related Benefit Payments ......................................................................... 6
Sick Pay or Private Disability Payments .................................................................................................... 6
Vacation Pay.............................................................................................................................................. 6
Workman's Compensation........................................................................................................................ 7
Government Payments ................................................................................................................................. 7
Social Security Benefits (see Appendices A and B for more information) ................................................ 7
Unemployment Compensation ................................................................................................................. 8
Supplemental Security Income (SSI) ......................................................................................................... 8
State Assistance (Families First) ................................................................................................................ 9
Veterans Disability Payments ................................................................................................................... 9
Veterans Affairs Payments ...................................................................................................................... 10
Value of Food Assistance aka Food Stamps ............................................................................................ 11
Value of Housing Assistance ................................................................................................................... 11
Energy & Utility Assistance ..................................................................................................................... 12
Third Party Payments .................................................................................................................................. 12
Alimony ................................................................................................................................................... 12
Child Support .......................................................................................................................................... 12
NON Social Security Retirement-Related Payments ................................................................................... 13
Pensions & Annuities .............................................................................................................................. 13
IRA Individual Retirement Account ......................................................................................................... 13
Miscellaneous Income ................................................................................................................................ 14
Life Insurance Proceeds .......................................................................................................................... 14
Prizes and Awards ................................................................................................................................... 14
1|Page
Inheritances ............................................................................................................................................ 14
Gifts ......................................................................................................................................................... 15
Helpful Resources ....................................................................................................................................... 16
Appendix A - MAGI Income: Social Security ............................................................................................... 17
Appendix B - Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)? ............ 18
What is Modified Adjusted Gross Income (MAGI)?

Modified Adjusted Gross Income (MAGI) is a methodology for how income is counted. It is based on
federal tax rules for determining adjusted gross income, with some modifications.
For parents/caretaker relatives, pregnant women, and children (1 through 18), there is a 5% income
disregard for those who would otherwise be ineligible. This 5% income disregard does not apply to
premium-tax credits and cost-sharing reductions.
For MAGI, resources/assets are not taken into account and do not affect eligibility.
Whose TennCare eligibility is based on MAGI?

MAGI Non-MAGI
Parents and Caretaker Relatives SSI-related categories (DAC, DAW, Pickle, 1619(b))
Pregnant Women CHOICES
Children (1 through 18) Medically Needy Spend-down
Premium tax credits Medicare Savings Programs (MSP)
Cost-sharing reductions Breast and cervical cancer
Please note: This guide addresses certain sources of income you are most likely to encounter when
working with clients. It is not an exhaustive list. In addition, some Non-MAGI categories of eligibility like
Medically Needy Spend Down and the disability related categories rely on different income counting
2|Page
methodologies that utilize certain income disregards. This guide does not address the applicability of
those disregards when calculating household income.
Wages
MAGI - In most cases, the person must include in gross income everything he/she
receives in payment for personal services. This includes: wages, all tips, overtime, salary,
bonuses, commissions, sheltered workshop payments, sick pay, strike benefits,
infrequent income.
NON MAGI - Wages includes all remuneration from employment, and the term is
broadly defined to mean gross wages.
o Gross wages are the amount paid before the deduction of taxes, garnishments,
pension fund contributions, and other optional deductions such as insurance
premiums, savings bonds, loan repayments, etc. Gross earnings are the total
compensation received for the performance of services while in the employ of
another including wages, salaries, bonuses, or commissions.
o Net Earnings are the amount of earnings remaining after mandatory deductions
such as federal withholding taxes and social security taxes and other types of
deductions have been withheld. Mandatory deductions for FICA and withholding
taxes are excluded from earned income of institutionalized individuals in
determining eligibility and patient liability. For program purposes, net earnings
equal the amount of income remaining after application of the earned income
disregards.
Self-Employment and Business Income

Self-employment/Proprietor
Defined: A person is self-employed if he/she carries on a trade or business as a sole
proprietor or an independent contractor.
o Sole proprietor - A sole proprietor is someone who owns an unincorporated
business by himself or herself.
o Independent Contractor The general rule is that an individual is an
independent contractor if the payer has the right to control or to direct only the
result of the work and not how it will be done.
o Business owned and operated by spouses. If spouses jointly own and operate an
unincorporated business and share in the profits and losses, the spouses are
partners in a partnership, whether or not they have a formal partnership
agreement.
MAGI - Unlike current Medicaid income counting rules that use gross revenue received
by a self-employed person (and then allow a deduction), the AGI generally counts only
3|Page
profit from a self-employed or proprietorship business (i.e. gross revenue minus
expenses). Filers calculate such income using Schedule C of the U.S. Individual Income
Tax Return.
NON MAGI - Self-employed individuals report their Net Earnings from Self-employment
(NESE) on federal income tax returns. NESE is the gross income from any trade or
business less allowable deductions for that trade or business.
o For the purposes of determining financial eligibility for TennCare Medicaid,
count the NESE on a taxable year basis and divide the total of these earnings
equally among the months in the taxable year to get the earnings for each
month.
o For example, if net earnings for a taxable year are $2,400, consider that $200
was received each month.
Farm Income & Farm Rental Income

MAGI The rent received for the use of farmland is generally considered rental income,
not farm income. However, it is considered farm income if the person materially
participates in farming operations on the land, thus any rent received is considered farm
income.
o IRS Test: The person materially participates if he/she has an arrangement with
the tenant for his/her participation and meet one or more of the following tests:
does at least three of the following:
Pay, using cash or credit, at least half the direct costs of producing
the crop or livestock.
Furnish at least half the tools, equipment, and livestock used in
the production activities.
Advise or consult with the tenant.
Inspect the production activities periodically.
Regularly and frequently make, or take an important part in making,
management decisions substantially contributing to or affecting the
success of the enterprise.
Work 100 hours or more spread over a period of 5 weeks or more in
activities connected with agricultural production.
Does things that, considered in their totality, show he/she is materially
and significantly involved in the production of the farm commodities.
NON MAGI Farm income as:
o Unearned Income- money an individual receives that is NOT the result of his
current work efforts but accrues to him as the result of investment, inheritance,
previous work efforts, etc.
4|Page
o Earned Income Test- Farm Income is earned if:
an arrangement between the client and another person whereby the
other person produces the agricultural or horticultural commodities on
the land the client owns or leases; AND
the commodities produced or the income from the sale is divided
between the client and the other person; AND
the amount of the clients share depends on the amount of commodities
produced; AND
client periodically advises, instructs or consults the other person and
inspects the production activities and furnishes the machinery, tools,
livestock or advance monies required in the production of the income.
o OK to Prorate: Converting to net monthly income by taking the rental income
from last year's tax return or by taking yearly rent and dividing by 12. NOTE:
Gross Rental income - deductions = NET income. See TennCare Manual for
deductions although should mirror the rental income deductions from the IRS.
Remember, for IRS purposes, this is general rental income and not farm income.
Rental Income
Defined: Rents are payments for the use of real or personal property such as land,
housing or machinery.
MAGI: In most cases, a person must include in his/her gross income all amounts
received as rent. Rental income is any payment received for the use or occupation of
property.
NON MAGI: Rental income is considered unearned when the individual is not a real
estate dealer or property owner engaged in the business of buying, selling and/or
renting for profit.
o Rental income is earned income from self-employment when someone is in the
business of renting properties.
o Count the net rental income in determining income eligibility. Gross income from
rent is subject to the following deductions for paid (not unpaid) expenses
necessary for the production or collection of the income.
State and local real property taxes
General sales taxes
Interest on debts
Expenses of managing and maintaining the property
Mortgage interest and escrow payments
Real estate insurance
Fire insurance premiums
5|Page
Normal maintenance and repairminor corrections to an existing
structure. If the property was not rented during the previous year, deduct
those expenses the individual intends to pay excluding any expenses for
which the individual is unable to provide substantiation such as projected
repairs.
Lawn care and snow removal
Advertising for tenants
o NON Deductible Expenses:
Principal portion of a mortgage payment
Capital expenditures (i.e., an expense for an addition or increase in the
value of property which is subject to depreciation for income tax
purposes).
o MAGI: In most cases, a person must include in his/her gross income all amounts
received as rent. Rental income is any payment received for the use or
occupation of property. Do not forget to inclue the rental expenses as a
deduction. See IRS Publication 17 Your Federal Income Tax "Rental Income".
NON-Government Employment Related Benefit Payments

Sick Pay or Private Disability Payments
Defined: is time off from work that workers can use during periods of temporary illness
to stay home and address their health and safety needs without losing pay.
MAGI: In most cases, a person must report as income any amount received for personal
injury or sickness through an accident or health plan that is paid for by his/her
employer. If both the employee and the employer pay for the plan, only the amount
he/she receives that is due to the employer's payments is reported as income.
NON MAGI: Any payment made by an employer or third party (e.g., insurance
company) due to sickness, accident or disability is considered income.
o Earned Income: if received in the first six months after the individual stopped
working;
o Unearned Income: if more than 6 months after the individual last worked are
considered to be unearned income.
Vacation Pay
Defined: the wages that an employee has been paid or is legally entitled to receive
either as a paid vacation or in lieu of it.
MAGI: included as wages.
6|Page
NON MAGI: Payments made by an employer or union including annual/vacation leave,
dismissal pay, holiday pay, idle pay, severance pay, sick leave pay, stand-by pay, and
strike pay are considered earned income.
Workman's Compensation
Defined: Workers' compensation law is governed by statutes in every state. An
employee is automatically entitled to receive certain benefits when he/she suffers an
occupational disease or accidental personal injury arising out of and in the course of
employment.
MAGI: Amounts received as workers' compensation for an occupational sickness or
injury are fully exempt from tax if they are paid under a workers' compensation act or a
statute in the nature of a workers' compensation act.
NON MAGI: Workers Compensation is paid to a permanently or temporarily disabled
worker by his/her employer or the employers insurance company. In addition to a cash
payment, usually some percentage of the disabled workers salary, the individual may
also be entitled to third party medical support either through continued coverage from
the employers insurance plan or through a special fund set aside for injured workers.
o TennCare will review possible third party support for every individual receiving
Workers Compensation benefits.
o Count the gross amount of all benefits the individual receives as unearned
income in the month of receipt.
Government Payments
Social Security Benefits (see Appendices A and B for more information)
Types of Social Security Benefits
o Retirement Benefits: The social security retirement program is a federal
insurance program for eligible workers 62 years and over. The program provides
cash benefits for retired workers who have worked in social security covered
jobs and have earned enough credits to qualify. Social security retirement is not
a need-based program.
o Social Security Disability Insurance: pays benefits to a person (and certain
members of his/her family) provided the person is "insured," meaning that
he/she worked long enough and paid social security taxes. This type is not need
based, but rather on a persons earning record. (See Appendix B)
o Widow(er) Benefits: social security benefits based on their deceased spouse's
earnings record.
o Survivors Benefits: survivors' benefits are payments made to family members
when a worker dies based on the persons earnings record.
7|Page
MAGI: For tax-filers, all social security is counted as income in the end. When
calculating Adjusted Gross Income (AGI), only that portion of the persons social security
benefit that is taxable is included. However, to calculate the persons Modified
Adjusted Gross Income (MAGI), the nontaxable part of social security is added back into
the calculation. Thus, for tax-filers all social security is treated as income.
o SPECIAL NOTE: for tax dependents, only count their social security benefits if the
tax dependent is required to file taxes. When determining if a tax dependent is
required to file taxes, only count the taxable amount of the social security
benefit towards the unearned income threshold. Generally, if the tax
dependents only source of income is social security benefits, then none of it will
be taxable, and hence, not count towards the unearned income threshold for
filing taxes. (See IRS Publication 929 Tax Rules for Children and Dependents and
IRS Publication 915 Social Security and Equivalent Railroad Retirement Benefits)
o Fast check for Social Security benefits:
Divide the persons social security benefit by 2. If married, combine the
spouses social security payment;
Add all other income (excluding social security). If married, combine the
spouses other income;
If the total is less than $25,000* for a single person and $32,000* for a
married couple, then none of the social security benefit is taxable. If the
total is greater than the above limits see the worksheet in IRS Publication
915 Social Security and Equivalent Railroad Retirement Benefits to
calculate the taxable amount.
See Appendix A
NON MAGI: all social security is treated as unearned income.
Unemployment Compensation
Defined: Unemployment insurance provides workers who have lost their job through no
fault of their own with monetary payments for a given period of time or until they find a
new job. This compensation is designed to give an unemployed worker time to find a
new job equivalent to the one lost without major financial distress.
MAGI: All unemployment compensation is taxable.
NON MAGI: Count the full value of unemployment compensation benefits as available
unearned income in the month of receipt.
Supplemental Security Income (SSI)

Defined: A federal income supplement program funded by general tax revenues (not
social security taxes) and is designed to help aged, blind and disabled people who have
little or no income.
8|Page
MAGI: SSI payments are not taxable.
NON MAGI: Individuals receiving social security benefits based on their blindness or
disability are considered to meet the incapacity criteria for TennCare Medicaid purposes
and should be already enrolled in TennCare.
o SSI individuals have eligibility determined by the SSA;
o SSI payments are excluded from income.
o See Appendix B
State Assistance (Families First)

Defined: Families First provides temporary cash benefits to families who have children,
and are experiencing financial difficulties. These benefits are time-limited to 60 months
in a participants lifetime.
MAGI: Do not include in income governmental benefit payments from a public welfare
fund based upon need, such as payments to blind individuals under a state public
assistance law.
NON MAGI:
o Retroactive Families First is excluded from income;
o Families First is included as unearned income.
Veterans Disability Payments

Defined: Disability Compensation is for veterans who have conditions that were caused
or aggravated by their service in the military. These conditions cover the full range of
human physical and emotional experience.
MAGI: Do not include in the persons income any veterans' benefits paid under any law,
regulation, or administrative practice administered by the Department of Veterans
Affairs (VA). This includes disability compensation and pension payments for disabilities
paid either to veterans or their families.
NON MAGI: VA Benefits are considered unearned income, however, some of the
payment may be excluded from income while some reductions in the payment may be
considered as income.
o ADD BACK the payment amount that was deducted for:
Garnishment
Previous overpayment
Certain payments like: Medicare premiums deducted from a social
security benefit payment, other medical insurance premiums, or life
insurance premiums.
o EXCLUDE from the payment the amount of:
Any VA payment identified as an Aid and Attendance allowance in
determining an individuals income eligibility.
9|Page
Any VA payment identified as being received due to unusual medical
expenses when determining an individuals income eligibility.
Payment that has been augmented to include a payment made on behalf
of a dependent or dependents.
Veterans Affairs Payments

Defined: A broad range of benefits are offered to veterans of the U.S. Armed Forces and
to certain members of their families by the U.S. Department of Veterans Affairs (VA).
Among these benefits are various types of financial assistance, including monthly cash
payments to disabled veterans, health care, education, and housing benefits. Basic
criteria must be met to be eligible to receive any of the benefits administered by the VA.
MAGI: Do not include in the persons income any veterans' benefits paid under any law,
regulation, or administrative practice administered by the Department of Veterans
Affairs (VA). This includes disability compensation and pension payments for disabilities
paid either to veterans or their families.
NON MAGI: The Department of Veterans Affairs (VA) has numerous programs which
make payments to individuals and/or their families. Treatment of these VA payments
depends on the nature of the payment (for in depth analysis see DHS TennCare Manual
2009 pages 102-109).
o Potentially eligible VA recipients may be:
A veteran
The child or spouse of a disabled or deceased service person or veteran.
The unmarried widow/widower of a deceased service person or veteran.
The parent of a service person who died before January 1, 1997 from a
service connected cause.
o The most common types of VA payments are:
Pensions - VA pension payments are made on the basis of a combination
of service and an age of 65 or over or a non-service connected disability
or death. VA pension payments are usually based on need. VA payments
based on need are not considered income.
The VA may take dependents needs into account in determining
a pension. However, normally the VA will not make a pension
payment directly to a dependent during the lifetime of the
veteran. Instead, the amount of the veterans basic pension is
increased if the veteran has dependents.
A VA pension payment that has been increased for dependents is
called an augmented VA payment.
A VA pension payment made directly to the dependent of a living
veteran is called an apportioned payment.
10 | P a g e
Compensation - Compensation payments are unearned income for
TennCare Medicaid purposes. VA compensation payments are made on
the basis of a service-connected disability or death.
A VA payment that has been increased for dependents is called an
augmented VA payment.
A VA payment made directly to the dependent of a living veteran
is called an apportioned payment.
Value of Food Assistance aka Food Stamps

Defined: A coupon sold or given under a federal program to eligible needy persons and
redeemable for food at designated stores or markets.
fund based upon need including food.
NON MAGI: Value of food coupons under the Food Stamp Act of 1977 are considered
excluded unearned income.
Value of Housing Assistance

Defined: Congress passed the Housing and Community Development Act of 1974,
further amending the U.S. Housing Act of 1937 to create the Section 8 Program. In the
Section 8 Program, tenants pay about 30 percent of their income for rent, while the rest
of the rent is paid with federal money.
fund based upon need including housing.
NON MAGI: Excluded as unearned income is the value of any assistance paid with
respect to a dwelling unit under:
o Housing Authorization Act of 1976
o The National Housing Act
o The Housing & Urban Development Act (sec. 101) Title V of the Housing Act of
1949
o Section 202(h) of the Housing Act of 1959
o Any Housing Assistance in which HUD or FMHA is involved (includes subsidized
housing, public housing, reduced rent, cash towards utilities; loans for
renovation, construction, improvement or replacement of farm homes and other
buildings; mortgage or investment insurance; guaranteed loans and mortgages,
etc.)
11 | P a g e
Energy & Utility Assistance
Defined: The program aims to assist low income households, primarily those who pay a
high proportion of household income on home energy, in meeting their immediate
energy needs.
MAGI: Payments made by a state to qualified people to reduce their cost of winter
energy use are not taxable.
NON MAGI: Excluded unearned income and includes the following:
o Fuel assistance payments and allowances under the Home Energy Assistance Act
of 1980;
o Assistance to prevent full utility cut-offs and to promote energy efficiency under
these programs authorized by the Economic Opportunity Act of 1964 (PL No. 63-
611 and 95-568):
Emergency Energy Conservation Services Program
Energy Crisis Assistance Program
o Low Income Energy Assistance payments provided through the Department of
Health and Human Services including that authorized by the Energy Crisis
Assistance and Crisis Intervention programs.
Third Party Payments

Alimony
Defined: Payments made to a separated or divorced spouse as required by a divorce
decree or separation agreement. Alimony is different from child support, because it is
based on the idea that a husband and wife must both support each other.
MAGI: Alimony is a payment to or for a spouse or former spouse under a divorce or
separation instrument. It does not include voluntary payments that are not made under
a divorce or separation instrument.
o Recipient is included in gross income.
o Payor may deduct alimony payments (see Deductions section)
NON MAGI: is counted as unearned income in the month of receipt.
Child Support
Defined: a payment that a noncustodial parent makes as a contribution to the costs of
raising his/her child.
MAGI: Child support payments are not deductible by the payor and are not taxable to
the recipient.
NON MAGI: The value of support payments is counted in its entirety for individuals age
21 or older as unearned income in the month of receipt.
12 | P a g e
o Exclude up to $50 per month per family of absent parent support payments
received for the child under age 21. The remaining value is counted as unearned
income in the month of receipt.
o Exclude 1/3 of the value of absent parent support payments received by an
institutionalized individual under age 18. The remaining two-thirds value is
counted as unearned income in the month of receipt.
o If support is paid out of a benefit (e.g. VA, SSA, etc.), it does not retain its benefit
status. The Child Support exclusion of $50 is deducted.
o If the benefit is paid directly to the child or to a representative payee who turns
it over to the court, it is not considered Child Support.
NON Social Security Retirement-Related Payments

Pensions & Annuities
Definitions:
o Pension: A sum of money paid regularly as a retirement benefit or by way of
patronage.
o Annuity: A contract or agreement by which one receives fixed payments on an
investment for a lifetime or for a specified number of years
MAGI: Generally, if the person did not pay any part of the cost of his/her employee
pension or annuity and the employer did not withhold part of the cost from his/her pay
while he/she worked, the amounts received each year are fully taxable. If the person
paid part of the cost of his/her pension or annuity, he/she is not taxed on the part of the
pension or annuity he/she receives that represents a return of the persons cost.
However, any appreciation or gain is taxable.
NON MAGI: Considered unearned income and is usually related to prior work or service
and is received on a regularly recurring basis, usually monthly.
IRA Individual Retirement Account

Defined: investment account in which a person can set aside income up to a specified
amount each year. Traditional IRA usually allows the person to deduct the contributions
from taxable income, with the contributions and interest being tax-deferred until
retirement. Roth IRA is a type of IRA that is funded by money after it has been taxed.
Thus, there is no deduction for the contribution, and the money is allowed to grow tax
free.
MAGI: Need to determine the type of IRA in order to determine if it is included in
income.
o Traditional IRA distributions are taxable as ordinary income
o Roth IRA distributions are non-taxable.
13 | P a g e
NON MAGI: Considered unearned income.
Miscellaneous Income
Life Insurance Proceeds
Defined: The benefits payable from a claim on an insurance policy. The proceeds are
paid after claims are confirmed. Proceeds are paid to providers or directly to the
insured, depending on the type of insurance.
MAGI: Life insurance proceeds paid to a person as the beneficiary of the insured person
are usually not taxable. But if he/she receives the proceeds in installments, he/she must
usually report a part of each installment payment as interest income.
NON MAGI: All payments the individual receives as the beneficiary of a life insurance
policy are proceeds of life insurance and are considered unearned income in the month
of receipt.
o Exception: A portion of the proceeds of life insurance may be disregarded if the
client paid last illness medical expenses and/or burial expenses for the deceased.
Disregard the smaller of the following and count the remainder as unearned
income in the month received:
The amount paid for medical expenses related to the last illness and/or
burial expenses, OR
The amount of the death benefit itself.
Prizes and Awards

Defined: Winnings from lotteries and raffles are considered gambling winnings. In
addition, the fair market value of bonds, cars, houses, and other noncash prizes.
MAGI: Prizes and awards. If a person wins a prize in a lucky number drawing, television
or radio quiz program, beauty contest, or other event, he/she must include it in his/her
income. For example, if a person wins a $50 prize in a photography contest, he/she
must report this income on Form 1040, line 21.
NON MAGI: Unearned income is money an individual receives that is not the result of
his/her current work efforts but accrues to him - includes prizes and awards.
Inheritances
Definitions
o Gift - gift is an item given to someone without the expectation of payment. The
gifted item should not be owned by the recipient. (See Gifts Below)
o Inheritance - is the practice of passing on property, titles, rights and obligations
to another upon the death of an individual.
14 | P a g e
MAGI: In most cases, property a person receives as a gift, bequest, or inheritance is not
included in his/her income. However, if property he/she receives this way later
produces income such as interest, dividends, or rents, that income is taxable.
NONMAGI:
o Gifts: A gift, as countable income, is limited to cash received by a Budget Group
member without the givers legal obligation or as repayment for goods or
services. The value of a gift, either cash or in-kind, the individual receives is
counted as unearned income in the month of receipt. The value of cash gifts is
counted in whole in the month of receipt, unless it can be excluded as infrequent
and irregular income.
o Inheritances: Until an item or right has a value (i.e., can be used to meet the
heirs need for food, clothing or shelter), it is neither income nor a resource. An
inheritance is not income to an individual if the inheritance is something that
was considered that individuals resource immediately before the death, i.e., the
proceeds of a life insurance policy were not a resource before the death.
o Income/Resource: The value of inherited cash is counted as income in the month
of receipt and if the individual retains it, as a resource in the months thereafter.
The month of receipt for an inheritance composed of cash is the month the
individual receives the money.
Gifts
Defined: gift is an item given to someone without the expectation of payment. The
gifted item should not be owned by the recipient.
MAGI: In most cases, property a person receives as a gift, bequest, or inheritance is not
included in his/her income. However, if property he/she receives this way later
produces income such as interest, dividends, or rents, that income is taxable.
NON MAGI: The value of a gift, either cash or in-kind, the individual receives is counted
as unearned income in the month of receipt. The value of cash gifts is counted in whole
in the month of receipt, unless an exception applies:
o Under $30/Quarter - Casual and inconsequential income (monetary
gifts/contributions not exceeding $30.00 per calendar quarter) received by each
recipient.
o Infrequent & Irregular Income - Up to $20 per month individual/couple unearned
income can be excluded as infrequent or irregular when it meets the following
criteria:
it is received only once in a quarter from one source, e.g., one individual,
household, organization or investment. AND
it cannot reasonably be expected to be received on a regular basis.
15 | P a g e
NOTE: Infrequent or irregular income is not counted in determining
patient liability for institutionalized individuals
o Domestic Travel Tickets - commercial travel tickets for domestic travel are
excluded from income if they are not converted to cash.
Helpful Resources
IRS Publication 17 Your Federal Income Tax this publication covers general rules for
filing a federal income tax return.
IRS Publication 929 Tax Rules Children and Tax Dependents this publication covers the
rules for determining if a person is a qualified child dependent or qualified relative
dependent of another.
IRS Publication 915 Social Security and Equivalent Railroad Retirement Benefits this
publication contains rules and helpful worksheets to determine if the benefits are
taxable as well as the taxable amount of the benefit.
16 | P a g e
Appendix A - MAGI Income: Social Security
Is the person receiving Supplemental

Security Income (SSI) or Social
Security benefits*? Supplemental Security Income (SSI)
*Types of Social Security Benefits: Supplemental Security Income does
-Retirement Benefits not count as part of MAGI household
-Social Security Disability Insurance income.
-Widow(er) Benefits
-Survivors Benefits
(If someone receives both, follow

both pathways.)
No:
Social Security Benefits
All Social Security benefits are
Is the person receiving social security
included as part of MAGI household
benefits a tax dependent?
income.
Yes:
Yes: The tax dependent is most likely
Complete the following equation not required to file taxes, which
(only include the income of the tax means that the tax dependents
dependent and the tax dependents income should not be counted as
spouse, if applicable): part of the MAGI household
income.
Social Security benefits*/2
+ All other income*
No:
Is the amount less than $25,000** Calculate the taxable amount to determine if the tax
(single) or $32,000** (married)? dependent is required to file a tax return. (No one pays
federal income tax on more than 85 percent of his or her
*If married, include spouses income Social Security benefits.) If tax dependent is required to file
and benefits. taxes, include the tax dependents income as part of the
** 2017 limits MAGI household income.
17 | P a g e
Appendix B - Supplemental Security Income (SSI) or Social Security
Disability Insurance (SSDI)?
Yes:
It is probably Supplemental Security
Income (SSI).
SSI benefits are paid on the first day of each month.
If the first of the month is on a Saturday, Sunday, or
legal holiday, the benefits will be paid on the
Do you receive your check banking day before.
on or before the 1st of
the month? No:
It is probably Social Security Disability
Insurance (SSDI).
SSDI benefits are paid on:
(If started receiving SSDI after 1997) 2nd, 3rd or
4th Wednesday of the month.
(If started receiving SSDI before 1997) on the
3rd day of the month.
Yes:
Is your check more than It is probably Social Security
$735*/month (individuals) Disability Insurance (SSDI).
or $1,103*/month
(couples)?
*2017 limits No:
It may be SSI or SSDI.
SSI income limits are $735* for
individuals and $1,103* for couples.
*2017 limits
18 | P a g e
PriorCoverage
TriggeringEvent Necessary? Timing CoverageEffectiveDate
60days IFPLANSELECTED
LossofMinimum YES,atleastonedayof BEFOREor BEFORELOSS:1stdayof
EssentialCoverage coveragein60daysprior AFTERlossof monthfollowinglossof
(MEC) tolossofcoverage coverage previouscoverage
REGULARCOVERAGE
EFFECTIVEDATES:plan
willbegin1stofthe
monthfollowingplan
selectionifplanselected
bythe15thorthe1stof
YES,atleastonedayof thesecondfollowing
coveragein60daysprior monthifplanselected
tolossofcoverageUNLESS betweenthe16thand
consumerismovingfrom Upto60days thelastdayofthe
PermanentMove outofstateorisanAI/AN AFTERmove month.
CreatedJune2017byGetCoveredTenn
For more information on which types of documents consumers can submit to resolve an SVI, please refer to the
following links:
How to submit your documents: https://www.healthcare.gov/tips-and-troubleshooting/uploading-documents/
After you submit documents: https://www.healthcare.gov/verify-information/after-you-submit-documents/
When the Marketplace asks for more documents: https://www.healthcare.gov/verify-information/

Special Enrollment Periods Available to Consumers: https://marketplace.cms.gov/outreach-and-education/special-
enrollment-periods-available-to-consumers.pdf
SEPVGlossary
GFE:GoodFaithExtension.Consumerswhoarenearingtheir30daydeadlinetoresolvetheirSVIcan
requestaGFEfromtheMarketplaceformoretime.TheGFEwillbegrantedonacasebycasebasisand
preferencewillbegiventothoseconsumerswhohavealreadysubmitteddocumentationthatwas
foundtobeinsufficient.GFEscanalsoberequestedforextensionsofDMIdeadlines.
PPS:PendedPlanSelectionNotice.InformsconsumersthatanSVIhasbeengeneratedandthatthey
have30daystosubmitsupportingdocumentationoftheirSEP.ThePPSisonlygeneratedafteraQHP
hasbeenselected.
SEPV:SpecialEnrollmentPeriodVerification;PreenrollmentSEPverification(SEPV)isanewfeatureof
theSEPprocessthatwillbeimplementedbeginningJune23rd,2017.SEPVwillrequirenewmarketplace
enrolleestosubmitdocumentationverifyingtheireligibilityforcertaintypesofSEPs,describedinmore
detailbelow.OnceaconsumerhasbeendeterminedeligibleforaSEPandselectsaplan,heorshewill
have30daystosubmitacceptableverifyingdocumentation.Theconsumersplanselectionwillbe
pendeduntildocumentsarereviewed,andoncetheyareapproved,aconsumercaneffectuatehisor
hercoverage.
SVI:SEPVerificationIssue;Likethedatamatchingissue(DMI)process,HealthCare.govwillgeneratean
SVIwhenanewenrolleeappliesforoneoftheSEPsnowsubjecttoSEPV.Theseconsumersshouldboth
selectaplanwithintheir60daySEPwindowaswellassubmitverifyingdocumentationwithin30days
ofplanselection.Consumerscaneitheruploadtheirdocumentsorsubmitthembymail.Thetypesof
acceptabledocumentationwillbelistedonnoticestheyllreceivefromHHSdetailingtheireligibilityfor
theSEPV,aswellasonmarketplace.cms.govbeginningJune23rd.Examplesofacceptable
documentationforthelossofcoverageandpermanentmoveSEPscanalsobeseeninslides3738of
thisCMSwebinar.Consumerswillbenotifiedoftheserequirementsontheireligibilitydetermination
notice,andoncetheyselectaplan,theyllalsoreceivenoticethattheirplanselectionwillbepended
untiltheprocessiscomplete.
CreatedJune2017byGetCoveredTenn
Assisters Guide to New Changes in the Market Stabilization Final Rule
Does this new policy apply in SBM
Provision What will change? states, and when does it go into How can you help consumers?
effect?
Shorter open enrollment The 2018 open enrollment period will run from Applies to all SBM and FFM states. Engage in outreach and education
to 6 weeks November 1-December 15, 2017. to make sure consumers know
However, SBM states may extend the about the new timeframe.
This is a change from the old open enrollment open enrollment period with a special
period, which ran from November 1 to January 31. enrollment period, as a transitional
measure, to account for operational
difficulties they may encounter in
implementing this new policy.
SEPs: pre-verification of New marketplace consumers will have to prove their Applies in all FFM states. This policy Engage in outreach and education
docs prior to enrollment eligibility for certain SEPs before they can enroll in will be rolled out in phases, beginning about the new policy, including
coverage. Once a consumer chooses a plan, coverage on July 23, 2017 with the loss of changes in verification procedures,
will be pended until the SEP is verified. The coverage and permanent move SEPs. SEP eligibility, coverage effective
consumer will not be covered by the plan during See In the Loops SEP fact sheet to dates, and deadlines for applying
months of pended coverage. learn more. for the SEP and submitting
documents.
This is a change from the old Special Enrollment SBMs are not required to implement
Confirmation Process, which required some SEP pre-verification, but are
consumers to verify SEP eligibility after enrolling in encouraged to do so.
coverage. Work closely with consumers and
SEPs: Limiting ability of Current enrollees may not change metal levels Applies in all FFM states. This change help them through the SEP
existing enrollees to during an SEP (some exceptions applysee In the will go into effect starting June 2017. verification processa very small
change plans Loops SEP fact sheet to learn more). percentage of consumers who are
SBMs are required to limit the ability eligible for SEPs actually enroll in
There was previously no such limitation placed on of current enrollees to switch metal coverage, and the new verification
consumers ability to switch plans during an SEP. levels during an SEP, and are process may pose an additional
encouraged to implement this policy obstacle.
as quickly as possible.
SEPs: Coverage effective Consumers who enroll in coverage under the new Applies in all FFM states. This policy
dates SEP pre-verification process will have a coverage will be rolled out in phases, beginning
effective date that is based on the date of plan on June 23, 2017 with the loss of Talk to consumers about the new
selection. This means that consumers may have a coverage and permanent move SEPs. coverage effective dates and
retroactive coverage effective date (and they will be In August, SEPV will apply to SEPs explain how pended plan
paying premiums for months of pended coverage). based on marriage, Medicaid/CHIP selection works. Explain how the
In this case, the binder payment must consist of denials, and gaining a dependent timing of enrollment could impact
premiums due for all months of retroactive coverage through adoption, foster placement, when their coverage begins and
and for the first month of prospective coverage or court order (note: not the birth how much they must pay in
SEP). See In the Loops SEP fact sheet retroactive premiums. Remember
Under the previous policy, consumers were enrolled to learn more. that claims incurred during periods
in coverage right away--they did not need to of pended coverage will only be
complete the SEP verification process for their SBMs are not required to implement processed retroactively, and only
coverage to start, nor did they need to pay for SEP pre-verification, but are after the consumer successfully
months of retroactive coverage. encouraged to do so. completes the SEPV process and
enrolls in a plan.
SEPs: Additional limits Consumers applying for the marriage SEP must prove SBMs are required to implement
Require prior prior coverage (with some exceptions). There was these changes, and are encouraged to
coverage for at previously no prior coverage requirement for the implement this policy as quickly as
least one spouse marriage SEP. possible.
in SEP for For consumers who have had their
marriage Consumers applying for the permanent move SEP coverage pended for more than
No longer accept must submit documentation proving both their move 2 months, remind them that they
attestation of and their prior coverage. Under previous policy, may have their coverage effective
prior coverage consumers needed to provide documentary date delayed by one month but
for permanent evidence of their move, but could attest to having they must proactively request this
move SEP had prior coverage. from the marketplace.
Restrict use of
Exceptional The new rule increases the burden of proof for
Circumstances proving eligibility for the exceptional
SEP circumstances SEP. The consumer must provide
sufficient documentation of a highly exceptional
circumstance.
BlueCrossBlueShieldofTennessee
NetworkS:aPPO;availableinregions1,2,3,5,7and8.
Cigna
Connect:anEPO;notoutofnetworkcoverage;availableinregions1,4and6
Oscar
availableinRegion4
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Speakinthefirstpersonusingbriefsentences.Forexample,insteadofCanyouaskher
whatherincomeis?speakasifyouarespeakingdirectlytotheconsumer,Whatis
yourmonthlyincome?Pausewhenyoucompleteathoughttogivetheinterpreter
timetorelaytheinformation.
SendanemailtoSandyDimicksandy.dimick@fcsnashville.orgorMaryMoore
mary.moore@fcsnashville.orgwheneveryouusethelinelettingusknowwhatlanguage
wasneededandapproximatelyhowlongthecallwas.
AuthorizationFormforNavigatorsinaFederallyFacilitatedMarketplace
NavigatorOrganizationName:Family&ChildrensService
NavigatorOrganizationAddress:1704HeimanStreet,Nashville,TN37208
NavigatorOrganizationPhoneNumberandEmailAddress:
______________________________________________________________________________
IndividualNavigatorNameorStaff/VolunteerNameandCertificationNumber:
_________________________________________________________________________________
I.AcknowledgementofRolesandResponsibilitiesofNavigators(seeAttachmentA)
IhavebeeninformedaboutandunderstandtheNavigatorrolesandresponsibilitiessetforthon
AttachmentAandhavebeengiventheopportunitytodiscussthemwithFamily&ChildrensService.
II.DefinitionsandExplanationsofTermsUsedinThisForm
Inthisauthorizationform:
ThewordsI,me,ormyincludemyauthorizedrepresentativeifIhaveone.
PersonallyidentifiableinformationiscalledPII.ExamplesofmyPIIinclude,butarenotlimited
tomyname,phonenumber,emailaddress,homeaddress,immigrationstatus,income,and
householdsizeinformation.
HealthplansavailablethroughtheMarketplacearecalledQualifiedHealthPlansorQHPs.
Otherprogramscalledinsuranceaffordabilityprogramsarealsoavailablethroughthe
Marketplace.Theseprogramscanhelpmeormyfamilypayforhealthcoverage,andinclude
publicprograms,suchasMedicaidortheChildrensHealthInsuranceProgram(CHIP),premium
taxcredits,costsharingreductions,and,ifoneisavailableinmystate,theBasicHealth
Program.
NavigatorOrganizationincludesFamily&ChildrensService,theleadagencyforthefederal
fundingforNavigators.Italsoincludesthespecificorganizationandpersonlistedabovewho
arepartofthisfunding.
III.Authorizations
a.GeneralConsent
I,______________________,givemypermissiontoNavigatorOrganization,tocreate,collect,disclose,
access,maintain,store,and/orusemyPIIinordertocarryoutthefollowingdutiesofaNavigator,
unlessIhavelimitedthatconsentassetforthinthisdocument.IunderstandthatNavigator
Organizationmightneedtocreate,collect,disclose,access,maintain,store,and/orusesomeofmyPII
inordertoprovidethisassistance.
IV.AdditionalInformation
Iunderstandthat:
1.IdonthavetoprovideNavigatorOrganizationwithanyinformationthatIdonotwanttoprovide.
However,thehelpofNavigatorOrganizationprovidesisbasedonlyontheinformationIprovide,andif
Updated_ConsentFormRev6June2017 1of3
theinformationgivenisinaccurateorincomplete,NavigatorOrganizationmaynotbeabletoofferall
thehelpthatisavailableformysituation.
2.IunderstandthatNavigatorOrganizationwillaskmetoprovideonlytheminimumamountofmyPII
thatisnecessarytohelpmeandwilltellmeaboutthefullrangeofQHPoptionsandinsurance
affordabilityprogramsforwhichImaybeeligible,whichincludes:providingmewithfair,accurate,and
impartialinformationthatassistsmewithsubmittingaMarketplaceeligibilityapplication;clarifyingthe
distinctionsamonghealthcoverageoptions,includingQHPs;andhelpingmemakeinformeddecisions
duringthehealthcoverageselectionprocess.Theinformationmustbeprovidedinawaythatthat
meetsmyculturalandlanguageneeds.
3.NavigatorOrganizationwillmakesurethatmyPIIiskeptprivateandsecurewhencreating,collecting,
disclosing,accessing,maintaining,storing,and/orusingmyPII.NavigatorOrganizationwillfollowthe
privacyandinformationsecuritystandardsthatapplytothem.
4.IunderstandthatNavigatorOrganizationisalsorequiredtomaintainexpertiseineligibility,
enrollment,andprogramspecificationsforQHPsandinsuranceaffordabilityprograms,andtoconduct
publiceducationactivitiestoraiseawarenessabouttheMarketplace.NavigatorOrganizationshouldnot
needtocreate,collect,disclose,access,maintain,storeand/orusemyPIIforthesefunctions.If
NavigatorOrganizationdoescreate,collect,disclose,access,maintain,storeand/orusemyPIIforthese
functions,NavigatorOrganizationwillobtainmyconsentforthosespecificactivities.Navigator
OrganizationwillkeepmyPIIprivateandsecureexceptwhenIhaveconsentedtosharingmyPII
publicly.
5.IfIgivemycontactinformationwhensigningthisform,mygeneralconsentincludespermissionfor
NavigatorOrganizationtofollowupwithmeaboutapplyingfororenrollingintocoverageaftermyfirst
meetingwiththem.
6.IfNavigatorOrganizationdoesnothavetheresourcesorskillstohelpmerightaway,heorshewill
refermetoanotherNavigatororinpersonassistancepersonnel,ortothefederalMarketplaceCall
Center,whocanmeetmyspecificneedssooner.IfNavigatorOrganizationneedstorefermetoanother
sourceofhelp,heorshewillrefermetothesourcethatiseasiestformetoaccess.Iunderstandthat
NavigatorOrganizationmightneedtosharemycontactinformationandinformationaboutmyneeds
withpossiblereferralsourcesinordertohelpme.
7.IunderstandthatonceIhavesignedthisauthorizationform,IcanexpectNavigatorOrganizationto
helpmewithoutaskingmetosignanotherauthorizationform.
8.NavigatorOrganizationwillprovidemewithacopyofmyAuthorizationFormandthisAttachmentA,
oncecomplete.
9.NavigatorOrganizationisrequiredtocollect,handle,disclose,access,maintain,store,and/orusemy
PIItocarryoutactivitiesrequiredunderastatelaworregulation.NavigatorOrganizationhaslisted
belowthespecificstaterequirementsthatapply.
IV.ConsenttoShareInformation
IunderstandthatNavigatorOrganizationusesaschedulingsystemownedandoperatedbyYoung
Invincibles(anonprofit,nonpartisan,501(c)(3)organizationindependentfromthemarketplace)to
trackinformationrelatedtomyappointmentandfollowupthatmaycontainmyPII.
IunderstandthatwithmyconsentthisinformationmaybeincludedwithYoungInvinciblessecure,
onlinedatabaseforstatisticalpurposes,andthatImaybecontactedbecauseofthiswithadditional
informationabouthealthcoverageoptionsandimportantdeadlinesrelatedtokeepinghealth
insurance.Iunderstandmyinformationwillnotbeusedforcommercialpurposes.
Iunderstandthatthisconsentisnotrequiredinorderformetocontinuemyappointmentwith
NavigatorOrganizationorenrollincoverage,andthatImayrevokethisconsentatanytime.IfIwantto
revokeconsentIwillnotifyNavigatorOrganization.IfIrevokethisconsent,IunderstandthatIwillno
longerbecontactedrelatedtothisappointmentwithNavigatorOrganizationbasedonthisconsent
VI.ConsenttoSharemyStory
I,___________________________,agreetobeinterviewedinordertosharemyexperiencewiththe
processofenrolling/attemptingtoenrollintohealthcoverage.Iagreethatanyinterviewinformation,
video,audio,orphotograph(materials)canbeusedinpublications,presentations,websites,
advertising,orothermedia.
IunderstandthatNavigatorOrganizationmaycontactmeforaninterviewwithathirdparty(including
anotherorganizationormemberofthemedia),orforsharingmystoryatanevent.Ifthathappens,
NavigatorOrganizationwillcontactmebeforeeachopportunity,andIunderstandthatIamnot
obligatedtoparticipateinanyopportunity.
UnlessIsayotherwise,IunderstandandagreethatNavigatorOrganizationmayedit,use,publish,
distribute,andrepublishanymaterialsforworkwiththemediaoronpubliceducationefforts.I
understandthatIhavenorightsinthematerials.Iwaiveallrighttoinspectorapprovetheusesof
materials,noworinthefuture.IunderstandthatIwillnotbecompensatedforparticipatinginsharing
mystoryorfortheuseofthematerials.IreleaseNavigatorOrganizationanditsagents,employees,and
contractorsfromallclaims,demands,andliabilitiesinconnectionwiththeabove.
Iunderstandthatsharingmystoryisoptionalandmyconsentwillbeindicatedbelow.

PrintedConsumerName:_________________________________ConsumersBirthdate:___________

WaysIagreetobecontacted:

_
Myaddress:______________________________________________________zipcode:________________
Myphone:____________________________bytextmessage
Myemail:____________________________________________________________________________
Iwouldliketosharemystoryandagreetobecontactedandprovidemypersonalinformation
Ideclinetobecontacted,butwillallowmystorytobesharedwithoutmypersonalinformation
________________________________________________________Date:____________________

ConsumersSignature
SignatureofConsumerslegalorMarketplaceAuthorizedRepresentative
SpanishUpdatedJune2017
Formulario de Autorizacin para Navegadores del Mercado Federalmente Facilitado
Nombre de la Organizacin de Navegadores: Family & Childrens Services
Direccin de la Organizacin de Navegadores: 1704 Heiman Street, Nashville, TN 37208
Nmero de telfono y direccin de correo electrnico de la Organizacin:
Nombre del Navegador o Voluntario y Nmero de Certificacin:
I. Reconocimientos de Oficios os y Responsabilidades de Navegadores (vase anejo A)
He sido informado y comprendo el rol de Navegador y sus responsabilidades segn expresadas en el Anejo A y se me
brind la oportunidad de discutirlos con Family & Childrens Service.
II. Definiciones y Explicacin de Trminos Utilizados en Este Formulario.
Las palabras yo o mi incluyen a mi representante autorizado, si es que tuviere uno.
Informacin de Identificacin Personal se conoce como PII. Ejemplos de mi PII incluyen, pero no son limitados a mi
nombre, nmero de telfono, correo electrnico, direccin residencial, estatus migratorio, ingreso, informacin sobre
nmero de personas en mi hogar, etc.
Los planes de salud disponibles por medio del Mercado son llamados Qualified Health Plans o QHPs.
Otros planes llamados Insurance Affordability Programs tambin son disponibles por medio del Mercado. Estos
programas permiten que yo o a mi familia paguemos por cubierta de salud, e incluye programas pblicos, tales como
Medicaid o el de Childrens Health Insurance Program (CHIP) para nios, crditos fiscales de primera calidad,
reducciones de costos compartidos, y, si hay alguno disponible en mi estado, el Basic Health Program--Programa
Bsico de Salud.
GetCoveredTennNavigatorConsortium2017
1
SpanishUpdatedJune2017
III. Autorizaciones
Consentimiento General
Yo, , autorizo a Family & Childrens Service, incluyendo
a los Navegadores que sean parte de sta organizacin, para crear, recopilar, revelar, entrar, mantener, guardar, y/o usar
mi PII para poder llevar a cabo las siguientes tareas de un Navegador, a menos que yo haya limitado ese consentimiento
segn ste establecido en ste documento. Yo comprendo que Family & Childrens Service pudiera necesitar el crear,
recopilar, revelar, proveer acceso, mantener, guardar, y/o usar algo de mi PII para poder proveer sta asistencia.
IV. Informacin Adicional
Yo comprendo que:
1. No tengo que proveer a Family & Childrens Service ninguna informacin que yo no quiera proveer. Sin
embargo, la ayuda que Family & Childrens Service provee es basada nicamente en la informacin que yo provea,
y si la informacin provista es incorrecta o incompleta, Family & Childrens Service no podr ofrecer toda la
ayuda disponible para mi situacin.
2. Comprendo que Family & Childrens Service me pedir que les provea la cantidad mnima de mi PII necesaria
para ayudarme.
3. Family & Childrens Service asegurara que mi PII se mantenga de forma privada y segura mientras ellos crean,
recopilen, revelen, entren, mantengan, guarden, y/o usen mi PII. Family & Childrens Service aplicar los niveles
de seguridad necesarios para la privacidad y seguridad de la informacin.
4. Comprendo que a Family & Childrens Service se le requiere mantenerse competente en aspectos de elegibilidad,
inscripciones, requisitos del programa para QHPs y programas de seguros permisibles, y a conducir actividades de
educacin pblica para crear conocimiento sobre el Mercado. Family & Childrens Service no necesita crear,
recopilar, revelar acceso, mantener guardar y/o usar mi PII para estas funciones. Si Family & Childrens Service
llegara a crear, recopilar, revelar acceso, mantener, guardar y/o usar mi PII para estas funciones, Family &
Childrens Service obtendr mi consentimiento especfico para esas actividades. Family & Childrens Service
mantendr mi PII privado y seguro excepto cuando he dado mi consentimiento para compartir mi PII pblicamente.
5. Si yo doy mi informacin de contacto cuando firme este formulario, mi consentimiento general incluye permiso
para que Family & Childrens Service me contacte para aplicar o inscribirme a un plan mdico despus de mi
primera reunin con ellos.
6. Si Family & Childrens Service no tiene los recursos o capacidad para ayudarme inmediatamente, el o ella me
referir a otro Navegador en el Mercado, a un individuo que pueda asistirme en persona, o al Centro de llamadas
del Mercado Federal quien me pueda asistir con mis necesidades especficas lo ms pronto posible. En caso que
Family & Childrens Service necesite referirme a otro recurso de ayuda, el o ella me referir al recurso que sea el
ms fcil para yo entrar o tener acceso. Yo comprendo que Family & Childrens Service pueda tener la necesidad
de compartir la informacin de mi contacto y la informacin de mis necesidades con los recursos referidos para
ellos poderme asistir.
7. Yo comprendo que una vez yo firme ste formulario de autorizacin, puedo esperar que Family & Childrens
Service me ayude sin necesidad de pedirme que firme otros formularios de autorizacin.
8. Family & Childrens Service me proveer una copia de mi formulario de autorizacin y ste documento adjunto
una vez sea completado.
9. Family & Childrens Service esta requerido a recopilar, manejar, revelar, tener acceso, mantener, guardar y/o usar
mi PII para llevar acabo las actividades requeridas bajo la ley o regulaciones estatales. Family & Childrens
Service ha listado ms abajo los requerimientos especficos del estado que apliquen.
2
SpanishTranslatedNov2015
V. Consentimiento para Compartir Informacin
Yo comprendo que Family & Childrens Service utiliza un programa de registracin propiedad de y operado por Young
Invincibles (una organizacin independiente al Mercado sin fines de lucro, no partidista, 501(c) (3) ) para darle seguimiento
a la cita y otra informacin relacionada que puedan estar contenidos en mi PII.
Yo comprendo que con mi consentimiento sta informacin puede ser sincronizada electrnicamente con la base de datos
de Enroll America para fines estadsticos, y pudieran contactarme para obtener informacin adicional relacionada con
opciones de cobertura de salud y sobre fechas lmites para mantener mi seguro de salud vigente. Yo comprendo que mi
informacin no ser utilizada para propsitos comerciales.
Yo comprendo que ste consentimiento no es requerido para poder mantener mi cita con Family & Childrens Service o
inscribirme para cobertura, y que yo puedo anular este consentimiento en cualquier momento. Si deseo anular mi
consentimiento, notificar a Family & Childrens Service. Si anulara ste consentimiento, comprendo que ya no ser
contactado en relacin a sta cita con Family & Childrens Service de conformidad con ste consentimiento.
VI. Consentimiento para compartir mi historia
Yo, ___________________________, acepto ser entrevistado para compartir mi experiencia con el proceso de inscripcin/
intento de inscripcin en la cobertura de salud. Estoy de acuerdo en que cualquier informacin de entrevista, video, audio o
fotografa ("materiales") se puede usar en publicaciones, presentaciones, sitios web, publicidad u otros medios.
Entiendo que la Organizacin Navegadora puede contactarme para una entrevista con un tercero (incluyendo otra
organizacin o miembro de los medios de comunicacin), o para compartir mi historia en un evento. Si eso sucede, la
Organizacin Navegadora se comunicar conmigo antes de cada oportunidad, y entiendo que no estoy obligado a participar
en ninguna oportunidad. A menos que diga lo contrario, entiendo y estoy de acuerdo en que la Organizacin Navegadora
puede editar, usar, publicar, distribuir y republicar cualquier material para trabajar con los medios de comunicacin o en los
esfuerzos de educacin pblica. Entiendo que no tengo derechos en los materiales. Renuncio a todos los derechos de
inspeccionar o aprobar el uso de materiales, ahora o en el futuro. Entiendo que no voy a ser compensado por participar en
compartir mi historia o por el uso de los materiales. Libero a la Organizacin Navegadora y a sus agentes, empleados y
contratistas de todas las reclamaciones, demandas y responsabilidades relacionadas con lo anterior. Entiendo que compartir
mi historia es opcional y mi consentimiento para hacerlo o no ser indicado a continuacin.
Nombre del Cliente: Fecha de nacimiento
Autorizo a ser contactado de la siguiente forma:
Por correo a: Cdigo postal:
Por telfono a: por mensaje de texto
Por correo electrnico a: ______________________________________________________________________________________
_ Me gustara compartir mi historia y acepto ser contactado y proporcionar mi informacin personal

Niego ser contactado, pero permitir que mi historia sea compartida sin mi informacin personal
Fecha:
Firma del Consumidor

Firma del Representante Autorizado del cliente o del Mercado
3

The following consent serves as signed documentation for a Consumers verbal informed
consent(suchastelephoneassistance)toprovidepersonalinformation,fortheprotectionof
theConsumer.
NavigatorSignature Date

NavigatorName(Printed) NavigatorCertificationNumber

PrintedConsumerName:_________________________________ConsumersBirthdate:_______________

zipcode:________________

Byphoneat:____________________________bytextmessage
Byemailat:____________________________________________________________________________

ConsentScript:
DoyougivepermissiontoFamily&ChildrensService,includingtheindividualNavigatorswho
areapartofthisNavigatororganization,tocreate,collect,disclose,access,maintain,store,
and/oruseyourpersonallyidentifiableinformationinorderformetocarryoutthedutiesofa
Navigator?Family&ChildrensServiceusesaschedulingsystemownedandoperatedbyYoung
Invincibles(anonprofit,nonpartisan,501(c)(3)organizationindependentfromthe
marketplace)totrackinformationrelatedtoyourappointmentandfollowupthatmaycontain
yourPII.Withyourconsent,thisinformationmaybesyncedwithEnrollAmericassecure,
onlinedatabaseforstatisticalpurposes,andyoumaybecontactedbecauseofthiswith
additionalinformationabouthealthcoverageoptionsandimportantdeadlinesrelatedto
keepinghealthinsurance.Yourinformationwillnotbeusedforcommercialpurposes.This
consentisnotrequiredinorderformetoassistyou,andifyoudonotconsentIwillassistyou
asmuchaspossiblewithlimitedinformationavailable.Doyouhaveanyquestionsaboutyour
consentortherolesanddutiesofaNavigator?

GetCoveredTennNavigatorConsortium10/25/2015

Byprovidingyourpersonallyidentifiableinformation(contactinformation),belowyouaregrantingFamily&ChildrensService,includingthe
individualNavigatorswhoareapartofthisNavigatorOrganization,permissiontocollect,maintainandstoreyourinformationinordertocarry
outthedutiesofaNavigatorwhichmayincludefollowingupwithyouaftertodayinordertoensurethatyoureceiveasmuchassistanceasyou
needandwant.
Location:______________________________________________________________________Date:______________________________
Name PhoneNumber EmailAddress Number

in
Family

ConsumerSignInSheet October2015
ConsumerSignInSheet October2015
Healthcare.gov:
UserName:_______________________________Password:_____________________________
YourInsuranceCompany:____________________________________________________________
PlanName:_____________________________Phonenumber:____________________________
HospitalProvidersforyournetwork:__________________________________________________
____________________________MyNavigator/Assister:________________________________
MonthlyPremium$__________________CoPayforDr.visits:$__________________
Forquestions,calltheGetCoveredTNHotline:18446445443
Healthcare.gov:
Forquestions,callGetCoveredTNHotline:18446445443
Healthcare.gov:
Forquestions,callGetCoveredTNHotline:18446445443.
AfterEnrollmentInstructionsforTennCare:
DateofEnrollment:_______________.ApplicationID#:___________________________
In45days________________(date),ifyouhavenotreceivedaTennCarecard,pleasecallthe
TNHealthConnectionat:18552590701.AskforaDelayAppealandgivethe
RepresentativeyourapplicationIDanddateofenrollmentORcontactyourNavigator
____________,forhelpfilinganappealat:
Medicaid Coverage Gap SEP
Medicaid Coverage Gap

Special Enrollment
Period Overview
April 29, 2016

What is the Medicaid Coverage Gap?
Note: We provide this example because it contains additional information that may be useful. As with other external partner resources that
we share, we cannot attest to the accuracy of the information provided by third-party sites or any other linked site, and linking to a non-CMS
web site does not constitute an official endorsement by CMS.
Garfield, Damico, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid - An Update, The Henry J. Kaiser Family
Foundation, Jan 21, 2016 2
What is the Medicaid Coverage Gap
SEP?
This SEP offers consumers who previously fell
within the Medicaid Coverage Gap the
opportunity to enroll in a qualified health plan
(QHP) with Advanced Premium Tax Credits
(APTCs) if they experience an increase in
household income and meet all other criteria.
3
Who is eligible?
A consumer may qualify for the Medicaid

Coverage Gap SEP if he or she:
Resides in a non-Medicaid expansion state
Was previously ineligible for APTC solely because of
a household income below 100% of the Federal
Poverty Level (FPL)
Was ineligible for Medicaid during that same
timeframe
Has experienced a subsequent change in household
income that makes him or her newly eligible for
APTC
4
What is the process for
applying for this SEP?
Complete a Marketplace application either online or by calling the
Marketplace Call Center to determine if the consumer is now eligible for
APTC.
Call the Marketplace Call Center and let the representative know that the
consumer was previously ineligible for Medicaid because he or she lives in
a non-Medicaid expansion state, and was previously ineligible for APTC
because his or her income was too low.
Inform the Marketplace Call Center representative that the consumer has
experienced an increase in household income that now makes him or her
newly eligible for APTC.
Once the Marketplace Call Center confirms that the consumer is eligible
for APTC and meets requirements, the consumers application will be
escalated to a review team that will determine the consumers eligibility
for the SEP.
5
What is the process for
applying for this SEP? (Continued)
The review process should be completed within ten (10)
business days, barring exceptional circumstances.
After a determination is made, the Marketplace will send a
notification to the consumer via mail.
If the consumer is eligible for this SEP, he or she should return
their application to complete the enrollment process online or
through the Marketplace Call Center.
If the consumer is not eligible for this SEP, he or she must wait
until the next Open Enrollment Period or upon qualifying for a
different SEP to enroll in coverage.
Consumers who are determined ineligible for a SEP have the
right to appeal the decision. For more information, click here:
https://www.healthcare.gov/marketplace-appeals/.
6
What should assisters remember
about this SEP?
Consumers no longer have to submit a Medicaid denial
notice from their state Medicaid agency.
Additionally, consumers do not need to submit an
Exemption Certificate Number (ECN), or a Marketplace
Eligibility Determination Notice that shows they
previously werent eligible for APTC.
Consumers must call the Marketplace Call Center and
attest to a change in household income within 60 days
of experiencing the change.
Consumers are only eligible for this SEP if they live in a
non-Medicaid expansion state.
7
What should assisters remember
about this SEP? (Continued)
Consumers are only eligible for this SEP if their household
income was previously below 100% FPL and they recently
experienced an increase in household income that now
makes them eligible for APTC through the Marketplace.
An increase in income alone will not automatically make a
consumer eligible for APTC. There are other reasons why a
consumer may not be eligible for APTC, such as already
having access to other minimum essential coverage. A
consumer must be determined eligible for APTC in order
to qualify for this SEP.
Consumer enrolling through this SEP will receive
prospective coverage following regular coverage effective
dates.
8
CONTINUING EDUCATION
CERTIFICATION
for
NAVIGATORS and
CERTIFIED APPLICATION COUNSELORS
This Certificate of Completion will be accepted as evidence that the person named herein has complied with the continuing education
requirements for navigators and certified application counselors in accordance with
Tennessee Departmental Rule 0780-01-55
________________________________________________ ____________________________________
Entity Name Entity Tennessee Registration Number
________________________________________________ ____________________________________
Name of Navigator / Certified Application Counselor Tennessee Registration Number
________________________________________________________ __________________________________________
Signature of Entity Representative Date
_______________________________________________________ ___________________________________________
Entity Representative Phone Number Entity Representative Email
Navigator /Certified Application Counselor Name: _________________________________ TN Registration #:_____________________________
Course No. Credit

Course Title (if applicable) Completion Date Presenter/Provider Hours Earned
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ ___________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ __________________ ______________________________ ______________
______________________________ ____________ ___________________ _____________________________ ______________
TOTAL HOURS EARNED _____________________

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GetCoveredTennNavigatorManual

Security in AssistConnect and Passwords

If You Forget Your Password

AssistConnect Best Practices and Standard Operating Procedures 2

Steps for Entering a New Marketplace Outreach Record

1) Click on the Create New button on the left side of the

AssistConnect Best Practices and Standard Operating Procedures 3

AssistConnect Best Practices and Standard Operating Procedures 4

Entering a Marketing/Promotion Activity

AssistConnect Best Practices and Standard Operating Procedures 5

Editing and Deleting Records

AssistConnect Best Practices and Standard Operating Procedures 6

*ONLY the most general questions-

Formerly "Education only-no

Locating in-network providers for their

Choose when MP eligibility says "May be

Remember to not refer to a specific

Referrals to issuer (insurance company)

Per Exemption *For

Assistance with either DMI at the time of

Assisting consumer with getting an SEP

Those individuals under 100% of FPL who

Best Practices for Handling

This Fact Sheet Applies If You:

Have questions about personally identifiable information (PII)

Are looking for best practices and tips on handling PII

Personally Identifiable Information (PII): Overview

Examples of PII You May Encounter

Alien Registration Number

Medicaid/CHIP eligibility status

Citizenship or immigration status

Qualified health plan (QHP) eligibility status

Advanced payments of the premium tax credit/cost-sharing reduction (APTC/CSR)

Spoken and written language preference

When Assisters Will Encounter PII

Assessing options for lowering costs of health coverage

Selecting and enrolling in a qualified health plan (QHP)

Applying for an exemption from the individual shared responsibility payment

Filing an eligibility appeal

Best Practices related to Obtaining Consumer Authorization (or

Develop a standard operating procedure to document instances where a consumer

Best Practices related to Providing Application and Enrollment

o If in electronic format, PII should be stored securely in a password-

Protect e-mails that contain PII (e.g., encryption).

Do not upload PII to unauthorized websites (e.g., wikis).

Do not use unauthorized mobile devices to access PII.

Lock up portable devices (e.g., laptops, cell phones).

Disable auto-fill settings on your web browser.

All computer equipment, including mobile devices, should have a password-protected

If consumers mistakenly or accidentally leave behind PII at a facility or enrollment event,

What Assisters Need to Know About Breaches and Incidents (this

Issues you should report include:

Unauthorized personnel seeing or possessing PII

Minimum Acceptable Risk Standards for Exchanges (MARS-E)

Internal Revenue Service (IRS): Data Safeguards

OIG Fraud Hotline

Updated on 3/30/2017: Please check our website for updates at

211 7th Ave N., Suite 100 | Nashville, TN

How are Households Determined in MAGI Medicaid?

Or, use the flow chart on the next page.

211 7th Ave N., Suite 100 | Nashville, TN

Are you claimed as a

Yes: The household is the tax

<200% FPL 200%-255% FPL

Filer + Spouse +Qualifying Children + Qualifying Relatives*