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Statutory Text

SEC. 1411 [42 U.S.C. 18081]. PROCEDURES FOR DETERMINING ELIGIBILITY
FOR EXCHANGE PARTICIPATION, PREMIUM TAX
CREDITS AND REDUCED COST-SHARING, AND INDIVIDUAL
RESPONSIBILITY EXEMPTIONS.
(a) ESTABLISHMENT OF PROGRAM.—The Secretary shall establish
a program meeting the requirements of this section for determining—
(1) whether an individual who is to be covered in the individual
market by a qualified health plan offered through an
Exchange, or who is claiming a premium tax credit or reduced
cost-sharing, meets the requirements of sections 1312(f)(3),
1402(e), and 1412(d) of this title and section 36B(e) of the Internal
Revenue Code of 1986 that the individual be a citizen
or national of the United States or an alien lawfully present
in the United States;
(2) in the case of an individual claiming a premium tax
credit or reduced cost-sharing under section 36B of such Code
or section 1402—
(A) whether the individual meets the income and coverage
requirements of such sections; and
(B) the amount of the tax credit or reduced cost-sharing;
(3) whether an individual’s coverage under an employer-sponsored
health benefits plan is treated as unaffordable under
sections 36B(c)(2)(C) and 5000A(e)(2); and
(4) whether to grant a certification under section
1311(d)(4)(H) attesting that, for purposes of the individual responsibility
requirement under section 5000A of the Internal
Revenue Code of 1986, an individual is entitled to an exemption
from either the individual responsibility requirement or
the penalty imposed by such section.
(b) INFORMATION REQUIRED TO BE PROVIDED BY APPLICANTS.—
(1) IN GENERAL.—An applicant for enrollment in a qualified
health plan offered through an Exchange in the individual
market shall provide—
(A) the name, address, and date of birth of each individual
who is to be covered by the plan (in this subsection
referred to as an ‘‘enrollee’’); and
(B) the information required by any of the following
paragraphs that is applicable to an enrollee.
(2) CITIZENSHIP OR IMMIGRATION STATUS.—The following
information shall be provided with respect to every enrollee:
(A) In the case of an enrollee whose eligibility is based
on an attestation of citizenship of the enrollee, the enrollee’s
social security number.
(B) In the case of an individual whose eligibility is
based on an attestation of the enrollee’s immigration status,
the enrollee’s social security number (if applicable)
and such identifying information with respect to the enrollee’s
immigration status as the Secretary, after consultation
with the Secretary of Homeland Security, determines
appropriate.
(3) ELIGIBILITY AND AMOUNT OF TAX CREDIT OR REDUCED
COST-SHARING.—In the case of an enrollee with respect to
whom a premium tax credit or reduced cost-sharing under section
36B of such Code or section 1402 is being claimed, the following
information:
(A) INFORMATION REGARDING INCOME AND FAMILY
SIZE.—The information described in section 6103(l)(21) for
the taxable year ending with or within the second calendar
year preceding the calendar year in which the plan year
begins.
(B) CHANGES IN CIRCUMSTANCES.—The information described
in section 1412(b)(2), including information with
respect to individuals who were not required to file an income
tax return for the taxable year described in subparagraph
(A) or individuals who experienced changes in marital
status or family size or significant reductions in income.
(4) EMPLOYER-SPONSORED COVERAGE.—In the case of an
enrollee with respect to whom eligibility for a premium tax
credit under section 36B of such Code or cost-sharing reduction
under section 1402 is being established on the basis that the
enrollee’s (or related individual’s) employer is not treated
under section 36B(c)(2)(C) of such Code as providing minimum
essential coverage or affordable minimum essential coverage,
the following information:
(A) The name, address, and employer identification
number (if available) of the employer.
(B) Whether the enrollee or individual is a full-time
employee and whether the employer provides such minimum
essential coverage.
(C) If the employer provides such minimum essential
coverage, the lowest cost option for the enrollee’s or individual’s
enrollment status and the enrollee’s or individual’s
required contribution (within the meaning of section
5000A(e)(1)(B) of such Code) under the employer-sponsored
plan.
(D) If an enrollee claims an employer’s minimum essential
coverage is unaffordable, the information described
in paragraph (3).
If an enrollee changes employment or obtains additional employment
while enrolled in a qualified health plan for which
such credit or reduction is allowed, the enrollee shall notify the
Exchange of such change or additional employment and provide
the information described in this paragraph with respect
to the new employer.
(5) EXEMPTIONS FROM INDIVIDUAL RESPONSIBILITY REQUIRE- MENTS.—In the case of an individual who is seeking an exemption
certificate under section 1311(d)(4)(H) from any requirement
or penalty imposed by section 5000A, the following information:
(A) In the case of an individual seeking exemption
based on the individual’s status as a member of an exempt
religious sect or division, as a member of a health care
sharing ministry, as an Indian, or as an individual eligible
for a hardship exemption, such information as the Secretary
shall prescribe.
(B) In the case of an individual seeking exemption
based on the lack of affordable coverage or the individual’s
status as a taxpayer with household income less than 100
percent of the poverty line, the information described in
paragraphs (3) and (4), as applicable.
(c) VERIFICATION OF INFORMATION CONTAINED IN RECORDS OF
SPECIFIC FEDERAL OFFICIALS.—
(1) INFORMATION TRANSFERRED TO SECRETARY.—An Exchange
shall submit the information provided by an applicant
under subsection (b) to the Secretary for verification in accordance
with the requirements of this subsection and subsection
(d).
(2) CITIZENSHIP OR IMMIGRATION STATUS.—
(A) COMMISSIONER OF SOCIAL SECURITY.—The Secretary
shall submit to the Commissioner of Social Security
the following information for a determination as to whether
the information provided is consistent with the information
in the records of the Commissioner:
(i) The name, date of birth, and social security
number of each individual for whom such information
was provided under subsection (b)(2).
(ii) The attestation of an individual that the individual
is a citizen.
(B) SECRETARY OF HOMELAND SECURITY.—
(i) IN GENERAL.—In the case of an individual—
(I) who attests that the individual is an alien
lawfully present in the United States; or
(II) who attests that the individual is a citizen
but with respect to whom the Commissioner of Social
Security has notified the Secretary under subsection
(e)(3) that the attestation is inconsistent
with information in the records maintained by the
Commissioner;
the Secretary shall submit to the Secretary of Homeland
Security the information described in clause (ii)
for a determination as to whether the information provided
is consistent with the information in the records
of the Secretary of Homeland Security.
(ii) INFORMATION.—The information described in
clause (ii) is the following:
(I) The name, date of birth, and any identifying
information with respect to the individual’s
immigration status provided under subsection
(b)(2).
(II) The attestation that the individual is an
alien lawfully present in the United States or in
the case of an individual described in clause (i)(II),
the attestation that the individual is a citizen.
(3) ELIGIBILITY FOR TAX CREDIT AND COST-SHARING REDUCTION.—The
Secretary shall submit the information described in
subsection (b)(3)(A) provided under paragraph (3), (4), or (5) of
subsection (b) to the Secretary of the Treasury for verification
of household income and family size for purposes of eligibility.
(4) METHODS.—
(A) IN GENERAL.—The Secretary, in consultation with
the Secretary of the Treasury, the Secretary of Homeland
Security, and the Commissioner of Social Security, shall
provide that verifications and determinations under this
subsection shall be done—
(i) through use of an on-line system or otherwise
for the electronic submission of, and response to, the
information submitted under this subsection with respect
to an applicant; or
(ii) by determining the consistency of the information
submitted with the information maintained in the
records of the Secretary of the Treasury, the Secretary
of Homeland Security, or the Commissioner of Social
Security through such other method as is approved by
the Secretary.
(B) FLEXIBILITY.—The Secretary may modify the methods
used under the program established by this section for
the Exchange and verification of information if the Secretary
determines such modifications would reduce the administrative
costs and burdens on the applicant, including
allowing an applicant to request the Secretary of the
Treasury to provide the information described in paragraph
(3) directly to the Exchange or to the Secretary. The
Secretary shall not make any such modification unless the
Secretary determines that any applicable requirements
under this section and section 6103 of the Internal Revenue
Code of 1986 with respect to the confidentiality, disclosure,
maintenance, or use of information will be met.
(d) VERIFICATION BY SECRETARY.—In the case of information
provided under subsection (b) that is not required under subsection
(c) to be submitted to another person for verification, the Secretary
shall verify the accuracy of such information in such manner as the
Secretary determines appropriate, including delegating responsibility
for verification to the Exchange.
(e) ACTIONS RELATING TO VERIFICATION.—
(1) IN GENERAL.—Each person to whom the Secretary provided
information under subsection (c) shall report to the Secretary
under the method established under subsection (c)(4)
the results of its verification and the Secretary shall notify the
Exchange of such results. Each person to whom the Secretary
provided information under subsection (d) shall report to the
Secretary in such manner as the Secretary determines appropriate.
(2) VERIFICATION.—
(A) ELIGIBILITY FOR ENROLLMENT AND PREMIUM TAX
CREDITS AND COST-SHARING REDUCTIONS.—If information
provided by an applicant under paragraphs (1), (2), (3),
and (4) of subsection (b) is verified under subsections (c)
and (d)—
(i) the individual’s eligibility to enroll through the
Exchange and to apply for premium tax credits and
cost-sharing reductions shall be satisfied; and
(ii) the Secretary shall, if applicable, notify the
Secretary of the Treasury under section 1412(c) of the
amount of any advance payment to be made.
(B) EXEMPTION FROM INDIVIDUAL RESPONSIBILITY.—If
information provided by an applicant under subsection
(b)(5) is verified under subsections (c) and (d), the Secretary
shall issue the certification of exemption described
in section 1311(d)(4)(H).
(3) INCONSISTENCIES INVOLVING ATTESTATION OF CITIZEN- SHIP OR LAWFUL PRESENCE.—If the information provided by
any applicant under subsection (b)(2) is inconsistent with information
in the records maintained by the Commissioner of Social
Security or Secretary of Homeland Security, whichever is
applicable, the applicant’s eligibility will be determined in the
same manner as an individual’s eligibility under the medicaid
program is determined under section 1902(ee) of the Social Security
Act (as in effect on January 1, 2010).
(4) INCONSISTENCIES INVOLVING OTHER INFORMATION.— (A) IN GENERAL.—If the information provided by an
applicant under subsection (b) (other than subsection
(b)(2)) is inconsistent with information in the records
maintained by persons under subsection (c) or is not
verified under subsection (d), the Secretary shall notify the
Exchange and the Exchange shall take the following actions:

(i) REASONABLE EFFORT.—The Exchange shall
make a reasonable effort to identify and address the
causes of such inconsistency, including through typographical
or other clerical errors, by contacting the applicant
to confirm the accuracy of the information, and
by taking such additional actions as the Secretary,
through regulation or other guidance, may identify.
(ii) NOTICE AND OPPORTUNITY TO CORRECT.—In the
case the inconsistency or inability to verify is not resolved
under subparagraph (A), the Exchange shall—
(I) notify the applicant of such fact;
(II) provide the applicant an opportunity to either
present satisfactory documentary evidence or
resolve the inconsistency with the person verifying
the information under subsection (c) or (d) during
the 90-day period beginning the date on which the
notice required under subclause (I) is sent to the
applicant.
The Secretary may extend the 90-day period under
subclause (II) for enrollments occurring during 2014.
(B) SPECIFIC ACTIONS NOT INVOLVING CITIZENSHIP OR
LAWFUL PRESENCE.—
(i) IN GENERAL.—Except as provided in paragraph
(3), the Exchange shall, during any period before the
close of the period under subparagraph (A)(ii)(II),
make any determination under paragraphs (2), (3),
and (4) of subsection (a) on the basis of the information
contained on the application.
(ii) ELIGIBILITY OR AMOUNT OF CREDIT OR REDUCTION.—If
an inconsistency involving the eligibility for,
or amount of, any premium tax credit or cost-sharing
reduction is unresolved under this subsection as of the
close of the period under subparagraph (A)(ii)(II), the
Exchange shall notify the applicant of the amount (if
any) of the credit or reduction that is determined on
the basis of the records maintained by persons under
subsection (c).
(iii) EMPLOYER AFFORDABILITY.—If the Secretary
notifies an Exchange that an enrollee is eligible for a
premium tax credit under section 36B of such Code or
cost-sharing reduction under section 1402 because the
enrollee’s (or related individual’s) employer does not
provide minimum essential coverage through an employer-sponsored
plan or that the employer does provide
that coverage but it is not affordable coverage,
the Exchange shall notify the employer of such fact
and that the employer may be liable for the payment
assessed under section 4980H of such Code.
(iv) EXEMPTION.—In any case where the inconsistency
involving, or inability to verify, information provided
under subsection (b)(5) is not resolved as of the
close of the period under subparagraph (A)(ii)(II), the
Exchange shall notify an applicant that no certification
of exemption from any requirement or payment
under section 5000A of such Code will be issued.
(C) APPEALS PROCESS.—The Exchange shall also notify
each person receiving notice under this paragraph of the
appeals processes established under subsection (f).
(f) APPEALS AND REDETERMINATIONS.—
(1) IN GENERAL.—The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland Security,
and the Commissioner of Social Security, shall establish procedures
by which the Secretary or one of such other Federal officers—
(A) hears and makes decisions with respect to appeals
of any determination under subsection (e); and
(B) redetermines eligibility on a periodic basis in appropriate
circumstances.
(2) EMPLOYER LIABILITY.—
(A) IN GENERAL.—The Secretary shall establish a separate
appeals process for employers who are notified under
subsection (e)(4)(C) that the employer may be liable for a
tax imposed by section 4980H of the Internal Revenue
Code of 1986 with respect to an employee because of a determination
that the employer does not provide minimum
essential coverage through an employer-sponsored plan or
that the employer does provide that coverage but it is not
affordable coverage with respect to an employee. Such
process shall provide an employer the opportunity to—
(i) present information to the Exchange for review
of the determination either by the Exchange or the
person making the determination, including evidence
of the employer-sponsored plan and employer contributions
to the plan; and
(ii) have access to the data used to make the determination
to the extent allowable by law.
Such process shall be in addition to any rights of appeal
the employer may have under subtitle F of such Code.
(B) CONFIDENTIALITY.—Notwithstanding any provision
of this title (or the amendments made by this title) or section
6103 of the Internal Revenue Code of 1986, an employer
shall not be entitled to any taxpayer return information
with respect to an employee for purposes of determining
whether the employer is subject to the penalty
under section 4980H of such Code with respect to the employee,
except that—
(i) the employer may be notified as to the name of
an employee and whether or not the employee’s income
is above or below the threshold by which the affordability
of an employer’s health insurance coverage
is measured; and
(ii) this subparagraph shall not apply to an employee
who provides a waiver (at such time and in
such manner as the Secretary may prescribe) authorizing
an employer to have access to the employee’s taxpayer
return information.
(g) CONFIDENTIALITY OF APPLICANT INFORMATION.—
(1) IN GENERAL.—An applicant for insurance coverage or
for a premium tax credit or cost-sharing reduction shall be required
to provide only the information strictly necessary to authenticate
identity, determine eligibility, and determine the
amount of the credit or reduction.
(2) RECEIPT OF INFORMATION.—Any person who receives
information provided by an applicant under subsection (b)
(whether directly or by another person at the request of the applicant),
or receives information from a Federal agency under
subsection (c), (d), or (e), shall—
(A) use the information only for the purposes of, and
to the extent necessary in, ensuring the efficient operation
of the Exchange, including verifying the eligibility of an individual
to enroll through an Exchange or to claim a premium
tax credit or cost-sharing reduction or the amount
of the credit or reduction; and
(B) not disclose the information to any other person
except as provided in this section.
(h) PENALTIES.—
(1) FALSE OR FRAUDULENT INFORMATION.—
(A) CIVIL PENALTY.—
(i) IN GENERAL.—If—
(I) any person fails to provides correct information
under subsection (b); and
(II) such failure is attributable to negligence
or disregard of any rules or regulations of the Secretary,
such person shall be subject, in addition to any other
penalties that may be prescribed by law, to a civil penalty
of not more than $25,000 with respect to any failures
involving an application for a plan year. For purposes
of this subparagraph, the terms ‘‘negligence’’ and
‘‘disregard’’ shall have the same meanings as when
used in section 6662 of the Internal Revenue Code of
1986.
(ii) REASONABLE CAUSE EXCEPTION.—No penalty
shall be imposed under clause (i) if the Secretary determines
that there was a reasonable cause for the
failure and that the person acted in good faith.
(B) KNOWING AND WILLFUL VIOLATIONS.—Any person
who knowingly and willfully provides false or fraudulent
information under subsection (b) shall be subject, in addition
to any other penalties that may be prescribed by law,
to a civil penalty of not more than $250,000.
(2) IMPROPER USE OR DISCLOSURE OF INFORMATION.—Any
person who knowingly and willfully uses or discloses information
in violation of subsection (g) shall be subject, in addition
to any other penalties that may be prescribed by law, to a civil
penalty of not more than $25,000.
(3) LIMITATIONS ON LIENS AND LEVIES.—The Secretary (or,
if applicable, the Attorney General of the United States) shall
not—
(A) file notice of lien with respect to any property of
a person by reason of any failure to pay the penalty imposed
by this subsection; or
(B) levy on any such property with respect to such failure.
(i) STUDY OF ADMINISTRATION OF EMPLOYER RESPONSIBILITY.—
(1) IN GENERAL.—The Secretary of Health and Human
Services shall, in consultation with the Secretary of the Treasury,
conduct a study of the procedures that are necessary to
ensure that in the administration of this title and section
4980H of the Internal Revenue Code of 1986 (as added by section
1513) that the following rights are protected:
(A) The rights of employees to preserve their right to
confidentiality of their taxpayer return information and
their right to enroll in a qualified health plan through an
Exchange if an employer does not provide affordable coverage.
(B) The rights of employers to adequate due process
and access to information necessary to accurately determine
any payment assessed on employers.
(2) REPORT.—Not later than January 1, 2013, the Secretary
of Health and Human Services shall report the results
of the study conducted under paragraph (1), including any recommendations
for legislative changes, to the Committees on
Finance and Health, Education, Labor and Pensions of the
Senate and the Committees of Education and Labor and Ways
and Means of the House of Representatives.