Health Reform WK-EDGE CCIIO provides guidance on hardship exemption
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Tuesday, April 24, 2018

CCIIO provides guidance on hardship exemption

By Joseph Arshawsky, J.D.

On April 9, 2018, the CMS Center for Consumer Information and Insurance Oversight (CCIIO), Centers for Medicare & Medicaid Services ("CMS"), issued guidance on hardship exemptions from the individual shared responsibility provision for persons experiencing limited issuer options or other circumstances (CCIIO Letter, April 9, 2018).

The guidelines describe four examples of circumstances that fall under the Federally-facilitated Exchange’s (FFE’s) hardship exemption policy that will address people facing limited issuer options or other circumstances preventing them from purchasing health insurance. The FFE grants hardship exemptions under 26 U.S.C. § 5000A(e)(5) (as added by section 1501(b) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148)), which provides the Secretary of HHS authority to determine eligibility for an exemption from the individual shared responsibility provision for a person who has "suffered a hardship with respect to the capability to obtain coverage under a qualified health plan."

No plan. The first category are people who live in a county, borough, or parish in which no qualified health plan (QHP) is offered through the FFE. CMS will grant a hardship exemption under 45 C.F.R. Sec. 155.605(d)(1)(iii) such that a person will receive an exemption from the individual shared responsibility provision for one plan year (plus the month before and after the plan year) when he or she applies for coverage through an FFE and no QHPs are offered in his or her county, parish, or borough.

One plan. The second category are people who live in a county, borough, or parish in which there is only one issuer offering coverage through the FFE and can show the resulting lack of choice has precluded them from obtaining coverage under a QHP. In accordance with 45 C.F.R. Sec. 155.605(d)(1)(iii), the FFE may grant a hardship exemption to such individuals. This exemption would apply for one plan year (plus the month before and after the plan year) if only one issuer in a county, borough, or parish offers coverage through a QHP and if this circumstance renders a person incapable of obtaining the coverage.

Abortion. The third category are people who have a hardship obtaining coverage because all affordable plans offered through the FFE in the person’s county, borough, or parish provide coverage of abortion, contrary to one’s beliefs, and the absence of any affordable plan without such coverage causes a hardship in obtaining health insurance. A person may qualify for an exemption in accordance with 45 C.F.R. Sec. 155.605(d)(1)(iii) if all affordable plans offered through the FFE in the person’s county, borough, or parish provide coverage of abortions, contrary to one’s beliefs, and the absence of any affordable plan without such coverage causes a hardship in obtaining health insurance.

Other circumstances. Finally, the fourth category are people who experience personal circumstances that create a hardship in obtaining health insurance coverage under a QHP, such as when a person needs specialty care by a specialist physician, but the affordable plans offered through the FFE do not provide access to such care.

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