OAR 945-040-0040: Eligibility for Insurance Affordability Programs

(1) Advance Payments of the Premium Tax Credit. In order to qualify for advance payments of the premium tax credit, a tax filer must have household income greater than or equal to 100 percent, but not more than 400 percent of the Federal Poverty Level for the benefit year; and one or more applicants for whom the tax filer expects to claim a personal exemption deduction on his or her tax return for the benefit year including the tax filer and his or her spouse must: (A) Be eligible for enrollment in a qualified health plan; and (B) Not be eligible for minimum essential coverage, with the exception of coverage in the individual market; and (b) Attest that he or she: (A) Will file an income tax return for the benefit year; (B) If married, will file a joint tax return for the benefit year; (C) Will not be claimed as a tax dependent by another tax filer for the benefit year; and (D) Will claim a personal exemption deduction on his or her tax return for the applicants identified as members of his or her family including the tax filer and his or her spouse. (2) An individual is treated as eligible for employer-sponsored minimum essential coverage only if: (a) The employee’s share of the annual premium for self-only coverage does not exceed 9.5 percent of the taxpayer’s household income for the taxable year and the insurer’s share of the total allowed costs of benefits provided under the plan is at least 60 percent of those costs; or (b) The individual actually enrolls in coverage, including coverage that does not provide minimum value and exceeds 9.5 percent of the taxpayer’s household income for the taxable year. (3) A qualified individual must enroll through the Marketplace in a qualified health plan that is not a catastrophic plan to receive advance payments of the premium tax credit. (4) A qualified individual may accept less than the full amount of advance payments of the premium tax credit for which he or she is determined eligible. (5) A qualified individual who receives advance payments of the premium tax credit and does not file an income tax return and reconcile payments of the tax credit as required by the federal government may not be eligible for advance payments of the premium tax credit for the next benefit year. (6) Cost Sharing Reductions. In order to qualify for cost sharing reductions, an individual must: (a) Be eligible for enrollment in a qualified health plan; (b) Be eligible for advance payments of the premium tax credit; (c) Have household income that does not exceed 250 percent of the federal poverty level; and (d) Be enrolled in a silver-level qualified health plan, except as provided in 945-040-0050 for members of federally recognized Indian tribes. (7) The Marketplace must use the following eligibility categories for cost sharing reductions: (a) Individuals that have household income less than or equal to 150 percent of the federal poverty level. Individuals in this category will be eligible for cost sharing reductions such that the silver plan covers between 93 and 95 percent of the average expected medical expenses for essential health benefits. (b) Individuals who have household income greater than 150 percent of the federal poverty level and less than or equal to 200 percent of the federal poverty level. Individuals in this category will be eligible for cost sharing reductions such that the silver plan covers between 86 and 88 percent of the average expected medical expenses for essential health benefits. (c) Individuals who have household income greater than 200 percent of the federal poverty level and less than or equal to 250 percent of the federal poverty level. Individuals in this category will be eligible for cost sharing reductions such that the silver plan covers between 72 and 74 percent of the average expected medical expenses for essential health benefits.