Overlapping Eligibility and Enrollment: Human Services and Health Programs Under the Affordable Care Act. Determination of eligibility for HIM subsidies


People qualify for subsidies in the marketplace (HIM) if—

  • They are not offered affordable ESI;
  • They are citizens or lawfully present in the U.S.;
  • They are ineligible for Medicaid or CHIP
  • They are not covered by Medicare52; and
  • They either –
    • Have annual MAGI between 100 and 400 percent of the poverty guideline; or
    • Have MAGI low enough to qualify for Medicaid (and below 100 percent of poverty) but are ineligible due to immigrant-related restrictions

Although the MAGI assessment for HIM purposes is annual, Medicaid/CHIP eligibility is assessed monthly and can change during the year. Thus, a person can be simulated as eligible for HIM in some months of the year, but eligible for Medicaid in other months of the year. The simulation captures the final regulations’ “safe harbor” that allows persons who are ineligible for HIM subsidies because annual MAGI is under 100 percent FPL to qualify for Medicaid in months where monthly MAGI exceeds 138 percent FPL.

Data from HIPSM was imported into TRIM and used to determine which workers were offered affordable ESI by their employer. If a worker had an affordable offer, the following household members were assumed to have access to that coverage as well:

  • Spouse
  • Children under 26 (even if married or a parent)53
  • Any person under 19 claimed as a dependent by the worker, or the worker’s spouse.

A worker with an affordable offer was not considered to have that offer in months where he or she was not working (i.e. months where he or she had no earnings). Likewise, spouses and dependents do not have access to that worker’s offer in months where the worker has no earnings.

While undocumented noncitizens are never eligible for subsidies, legal noncitizens face no special restrictions. Furthermore, if a legal noncitizen has MAGI under 100 percent of poverty but is not eligible for Medicaid solely because of Medicaid’s restrictions on noncitizens, he or she is eligible for subsidies.

Note that we assumed all persons eligible for a subsidy would enroll in a HIM plan, regardless of whether they were subject to the mandate. This also assumes that no eligible person would choose to pay the penalty for non-compliance.


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