Tag: Health Insurance

What Should I do if Someone Signed me up for Marketplace Coverage Without my Consent?

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Did your federal income tax return for last year indicate that you had health coverage through the Marketplace (Obamacare) and/or you owe IRS a repayment of premium tax credit, but you did not sign up for coverage?

If you were enrolled in a health plan in the Marketplace by another person (an insurance agent or broker) without your consent and knowledge, you should report this to the Marketplace and submit the claim for agent fraud.

Please follow these steps:

  1. Call the Health Insurance Marketplace (aka Obamacare) Call Center at 1-800-318-2596 to find the status of your enrollment. Even if you did not sign up of your own will, you may owe the IRS money back for premium tax credits you received.
  2. If the Marketplace reports you did not have coverage in 2022 and/or 2023, there is nothing else you need to do.
  3. If the Marketplace confirms you had coverage that you did not consent to AND you did not use this coverage for your doctor or hospital visits, follow these steps:
  • Report your enrollment without consent and submit an agent fraud claim so that your coverage may be terminated retroactively. Ask the Marketplace to cancel any current active coverage you were fraudulently enrolled in, so that you do not continue receiving premium tax credits that you may not be eligible for.
  • Next, the Marketplace will investigate your claim. This will take at least 30 days but may take longer. Upon investigation, you will receive a letter with the fraud claim resolution. You can call the Marketplace to check on the status of the claim if you do not hear from them within 30 days.
  • Depending on the fraud claim outcome, you may receive an amended 1095A tax form that you may need to file with your federal income tax return. Make sure the Marketplace has the correct mailing address for you. Charlotte Center for Legal Advocacy Low-Income Taxpayer Clinic may be able to provide guidance with tax questions regarding your 1095A form. You can contact the clinic at 980-202-7329.
  • It is recommended that you file an agent fraud claim with the NC Department of Insurance as well. Visit ncdoi.gov or call 919-807-6840 (Toll-Free 888-680-7684).
  • If you believe your identity has been stolen, you should report it to IdentityTheft.gov.
  • If you have questions about this process or your options for health coverage, Affordable Care Act Health Insurance Navigators can help. Call 980- 256-3782 for free assistance.

Health Insurance Navigators can help you with this process. You can call 980- 256-3782 for free assistance.

Health Insurance Navigators are licensed by the Center for Medicaid and Medicare, a federal agency that also administers Health Insurance Marketplace. Their services are free for everyone, and they do not get any financial incentives for their assistance. They help consumers understand what health options they are eligible for and assist with enrollment in Medicaid and Marketplace coverage. They cannot choose a health plan for you but can help answer questions about health coverage and guide a consumer through the enrollment process. Navigator services include reasonable accommodations for non-English speaking consumers or consumers with visual, hearing, or other impairments with no cost to consumers.

Why is it important to report fraudulent enrollment in Marketplace coverage?

Every time someone applies for coverage through Marketplace, they are also applying for government financial assistance through advance premium tax credit to help lower your monthly health insurance payment (or “premium”). Advance Premium Tax Credit is approved based on the estimate of your expected income, the tax filing status, and other criteria for the year you will have coverage. This is reported on your Marketplace application.

If you qualify for a premium tax credit based on your estimate, tax filing status, and ineligibility for other health coverage, you can use it to lower the cost of your monthly premium for the plan you enrolled in.

You are legally required to file a federal income tax return for the year you had Marketplace coverage and reconcile the advance premium tax credit with your actual income for that year:

  • If at the end of the year you have received more premium tax credit than you are due based on your final income, you will have to pay back the excess when you file your federal tax return.
  • If you have received less than you qualify for, you will get the difference back.

If you were eligible for premium tax credits when you had coverage on Marketplace and you received the correct amount, all you need to do is submit this information with your tax return.

There are several reasons someone is not eligible for premium tax credits, for example you may not have an eligible immigration status, or you had an offer of or enrolled in an employer sponsored insurance (some exceptions apply). If you were eligible/ enrolled in Medicaid, Medicare, or other health coverage that meets the minimum essential coverage requirement, you WERE NOT eligible for premium tax credits.

What is not a fraudulent enrollment?

You cannot claim that you were fraudulently enrolled in a Marketplace health plan if:

  1. You agreed to be enrolled in Marketplace plan after you talked to a health insurance agent or broker.
  2. You willingly enrolled into the Marketplace plan with the help of an agent/broker, but later changed your mind and decided you do not want this coverage.
  3. You used your Marketplace health plan at any point to cover the cost of any medical services provided during the coverage year to you or any other tax household member listed on your Marketplace application.
  4. Your health plan premium cost was not fully subsidized (you were paying a portion of the premium).

What If I was enrolled in health coverage on Marketplace without my consent, but now I want to keep it?

If you have been enrolled without consent on Marketplace health plan for 2023 and you decide that you may want to keep that plan, you should:

  1. Ask the Marketplace representative for the details of the plan (monthly premium, deductible amount, copays amount, out-of-maximum amount for 2023) so that you can understand the cost of this coverage and make an informed decision.
  2. Ask the representative to update your 2023 application to make sure you report any offer of insurance elsewhere (employer sponsored insurance, Medicare, Medicaid, TRICARE or VA Healthcare, etc..), your accurate tax filing status and your income for coverage year to make sure you will receive an accurate premium tax credit to lower you monthly premium. *Please note that if you are legally married you will need to include your spouse’s income on the Marketplace application and file jointly with your spouse for the year you had coverage, even if you do not live with your spouse. Some exceptions apply.
  3. If your employer offers health insurance, you are not eligible to be on Marketplace and receive premium tax credit unless the lowest premium cost of the plan your employer offers is more than 9.12% of your income.
  4. If you already enrolled in health insurance offered by your employer (or are eligible for any other minimum essential coverage, e.g., Medicaid, Medicare, or TRICARE), you are NOT eligible for Marketplace coverage and you should immediately cancel the Marketplace plan you were enrolled in for 2023. Otherwise, you may have to re-pay your premium tax credit when you file taxes.
  5. Make sure Marketplace has correct contact information to mail you your 1095A for 2023 coverage.
  6. Use your 1095A to reconcile any premium tax credits you received on your federal tax return.

Qué hacer si fui inscrito en la cobertura de salud en el Mercado (Obamacare) sin mi consentimiento

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¿Su declaración federal de impuestos del año pasado indicó que tenía cobertura de salud a través del Mercado (Obamacare) y/o que debe un reembolso del crédito fiscal premium al IRS, pero usted no se inscribió en la cobertura?

Si alguien más (un agente o corredor de seguros) lo inscribió en un plan de salud del Mercado sin su consentimiento y conocimiento, debe informar esto al Mercado y presentar una reclamación por fraude de agente.

Por favor, siga estos pasos:

  1. Comuníquese al Centro de Llamadas del Mercado de Seguros Médicos (también conocido como Obamacare)  al 1-800-318-2596 para conocer el estado de su inscripción. Es posible que deba realizar un reembolso al IRS si se le otorgó un crédito tributario de prima para el que no era elegible.
  2. Si le informan que no tuvo cobertura en 2022 y/o 2023, no debe hacer nada más.
  3. Si el Mercado confirma que usted tenía cobertura sin consentimiento y no utilizó esta cobertura para visitas al médico y/u hospital, siga estos pasos:
  • Informe sobre su inscripción sin consentimiento y presente una reclamación por fraude de agente para que su cobertura sea cancelada retroactivamente. Pida al Mercado que cancele cualquier cobertura activa actual en la que lo inscribieron fraudulentamente, para que no siga recibiendo créditos fiscales premium para los cuales puede no ser elegible.
  • A continuación, el Mercado investigará su reclamación. Esto tomará al menos 30 días, pero puede tomar más tiempo. Tras la investigación, recibirá una carta con la resolución de la reclamación por fraude. Si no recibe noticias de ellos en un plazo de 30 días, puede llamar al Mercado para verificar el estado de la reclamación.
  • Según el resultado de la reclamación por fraude, es posible que reciba el formulario fiscal de impuestos 1095A enmendado que deberá ser presentado con su declaración de impuestos federales. La Clínica de Contribuyentes de Bajos Ingresos del Centro de Apoyo Legal de Charlotte puede responder preguntas relacionadas con el formulario 1095A. Si lo requiere puede contactarse al: 980-202-7329.
  • Se recomienda que presente una reclamación por fraude de agente ante el Departamento de Seguros de Carolina del Norte también. Visite ncdoi.gov o llame al 919-807-6840 (Llamada gratuita 888-680-7684).
  • Si cree que su identidad ha sido robada, debe informarlo en IdentityTheft.gov.
  • Si tiene preguntas sobre este proceso o sus opciones de cobertura de salud, los Navegadores de Seguros de Salud de la Ley de Cuidado de Salud a Bajo Precio pueden ayudarlo. Llame al 980-256-3782 para obtener asistencia gratuita.

Los Navegadores de Seguros de Salud pueden ayudarlo con este proceso. Puede llamar al 980-256-3782 para obtener asistencia gratuita.

Los Navegadores de Seguros de Salud están licenciados por el Centro de Medicaid y Medicare, una agencia federal que también administra el Mercado de Seguros de Salud. Sus servicios son gratuitos para todos, y no reciben incentivos financieros al ofrecer su ayuda. Ayudan a los consumidores a comprender las opciones de salud para las que son elegibles y los asisten en la inscripción en Medicaid y en la cobertura del Mercado. No pueden elegir un plan de salud por usted, pero pueden ayudarlo a responder preguntas sobre la cobertura de salud y guiar al consumidor a través del proceso de inscripción. Los servicios del Navegador incluyen adaptaciones razonables para consumidores que no hablan inglés o que tienen discapacidades visuales, auditivas u otras discapacidades sin costo para los consumidores.

¿Por qué es importante informar la inscripción fraudulenta en la cobertura del Mercado?

Cada vez que alguien solicita cobertura a través del Mercado, también está solicitando asistencia financiera gubernamental a través del crédito fiscal premium por adelantado para ayudar a reducir su pago mensual del seguro de salud (o “prima”). El Crédito Fiscal Premium por Adelantado se aprueba en función de la estimación de sus ingresos esperados, el estado civil para efectos de declaración de impuestos y otros criterios para el año en que tendrá la cobertura. Esto se informa en su solicitud al Mercado.

Si califica para un crédito fiscal premium en función de su estimación, estado civil para efectos de declaración de impuestos y la falta de elegibilidad para otra cobertura de salud, puede utilizarlo para reducir el costo de su prima mensual del plan en el que se inscribió.

Está legalmente obligado a presentar una declaración de impuestos federales del año en que tuvo cobertura del Mercado y conciliar el crédito fiscal premium por adelantado con sus ingresos reales de ese año:

  • Si al final del año ha recibido más crédito fiscal premium del que le corresponde según sus ingresos finales, deberá devolver el excedente cuando presente su declaración de impuestos federales.
  • Si ha recibido menos de lo que califica, recibirá la diferencia.

Si fue elegible para créditos fiscales premium cuando tenía cobertura en el Mercado y recibió la cantidad correcta, todo lo que necesita hacer es presentar esta información con su declaración de impuestos.

Hay varias razones por las que alguien no es elegible para créditos fiscales premium, por ejemplo, es posible que no tenga un estatus migratorio elegible o que haya recibido una oferta o se haya inscrito en un seguro patrocinado por el empleador (con algunas excepciones). Si fue elegible/inscrito en Medicaid, Medicare u otra cobertura de salud que cumple con el requisito de cobertura esencial mínima, NO será elegible para créditos fiscales premium.

¿Qué no es una inscripción fraudulenta?

No puede afirmar que fue inscrito fraudulentamente en un plan de salud del Mercado si:

  1. Aceptó ser inscrito en un plan del Mercado después de hablar con un agente o corredor de seguros de salud.
  2. Se inscribió voluntariamente en el plan del Mercado con la ayuda de un agente/corredor, pero luego cambió de opinión y decidió que no desea esta cobertura.
  3. Utilizó su plan de salud del Mercado en algún momento para cubrir el costo de cualquier servicio médico proporcionado durante el año de su cobertura o si cualquier otro miembro del hogar fiscal mencionado en su solicitud al Mercado hizo uso de este servicio.
  4. El costo de la prima de su plan de salud no estaba completamente subsidiado (usted estaba pagando una parte de la prima).

¿Qué sucede si fui inscrito en cobertura de salud en el Mercado sin mi consentimiento, pero ahora quiero mantenerla?

Si fue inscrito sin consentimiento en un plan de salud del Mercado para 2023 y decide que podría querer mantener ese plan, deberá:

  1. Solicitar al representante del Mercado los detalles del plan (prima mensual, monto del deducible, monto de copagos, monto máximo fuera de bolsillo para 2023) para que pueda comprender el costo de esta cobertura y tomar una decisión informada.
  2. Solicitar al representante que actualice su solicitud de 2023 para asegurarse de informar cualquier oferta de seguro en otro lugar (seguro patrocinado por el empleador, Medicare, Medicaid, TRICARE o VA Healthcare, etc.), su estado civil y sus ingresos exactos para el año de cobertura, para asegurarse de que reciba un crédito fiscal premium preciso para reducir su prima mensual. *Tenga en cuenta que si está legalmente casado, deberá incluir los ingresos de su cónyuge en la solicitud del Mercado y presentar una declaración conjunta con su cónyuge para el año en que tuvo cobertura, incluso si no vive con su cónyuge. Se aplican algunas excepciones.
  3. Si su empleador ofrece seguro de salud, no es elegible para estar en el Mercado y recibir créditos fiscales premium a menos que el costo de la prima más bajo del plan que ofrece su empleador sea superior al 9,12% de sus ingresos.
  4. Si ya se inscribió en un seguro de salud ofrecido por su empleador (o es elegible para cualquier otra cobertura esencial mínima, como Medicaid, Medicare o TRICARE), NO es elegible para la cobertura del Mercado y debe cancelar inmediatamente el plan del Mercado en el que se inscribió para 2023. De lo contrario, es posible que deba reembolsar el crédito fiscal premium cuando presente sus impuestos.
  5. Asegúrese de que el Mercado tenga la información de contacto correcta para enviarle su formulario 1095A para la cobertura de 2023.
  6. Use su formulario 1095A para conciliar cualquier crédito fiscal premium que haya recibido en su declaración de impuestos federales.

Advocacy Center Responds to Medicaid Changes

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On April 1st, pandemic-era protections that kept individuals enrolled in Medicaid were rolled back.  The Local Department of Social Services (DSS) resumed redeterminations, reducing or terminating Medicaid coverage for those who are no longer eligible. Experts anticipated that approximately 300,000 North Carolinians would lose access to affordable health care as a result. 

To address the looming crisis, Advocacy Center staff engaged in extensive outreach and education efforts with beneficiaries and providers.  The team offered webinars educating those impacted by the change, initiated a state-wide communication effort to increase awareness and connect beneficiaries with critical resources, and engaged the community and our partners through numerous outreach events.  Efforts were focused on educating individuals and families about their rights and how to navigate the complicated process to ensure they maintain access to care.   In addition, staff continued to provide legal assistance to beneficiaries facing service or eligibility denials.

As a result of a settlement agreement reached in October 2022 in Franklin v. Kinsley, formerly known as Hawkins v. Cohen, the Advocacy Center is in a unique position to ensure beneficiaries’ rights will be protected during the redetermination process.  In the settlement agreement, the North Carolina Medicaid agency agreed to extensive and very detailed changes to its procedures, forms, and notices for redetermining Medicaid eligibility for those currently enrolled in Medicaid.  Through enforcement of the settlement agreement, legal staff can ensure the 2.8 million North Carolinians with Medicaid will not lose coverage for which they are still eligible due to procedural terminations. 

If you think your rights were violated by DSS, call 1-800-936-4971 or email hawkinsinfo@charlottelegaladvocacy.org

N.C. Medicaid Redetermination Begins as the end of COVID-19 Public Health Emergency Draws Near

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Charlotte Center for Legal Advocacy shares rights and recourse for beneficiaries

Charlotte, N.C. – Charlotte Center for Legal Advocacy has received calls and inquiries from clients who are concerned about Medicaid redetermination, a process the Department of Social Services (DSS) started earlier this month to verify those who receive Medicaid are still eligible.

Beneficiaries will be contacted by DSS through May 31, 2024, to determine eligibility; those who are no longer eligible will have their Medicaid coverage reduced or terminated. Medicaid redetermination dovetails with the end of pandemic-related relief in advance of the May 11, 2023, expiration of the federal COVID-19 public health emergency. More information is available on the Advocacy Center’s website.

“Since March 2020, Medicaid beneficiaries have had the peace of mind knowing that they would not lose health coverage in the midst of the pandemic,” explained Toussaint Romain, chief executive officer of the Charlotte Center for Legal Advocacy. “While we understand pandemic aid cannot last forever, challenges related to COVID-19 are still very present and real for those struggling to keep employment, health coverage and food on the table.”

Charlotte Center for Legal Advocacy urges clients to:

  1. Contact their local DSS office to ensure contact information is up to date.
  2. Watch for mail, texts or phone calls from DSS and respond promptly.
  3. Create an enhanced e-PASS account to update information, upload documents and view benefits.

● Reach DSS by phone, including the right to leave a message instead of remaining on hold, and to have a call returned within a reasonable time.
● Request and receive help from DSS to obtain the information needed to redetermine eligibility.
● Have DSS accept a detailed statement about income, assets and most other facts needed to verify eligibility, in writing or verbally, without providing supporting documents.
● Not to be asked to verify information that DSS can obtain through electronic sources or to verify information that is not needed to redetermine eligibility.
● Have Medicaid eligibility considered under all categories, including an alleged disability, before Medicaid can be terminated or reduced.
● Receive written notice that states what action has been taken and the reason it has been taken before Medicaid is stopped or reduced.

Thanks to a lawsuit filed by Charlotte Center for Legal Advocacy and the National Health Law Program, Medicaid beneficiaries are entitled to specific protections and rights during the redetermination process. These rights were defined as the result of a settlement reached on October 14, 2022, in Franklin v. Kinsley, (formerly known as Hawkins v. Cohen), which requires North Carolina Medicaid to change its procedures, forms and notices in redetermining Medicaid eligibility for the 2.8 million North Carolinians currently enrolled in Medicaid. Where Medicaid redetermination is concerned, beneficiaries have the right to:

If their Medicaid is terminated, Charlotte Center for Legal Advocacy urges clients to:

● File an appeal during which beneficiaries:
○ Will have 60 days from the date of the notice to ask for an appeal.
○ Can request Medicaid benefits be continued while the appeal is reviewed, if the appeal is filed within 10 business days
● Investigate whether they are eligible for a Special Enrollment Period (SEP) for Medicare or Health Insurance MarketplaceⓇ coverage
● Call Charlotte Center for Legal Advocacy if they feel their coverage was wrongfully reduced or terminated (call 704-376-1600 and press 2).

About Charlotte Center for Legal Advocacy

Charlotte Center for Legal Advocacy provides those in need with information, advice and advocacy in consumer protection, home preservation, health care access and public benefits, immigration, tax assistance and more. Our mission is to pursue justice for those in need. Our vision is to build a just community, where all people are treated fairly and have access to legal representation to meet their basic human needs of safety, economic security, and stability. Learn more: charlottelegaladvocacy.org

Las reglas en Medicaid cambiaron

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Con algunas excepciones, los beneficiarios de Medicaid no habían estado en riesgo de perder su cobertura desde marzo de 2020.  Sin embargo, a partir del 1 de abril de 2023, su Departamento de Servicios Sociales (DSS) local comenzará a verificar si aún es elegible para Medicaid.  Esto se conoce como redeterminación.

DSS comenzará a reducir o cancelar el servicio de Medicaid para aquellos que ya no son elegibles.  También podrían terminar la cobertura de quienes no devuelvan la información necesaria para determinar su elegibilidad.

Por esta razón, debe asegurarse de que DSS tenga su información de contacto actual (dirección, número de teléfono, etc.) y que responda de inmediato a las llamadas o mensajes que reciba sobre su Medicaid. Las redeterminaciones estarán vigentes hasta el 31 de mayo de 2024. DSS se comunicará con usted entre el 1 de abril de 2023 y el 31 de mayo de 2024 para determinar su elegibilidad.

¿Qué debo hacer?

  • Comuníquese con su oficina local de DSS para asegurarse de que tengan su dirección, número de teléfono, correo electrónico y otra información de contacto.
    • Local DSS Offices:
      • Condado de Mecklenburg
        • 704-336-3000
        • Wallace H. Kuralt Centre, 301 Billingsley Road, Charlotte, NC 28211
        • Centro de Recursos Comunitarios, Community Resource Center, 3205 Freedom Drive, Charlotte, NC 28208
      • Condado de Union
        • 704-296-4300
        • 2330 Concord Avenue Monroe, NC 28110
      • Condado de Cabarrus
        • 704-920-1400
        • 1303 S. Cannon Blvd. Kannapolis, NC 28083
  • Esté atento al correo electrónico, mensajes de texto o llamadas telefónicas que reciba del DSS y responda de inmediato.
  • Cree una cuenta ePass mejorada (https://epass.nc.gov):
    • Vea sus beneficios,
    • Cargue los documentos que respalden cualquier cambio, como ingresos o tamaño del hogar,
    • Actualice su información en línea.

Tiene derecho a:

¿Qué pasa si pierdo mi cobertura de Medicaid?

Tiene derecho a apelar

Si cree que ha habido un error, puede apelar esa decisión. Tiene 60 días (aproximadamente 2 meses) a partir de la fecha del aviso para solicitar una apelación. Si lo hace dentro de los siguientes 10 días hábiles, puede pedir que su Medicaid continúe mientras se revisa la apelación. Llame al 704-376-1600 y marque la opción 2 para obtener más información.

Los períodos especiales de inscripción (SEP por sus siglas en inglés) están disponibles para la cobertura de Medicare y del Mercado.

Personas que ya no son elegibles para Medicaid pueden ser elegibles para inscribirse en la cobertura de Medicare o del Mercado con un Período de Inscripción Especial.

Navegadores de Seguro Médico

Programa de Información de Seguro Médico para adultos mayores de Carolina del Norte (SHIIP por sus siglas en inglés)

  • Los consejeros de SHIIP ofrecen información gratuita e imparcial sobre los productos de atención médica y la elegibilidad de Medicare.
  • Llame a 1-855-408-1212

Asistencia legal gratuita disponible

Si cree que su Medicaid fue reducido o terminado injustamente, llame al 800-247-1931.

Para consultar más recursos que lo ayudarán en este proceso visite NCMedHelp.org.

Medicaid Rules Have Changed

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With a few exceptions, Medicaid beneficiaries have not been at risk of losing coverage since March 2020.  On April 1, 2023, your local Department of Social Services (DSS) will begin checking to see if you are still eligible for Medicaid.  This is known as redetermination. 

DSS will start reducing or terminating Medicaid for those who are no longer eligible.  They will terminate coverage for those that do not return the information needed to determine their eligibility.

You must make sure DSS has your current contact information (address, phone number, etc.) and that you promptly respond to letters you receive about your Medicaid.  Redeterminations will continue on a rolling basis. You will be contacted by DSS between April 1, 2023-May 31, 2024 to determine your eligibility.

What should I do?

  • Contact your local DSS office to make sure they have your current mailing address, phone number, email, and other contact information.
    • Local DSS Offices:
      • Mecklenburg County
        • 704-336-3000
        • Wallace H. Kuralt Centre, 301 Billingsley Road, Charlotte, NC 28211
        • Community Resource Center, 3205 Freedom Drive, Charlotte, NC 28208
      • Union County
        • 704-296-4300
        • 2330 Concord Avenue Monroe, NC 28110
      • Cabarrus County
        • 704-920-1400
        • 1303 S. Cannon Blvd. Kannapolis, NC 28083
  • Watch for mail, texts, or phone calls from DSS and respond promptly. 
  • Create an enhanced E-Pass account (https://epass.nc.gov):
    • View your benefits,
    • Upload documents supporting any changes, like income or household size,
    • Update your information online

You have the right to:

What if I lose my Medicaid coverage?

You have the right to appeal.

If you believe there has been an error, you can appeal that decision. You have 60 days (about 2 months) from the date of the notice to ask for an appeal. If you do so within 10 business days, you can request that your Medicaid be continued while the appeal is reviewed. Call 704-376-1600 and press 2 for more information.

Special Enrollment Periods (SEP) are available for Medicare and Marketplace coverage. 

Individuals who are no longer eligible for Medicaid may be eligible to enroll in Medicare or Marketplace coverage with a special enrollment period.

Health Insurance Navigators

NC Seniors’ Health Insurance Information Program (SHIIP)

  • SHIIP counselors offer free and unbiased information regarding Medicare health care products and eligibility
  • 1-855-408-1212

Free legal assistance may be available.

If you think your Medicaid was wrongfully reduced or terminated, call 704-376-1600 and press 2.

For more helpful resources, visit NCMedHelp.org.

Healthcare.gov Premium Tax Credits and Filing Your 2022 Taxes

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If you currently do not have health insurance, we can help! Click here to learn more and make an appointment with a health insurance navigator today.

Health insurance on Healthcare.gov is affordable for many people because the government subsidizes your monthly premiums based on your income. These subsidies are called Premium Tax Credits. If you receive them each month during the year, they are called Advance Payments of the Premium Tax Credit (APTCs).  

If you receive these government subsidies, you need to reconcile these payments on your tax return each year. The IRS requires you to do this to make sure that you received the proper amount of subsidies based on your income. 

Use Form 8962 to see how much premium tax credit you qualify for based on your actual year-end income.  If your income at the end of the year is higher than you estimated on your Healthcare.gov application, you will need to pay back some of your subsidies. This is because you were given more subsidies than you were qualified for, based on your annual income.  

If your income at the end of the year is lower than you estimated on your Healthcare.gov application, you may be eligible for a refund.  Use form 8962 to claim the Premium Tax Credit. 

How do I know if I received APTCs?

If you enrolled yourself or a family member in a Healthcare.gov plan, you will receive Form 1095-A from the Health Insurance Marketplace. This form will show the months that you were covered by a Healthcare.gov plan and will show the amount of APTC that was paid to your health insurance company on your behalf. The Marketplace also provides this information to the IRS. 

Are there changes for filing taxes in 2022? What do I need to do? 

If you received excess APTCs in 2022, you will be required to pay these back when you file your tax return.  

If you find on Form 8962 that you received a smaller amount of subsidies than you qualify for based on your year-end income, you may claim the Premium Tax Credit on form 8962. 

The deadline to file your 2022 federal income tax return is April 18, 2023. If you do not reconcile your APTCs by filing your 1095-A on your 2022 tax return, you run the risk of not being eligible for APTCs in future years. 

No Surprises Act: Protecting patients from surprise medical bills

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The No Surprises Act protects people from “surprise medical bills.” These protections apply to anyone enrolled in a private health insurance plan, including employer plans or a plan purchased on or off the marketplace.  New protections were added in 2022 to restrict excessive out-of-pocket costs from emergency and non-emergency services.  If you’re uninsured or you decide not to use your health insurance, these protections allow you to get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges.  

Even though surprise bills are now banned in many circumstances, enrollees should monitor their medical bills because they might need to take action to protect their rights. Note: Most of the law’s protections only apply to people with private insurance, and not to people who are uninsured or enrolled in Medicaid, CHIP, or Medicare.  

New protections for insured patients

The new law protects insured people in two major ways: 

  • For emergency care: An insured person can get care at any emergency department, even if the care is out of network. The out-of-network emergency facility, and the doctors and other providers who treat the patient, cannot bill the patient for more than in-network cost-sharing amounts (i.e., deductible, copay, coinsurance). The plan also must apply only in-network cost-sharing.  
  • For non-emergency care: If the insured person goes to an in-network facility, they cannot be billed for more than the in-network cost-sharing amount for their services, even if they receive care from an out-of-network provider.  

Note: Out-of-network ambulance services are not covered by the No Surprises Act and can still lead to high bills.   

Key terms 

  • In-network providers: Facilities and doctors who contract to accept a payment rate with your insurer. In-network care generally costs less than care that is out-of-network. You might still have to meet a deductible before your insurance pays the bill, or you might owe a copayment or coinsurance, depending on the type of service and your health plan.  
  • Out-of-network providers: Providers who do not contract with your insurer and instead charge you separately for their services. Unlike in-network providers, out-of-network providers set their own charges. Your health plan might cover some of the cost but often covers none of the cost of out-of-network services.   
  • Surprise medical bill: An out-of-network medical bill a person receives from an out-of-network provider for emergency services, or for non-emergency care while at an in-network facility.  

Frequently Asked Questions

What is a surprise medical bill? 

Generally, people enrolled in private insurance are responsible for checking their plan’s network before getting health services to ensure that the medical provider they’ve selected is in-network. In most situations, people who get medical services from an out-of-network provider are responsible for paying the out-of-network medical bills they receive. Most plans pay less for out-of-network care than they would pay for in-network care, and some don’t cover out-of-network bills at all, leaving the enrollee responsible for paying most or all the out-of-network bill. 

There are some situations where a person doesn’t get to choose their medical provider and ends up receiving out-of-network care. This can happen in medical emergencies when people are taken to the closest ER.  It can also happen when people select an in-network hospital for scheduled care but receive care from an out-of-network doctor they did not get to pick (such as the anesthesiologist).  These scenarios are common. An out-of-network medical bill a person receives after getting care from an out-of-network provider they didn’t get to choose is known as a surprise medical bill. 

What are the new protections if I don’t have health insurance or choose not to use it? 

If you don’t have insurance or choose not to use it, these new rules make sure you get a “good faith estimate” of how much your care will cost, before you get care.  They also allow you to file a dispute if you are charged more than $400 above the estimate. 

What out-of-network providers and services must follow the new law?  

Any health care provider in any emergency department or at the insured person’s in-network facility must follow the new law. A “provider” is defined broadly to include doctors, radiologists, therapists, and others. Services like imaging and lab work, preoperative and postoperative services, telemedicine, and equipment and devices are also covered. “Facilities” are hospitals, hospital outpatient departments, and ambulatory surgery centers. They don’t include other settings, such as urgent care. 

What should I do if I receive a surprise medical bill? 

The first step is to check with the insurance company to see if the provider made a mistake. The out-of-network provider shouldn’t bill for more than the in-network cost-sharing amount for the service(s) indicated on the Explanation of Benefits (EOB). If there is no EOB it might mean that the provider didn’t contact the insurance company as required.  

The second step is to contact the out-of-network provider and ask them to correct the bill. Providers can face fines up to $10,000 per violation for not following the new rules. 

If the provider refuses to resolve the issue by correcting the bill, then it might be necessary to file a complaint by calling the No Surprises Help Desk at 1-800-985-3059. The No Surprises Help Desk is also available for people who have questions or want more information about the new rules. Consumers can also file complaints online at www.cms.gov/nosurprises.  

A mistake made by a person’s insurance company could also result in a surprise medical bill. If that happens, the person should call their insurance company, explain the situation, and ask them to treat the claim as a surprise medical bill. If the insurance company doesn’t correct the issue, the next step is to file an appeal with the insurance company. If this is unsuccessful, the next step is to request an external appeal. 

Note: Every EOB a person receives is required to include instructions for how to file an appeal.  

In North Carolina, the Consumer Services Division of the Department of Insurance can help people file appeals and resolve billing and coverage problems, including surprise medical bills.  

What out-of-network providers and services are not covered by the new law? 

Services that are scheduled in advance directly with an out-of-network provider are not covered under the new law, and the provider can charge patients the full cost for services.  

Are all high medical bills considered surprise bills? 

Cost-sharing charges can vary widely across insurance plans, which means that a person could still receive very high medical bills due to their plan’s standard in-network cost-sharing charges being high. These kinds of bills are not considered surprise medical bills. 

More Resources: 

No Surprises Act, Centers for Medicare and Medicaid Services (CMS) 

Overview of rules & fact sheets | CMS 

Consumers: new protections against surprise medical bills |CMS 

New Extended Coverage for Postpartum Medicaid Beneficiaries

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An important change is here for pregnant and postpartum Medicaid beneficiaries.  A provision of the American Rescue Plan gave states the option to extend Medicaid postpartum coverage from 60 days to 12 months.  Extended coverage became effective in North Carolina on April 1, 2022.  Individuals enrolled in Medicaid for Pregnant Women will now see their coverage extended for a 12-month period after their pregnancy ends.

Research has found that 1 in 3 pregnancy-related deaths occur 1 week to 1 year after delivery. Furthermore, Black and American Indian/Alaska Native women are about 3 times as likely to die from a pregnancy-related cause as White women.  By extending coverage, this needed change stands to improve maternal health and stabilize healthcare coverage for postpartum individuals. 

Who is eligible?

As of April 1, 2022, Medicaid for Pregnant Women beneficiaries in North Carolina saw their coverage extended for a 12-month period after the pregnancy ends, regardless of any changes in circumstances or if the pregnancy ends for any reason.

A renewal must be completed at the end of the 12-month postpartum period to determine if beneficiary will be eligible for Medicaid after the postpartum period. If/when Medicaid terminates, individuals may be eligible to enroll in affordable coverage with the Health Insurance Marketplace through a Special Enrollment Period.

Please note, Medicaid eligibility rules have not changed in the state of North Carolina.

What is the postpartum period?

The postpartum period is a full 12-months following the end of pregnancy for any reason. This includes pregnancies that may end in miscarriage or stillbirth. The period begins on the date the pregnancy ends and extends through the end of the month in which the 12-month period ends. For example, if a Medicaid beneficiary gives birth on May 5, 2022, their Medicaid coverage will be extended through May 31, 2023.

How do I enroll?

Individuals may apply for NC Medicaid online at epass.nc.gov, in person or by phone at their local Department of Social Services (DSS) office, or by filling out a paper application and mailing, faxing, or dropping it off at their local DSS office.

Health Insurance Navigators are available to help individuals to learn if they are eligible for Medicaid programs in North Carolina, and to complete a Medicaid application. Visit NCNavigator.net, call 855-733-3711, or 980-256-3782 in Mecklenburg, Cabarrus, or Union counties to schedule a free appointment.

If Medicaid is approved, individuals need to report when the baby is born to their local DSS office. This must be done no matter which Medicaid program/category the beneficiary receives. The case worker will then extend the Medicaid coverage through the postpartum period. A letter will be sent to the beneficiary letting them know of the change and the certification periods.

When does the change start?

The effective date of this policy is April 1, 2022. The extended coverage is currently authorized through March 2027.

What if I have questions or need help?

Health insurance navigators are ready to help!  Visit NCNavigator.net, call 855-733-3711, or 980-256-3782 in Mecklenburg, Cabarrus, or Union counties to schedule a free appointment.

Still need health insurance? You may qualify for a Special Enrollment Period!

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What you need to know about Special Enrollment Periods

The Marketplace deadline to enroll in or change health insurance plans ended on January 15, 2022 for most people.  You still may qualify for a Special Enrollment Period to enroll in Marketplace coverage if you experience certain life changes.  You may also be eligible to enroll for coverage through Medicaid or the Children’s Health Insurance Program all year long.

Read more to learn who is eligible and contact a Health Insurance Navigator for help!

Frequently Asked Questions

What life changes may make you eligible for a Special Enrollment Period?

You may qualify if:

You or anyone in your household in the past 60 days:

  • Got married
  • Had a baby, adopted a child, or placed a child for foster care
  • Got divorced or legally separated and lost health insurance

You changed your residence:

  • Moved to a new home in a new ZIP code or county
  • Moved to the U.S. from a foreign country or United States territory
  • If you’re a student and moved to or from the place you attend school
  • If you’re a seasonal worker and moved to or from the place you both live and work
  • Moved to or from a shelter or other transitional housing

You lost your health insurance:

  • You or anyone in your household lost qualifying health coverage in the past 60 days
  • You or anyone in your household expects to lose coverage in the next 60 days
  • You lost health insurance since 1/1/2020

Important note: You only have 60 days to enroll in Marketplace coverage after one of these changes has occurred.

What is the new qualification for a Special Enrollment Period?

You may now qualify if your estimated annual household income is at or below 150% Federal Poverty Level (FPL).

If you are an immigrant not eligible for Medicaid due to your immigration status, you may still qualify for this Special Enrollment Period even if your income is below the 100% FPL. Household income limits will vary depending on the number of members of a household.

Who qualifies for the new Special Enrollment Period for low-income people?

To qualify, a person must have an annual projected income that is at or below 150% of the Federal Poverty Line: 

Number in HouseholdAnnual Household Income
1$19,320
2$26,130
3$32,940
4$39,750
5$46,560
6$53,370
7$60,180
8$66,990

If you are a household of one, and your projected income in 2022 is between $12,880 and $19,320, you may be eligible to enroll in Marketplace now or change plans if you are currently enrolled in a Marketplace plan.

If you are a household of four, and your projected income in 2022 is between $26,500 and $39,750, you may be eligible to enroll in Marketplace now or change plans if you are currently enrolled in a Marketplace plan.

If you are an immigrant not eligible for Medicaid due to your immigration status, and your income is below $19,320 (for a household of one), you may be eligible to enroll in Marketplace now or change plans if you are currently enrolled in a Marketplace plan.

When is the new Special Enrollment Period for low-income people available?

Beginning March 22, consumers are able to enroll through this Special Enrollment Period at HealthCare.gov or cuidadodesalud.gov or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) for enrollment help.

When does coverage begin for someone using a Special Enrollment Period?

A person who enrolls in Marketplace coverage using a Special Enrollment Period will be covered the first day of the month following plan selection, no matter what day you apply.

Who is eligible for Medicaid or the Children’s Health Insurance Program?

Medicaid: People with low income, including individuals, families and children, pregnant women, older adults, and people with disabilities, may qualify. If eligible, you can apply any time.

Children’s Health Insurance Program (North Carolina Health Choice for North Carolina residents): helps children in households that earn too much money to qualify for Medicaid, but not enough to buy private insurance.

Need help enrolling in a Special Enrollment Period, Medicaid, or the Children’s Health Insurance Program?

Health insurance navigators are ready to help!  Visit NCNavigator.net, call 855-733-3711, or 980-256-3782 in Mecklenburg, Cabarrus, or Union counties to schedule a free appointment!

Get Help