QHP – Basic Eligibility Rules

QHP – Basic Eligibility Rules

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This article describes the three criteria that make an applicant eligible to purchase a Qualified Health Plan (QHP) from HealthSource RI (HSRI).  Some people will qualify for financial assistance to purchase coverage, while others will need to pay full price.

In order to be eligible to purchase a QHP, the applicant:

  • Must be a Rhode Island resident;
  • Must be a U.S. citizen, national, or be “lawfully present” in the U.S.; and
  • Must not be incarcerated.

There are two additional eligibility requirements to get financial assistance (like tax credits) to purchase a QHP, and those additional requirements are described here (lack of access to other affordable coverage) and here (income limits).  Applicants can enroll into a QHP during an Open Enrollment Period (typically in November, December, and January) or a Special Enrollment Period (both types of enrollment periods are described in detail here).

Each of the three basic eligibility requirements outlined above is described in more detail below.

Rhode Island Residence

To be eligible to enroll in QHP through HSRI, an applicant must be a Rhode Island resident.  The focus is on the applicant’s “intent” to reside in Rhode Island, which can be subjective.  The definition of resident specifically includes those without a fixed address (e.g. homeless), and those who have come to Rhode Island for a job or are seeking employment here.  For children (under 21), residency can be established by residing with a parent or caretaker who meets the adult definition of resident.

The HSRI application merely asks for the applicant’s address.  Proof of address is not typically required.

There are some special exceptions from these rules for individuals residing in an institution, incapable of forming intent, or receiving State supplementary payments linked to SSI.  In these cases, the state residence rules described at 42 C.F.R. § 435.403 are applied.

Example 1
Kerry normally lives in Cranston, RI, but she has been living in Kansas for the past four months to care for her ailing mother.  She does not know how long she will be in Kansas, but she knows that she will return to Rhode Island when she is finished caring for her mother.
→ Kerry is a Rhode Island resident for the purpose of using HSRI.  Her stay in Kansas is only temporary, so her intent is to reside in Rhode Island, not in Kansas.

Example 2
Jennifer is a graduate student at URI.  Her family lives in Connecticut, but Jennifer plans to stay in Rhode Island after graduation.
→ Jennifer is a Rhode Island resident and is eligible to purchase through HSRI.  She lives in Rhode Island and intends to reside here.

There is also a special rule for tax households (see article on QHP household rules here) with members living in multiple states.  Every member of such a “multi-state household” may enroll through the exchange of any state where any member of the household resides, with one exception:  If both spouses enroll through the same exchange, then their dependent may only enroll in (i) the exchange in the state where the spouses are enrolled, or (ii) the exchange in the state where the dependent resides.

Example 3
Mark and Jessica are married, file taxes jointly, and claim their 21-year-old daughter Maggie as a dependent.  Mark lives in Rhode Island, Jessica lives in California, and Maggie lives in Texas.
→ Any member of this household can buy on the exchanges of RI, CA, and TX.  But if both Mark and Jessica (the spouses) buy through the same exchange, then Maggie can only enroll through that exchange or through the exchange in Texas (where she resides).

Citizenship or Immigration Status

To be eligible to enroll in a QHP through HSRI, an applicant must be a U.S. citizen, U.S. national, or “lawfully present” in the U.S.  “Lawfully present” includes refugees, people granted asylum, lawful permanent residents (“green-card” holders), people granted withholding of deportation, and other lawful immigration status.  “Lawfully present” is defined at 45 C.F.R. 152.2, and a good list of qualifying immigration statuses can also be found at www.healthcare.gov/immigrants/immigration-status.  (HSRI will use the same immigration eligibility rules as healthcare.gov.)

The list of eligible immigration statuses for HSRI is quite broad.  People who do not have legal status (such as those who entered the country without authority, or those who overstayed their visa) are not eligible.  Tourists and other visitors are also not eligible.  But practically speaking, most people who have immigrated here legally and are not undocumented will be eligible.

Two key points to keep in mind:

  • Unlike under Medicaid rules that require a five-year waiting period for many lawful permanent immigrant adults, there is no five-year waiting period before an immigrant is eligible to enroll in a QHP through HSRI.
  • It is not enough to know simply whether the applicant has an employment authorization card (or “work permit”).    Immigration status and work permits are two different concepts.  If an applicant only discloses that she has a work permit, more questions must be asked to determine that applicant’s immigration status.
  • There are some immigrants with work permits who are not eligible to enroll in a QHP through HSRI.  One example would be an immigrant present under the deferred action for childhood arrivals process, popularly called “DACA.”
  • There are also immigrants who cannot get work permits, but are eligible to enroll in a QHP through HSRI.  One example would be the holder of an R-2 visa, which are issued to the spouses of certain foreign religious workers.

U.S. “nationals” are rare.  A “national” is most often is someone born in American Samoa or the Norther Mariana Islands who has elected to be treated as a U.S. national rather than as a citizen.

Incarceration Status

To be eligible to enroll in a QHP through HSRI, an applicant must not be incarcerated, other than incarceration pending disposition of charges.  This means that pre-trial detainees (arrested but waiting for trial) are not considered incarcerated.  Those on home confinement, parole, probation, or court ordered substance abuse treatment are also not considered incarcerated for this purpose.

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