Transcript Health Care Review and Update

Health Coverage
under the
Affordable Care Act
John S. Whitelaw
Kristen M. Dama
October 23, 2013
The Affordable Care Act (ACA)
• Three primary prongs of health coverage:
• Employment-based coverage
• New rules about who must be covered and what benefits must
be provided – not covered in this training.
• Private coverage through the MARKETPLACE
• Medicaid
• (Medicare is still an option – no change to coverage)
2
Most Important Information
• Federal enrollment web site:
www.healthcare.gov
• Federal enrollment hotline:
1-800-318-2596
• Local help is available, too:
localhelp.healthcare.gov
3
What’s New Under the ACA?
• The Affordable Care Act (ACA) creates a new online
“shopping center” for health insurance, called the
Marketplace.
• The Marketplace is where individuals go to buy
private health insurance, and to receive financial
help to offset costs.
4
What’s New Under the ACA?
• Open enrollment runs from October 1, 2013 to
March 31, 2014.
• People may apply for Medicaid/CHIP at any time of the
year.
• People may apply for insurance through the
Marketplace outside open enrollment if they have a
“qualifying life event”:
•
•
•
•
•
Birth of a child
Death of household member
Change in employment
Divorce or marriage
Move in or out of state where they had coverage
5
What’s New Under the ACA?
• Coverage through the Marketplace is available
beginning on January 1, 2014.
• Tax credits are available to help people between
100% and 400% of the poverty level pay for
insurance premiums through the Marketplace.
• Cost-sharing subsidies are available to people
between 100% and 250% of the poverty level to
pay for copayments and other costs.
6
What’s New Under the ACA?
• Medicaid is available for some adults below 100%
of the poverty level (more on this later).
• Medicaid or CHIP is available for children between
0% and 400% of the poverty level (more on this
later).
• States can expand Medicaid to cover almost
everyone below 100% of the poverty level –
Pennsylvania has not yet taken this option.
7
What’s New Under the ACA?
• New eligibility rules for financial help through the
Marketplace, Medicaid, and CHIP:
• Uses Modified Adjusted Gross Income (MAGI)
methodology, based on tax rules.
• Alters current eligibility rules for many Medicaid
applicants and recipients.
• NOTE: No Medicaid eligibility changes for
individuals with disabilities and seniors (Healthy
Horizons, MAWD, Waiver and Nursing Home
programs).
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Three “Buckets” of Coverage
• Traditional Medicaid (a.k.a. Medical Assistance or
MA)
• Medicaid and CHIP under MAGI Rules
• Private insurance through the Marketplace
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Medicaid
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Traditional Medicaid
• The traditional Pennsylvania Medicaid program
provides free or very low-cost health insurance to lowincome, low-asset Pennsylvanians who meet certain
“categorical” requirements for eligibility.
• While Medicaid rules will change for most current
Medicaid recipients, they will stay the same for
individuals with disabilities and seniors.
• Programs include Healthy Horizons, MAWD, Waiver,
and Nursing Home programs.
11
Healthy Horizons Medicaid
• Individuals may receive Healthy
Horizons if they are 65 and older or
have disabilities that will last for
twelve months or longer.
• $2,000 resource limit for single
adults; $3,000 for couples and
families.
2013 Income Limits* –
100% FPIG
1
$ 958
2
$ 1,293
* $20 income disregard; $65
plus 50% earned income
disregard.
12
Medical Assistance for Workers with
Disabilities
• Individuals with too much income or
resources for Healthy Horizons may
receive Medical Assistance for Workers
with Disabilities (MAWD) if:
• They have disabilities that last for twelve
months or longer.
• AND they work at least one hour per
week.
• They will be required to pay a premium
based on income (5%) – usually $50 to
$100 per month.
2013 Income Limits* –
250% FPIG
1
$ 2,394
2
$ 3,232
* $20 income disregard; $65
plus 50% earned income
disregard.
• $10,000 resource limit for everyone.
13
GA-Related Medical Assistance (Last
Resort)
• Individuals with very little income may
receive state funded Medical Assistance if
they:
• Have short-term disabilities (lasting longer
than 30 days but less than twelve months).
• Are domestic violence survivors (9 months
in a lifetime).
• Are in active drug and alcohol treatment (9
months in a lifetime).
• Are caring for unrelated children or
individuals with disabilities.
• Need health-sustaining medications.
Income Limits*
1
$ 205
2
$ 316
3
$ 403
4
$ 497
5
$ 589
6
$ 603
* $250 resource limit for
single adults; $1,000 for
everyone else.
14
Medicaid and CHIP under MAGI
• MAGI = Modified Adjusted Gross Income methodology for
calculating eligibility.
• Applies to Medicaid in non-elderly, non-disabled/GA-related
categories:
• Children.
• Pregnant women.
• Parents and related caretakers.
• Non-disabled, non-GA-related adults under 65 in Medicaid
expansion states will use MAGI rules (not in Pennsylvania).
15
MAGI Analysis for Medicaid and CHIP
• Based on tax rules.
• Two steps:
• Who is in the household?
• What income counts toward eligibility?
16
Step One: Household Composition – Personby-Person Analysis
• Analysis is based on expected filing status for the
tax year of application or renewal.
• Every person is assigned one of three categories – it
is a person-by-person analysis.
• There is no such thing as group/family status!
17
Household Composition
• Three categories of individuals:
• Tax Filer: a person who expects to file a tax return.
• Tax Dependent: a person who expects to be claimed by
another taxpayer.
• Non-Filer: a person who does not expect to file a tax
return and does not expect to be claimed by another
taxpayer.
18
Household Composition
• For Non-Filers, the household is generally
parents, step-parents, and children.
• Some Tax Dependents are treated as Non-Filers
for Medicaid – the rules can get complicated.
• Complicated scenarios:
•
•
Children living with non-parent relatives.
Children living with unmarried parents.
19
Step Two: Income
• Household income = the sum of MAGI of all
individuals in the household, as defined in Step
One.
• The income of children and Tax Dependents is not
counted unless they are expected to file a tax
returns.
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Income
• Income that is counted:
•
•
•
•
•
•
•
•
Wages and tips
Pensions and annuities
Unemployment compensation
Self-employment income
Dividends and taxable interest
Alimony received
Rent received
Social Security
21
Income
• Income that is not counted:
•
•
•
•
•
•
SSI
TANF
Worker’s compensation
Veteran’s benefits
Child support
Gifts
22
Income: MAGI vs. Traditional
Medicaid
• MAGI income counting rules differ significantly:
•
•
•
•
Some income that is currently counted is no longer
counted (e.g., child support, worker’s compensation
benefits, veteran’s benefits, many public benefits).
New household rules result in changes in whose
income is counted (e.g., step-parents).
Most income disregards and deductions are
eliminated.
Current income limits were changed.
23
New Income Limits
Pregnant Women &
Children under 1 –
215% FPL
Children 1-5 –
157% FPL
Children 6-18 – 133%
FPL
Parents –
33% FPL
Monthly
5% Dis *
Monthly
5% Dis *
Monthly
5% Dis *
Monthly
5% Dis *
1
$2,059
$103
$1,504
$75
$1,274
$64
$316
$16
2
$2,779
$139
$2,030
$102
$1,720
$86
$427
$21
3
$3,500
$175
$2,556
$128
$2,165
$108
$538
$27
4
$4,220
$211
$3,082
$154
$2,611
$131
$648
$32
* DPW’s calculation of the 5% disregard is incorrect, and may change in the coming months.
24
No Asset Test for MAGI Medicaid
• Resources do not matter for individuals who qualify
for MAGI Medicaid.
• Resource rules still apply for seniors, individuals
with disabilities, and individuals who qualify for GArelated MA.
25
Young Adults Aging out of Foster Care
• Regardless of income or assets, Medicaid is
available for individuals who:
• Are under age 26;
• AND are not otherwise eligible for or enrolled in
Medicaid;
• AND were receiving Medicaid in federal or state-funded
foster care on or after their 18th birthday.
26
Immigrant Eligibility for Medicaid and
CHIP
• The rules for immigrant eligibility for Medicaid do not change under the ACA.
• Lawfully present immigrants who are pregnant or children are eligible for Medicaid
without a wait.
• Certain other qualified immigrants – refugees, asylees, Cuban-Haitian entrants, and some
others – are eligible without a wait.
• Most other qualified immigrants must be lawfully present for five years to qualify for
federally funded Medicaid.
• Immigrants subject to the “five-year bar” may qualify for state funded Medical Assistance
if they meet the very low income limits.
• Otherwise, lawfully present immigrants who are not eligible for Medicaid because of their
immigration status, as well as undocumented immigrants, may qualify for Medicaid only if
they have an emergency medical condition.
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Who Is Left Out?
• Adults who are:
• Between the ages of 19 and 64;
• AND not disabled/GA-related;
• AND not pregnant;
• AND not parents or related caregivers with very low
incomes.
28
What Is “Healthy Pennsylvania”?
• Governor Corbett recently issued a plan to expand
coverage for some people under 100% of the poverty
level who would not otherwise qualify.
• Eligible people would be able to buy subsidized private
insurance through the Marketplace.
• The proposal would restrict coverage in key ways:
• Work requirements.
• Premiums for people over 50% of the poverty level.
• Limits on benefits.
29
Insurance through the
Marketplace
30
Insurance through the Marketplace
• Income tax credits and subsidies are available for
people over 100% of the poverty level who buy
insurance through the Marketplace and do not qualify
for Medicaid and CHIP.
• Advanced premium tax credits are available for people
with incomes up to 400% of the poverty level.
• Cost sharing subsidies are available for people with
incomes to up to 250% of poverty.
31
Insurance through the Marketplace
• To qualify for tax credits and subsidies, people must
file annual tax returns beginning with the 2014 tax
year (due April 15, 2015).
• Beware of scams: Tax credits and subsidies are only
available through the Marketplace, not through
private plans sold elsewhere.
32
Insurance through the
Marketplace
• Advance premium tax credits:
• Refundable tax credit.
• Payable in advance as credit toward monthly premium
payments.
• Similar to Earned Income Tax Credit (EITC).
• Cost sharing subsidies:
• Help from the federal government to pay for
copayments and deductibles.
• Supposed to be seamless for patients at sites of medical
treatment.
33
Insurance through the
Marketplace
• Tax credits and subsidies are based on expected
income and reconciled at tax time:
• Individuals will have to file taxes in 2015 for the 2014
enrollment year.
• They may owe money to the IRS if the subsidy was
overpaid.
34
Immigrant Eligibility for Insurance
through the Marketplace
• All lawfully present immigrants under 400% of the poverty guidelines
who are not eligible for Medicaid or CHIP may qualify for tax credits and
subsidies:
• Unlike in Medicaid, there is no five-year bar.
• Lawfully present immigrants under 100% of the poverty guidelines may qualify for
tax credits and subsidies if they do not qualify for Medicaid or CHIP.
• DACA-eligible individuals (childhood arrivals permitted to work under
President Obama’s Executive Order) and undocumented individuals are
not eligible for tax credits and subsidies, and they may not buy full-cost
insurance through the Marketplace.
35
Insurance through the Marketplace
• Premium tax credits and subsidies are calculated
based on MAGI methodology:
• Households = tax filing units.
• All members of a tax filing unit have the same household
size – person-by-person analysis is not necessary.
• Simpler than Medicaid!
• Benefits are renewed once per year.
36
Income Guidelines for Insurance
through the Marketplace
HH = 1
Income
% Income Paid
HH = 2
Income
% Income Paid
HH = 3
Income
% Income Paid
HH = 4
Income
% Income Paid
< $15,280
$15,281 $17,240
$17,241 $22,980
$22,981 $28,730
$28,731 $34,470
$34,471 $45,960
> 45,960
2%
3%
4%
6.3%
8.1%
9.5%
Full Amount of
Premium
< $20,630
$23,631 $23,270
$23,271 $31,020
$31,021 $38,780
$38,781 $46,530
$46,531 $62,040
> $62,040
2%
3%
4%
6.3%
8.1%
9.5%
Full Amount of
Premium
< $25,970
$25,971 $29,300
$29,301 $39,060
$39,061 $48,830
$48,831 $58,590
$58,591 $78,120
> $78,120
2%
3%
4%
6.3%
8.1%
9.5%
Full Amount of
Premium
< $31,320
$31,321 $35,330
$35,331 $47,100
$47,101 $58,880
$58,881 $70,650
$70,651 $94,200
> $94,200
2%
3%
4%
6.3%
8.1%
9.5%
Full Amount of
Premium
37
Insurance through the Marketplace
• Bronze, Silver, Gold, and Platinum plans are
available with differing levels of coverage:
• Bronze: lowest monthly premium/highest out of pocket
costs.
• Platinum: highest monthly premium/lowest out of
pocket costs.
38
Insurance through the Marketplace:
The Silver Plan
• Premium tax credits are based on the Silver plan,
but they can be used to purchase any level plan.
• Cost sharing subsidies are only available in a Silver
plan.
39
Essential Benefits Package
•
The ACA requires insurance sold through the
Marketplace to provide coverage in ten categories:
•
•
•
•
•
•
•
•
•
•
•
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health
treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services
Chronic disease management
Pediatric services, including oral and vision care
40
Applying for Health Insurance
• If people apply on the Marketplace and are eligible for Medicaid
because they have disabilities, their applications will be sent to the
Pennsylvania Department of Public Welfare (DPW) and treated just like
new applications for Medicaid.
• If people apply on the Marketplace and are MAGI Medicaid or CHIP
eligible:
• If they apply between October 1, 2013 and December 31, 2013, their eligibility
information will be sent to DPW or the Pennsylvania Insurance Department
(PID), and they will be enrolled automatically (if DPW fixes a systems issue).
• If they apply on or after January 1, 2014, their applications will be sent to DPW
or PID for final determinations of eligibility.
• If people apply at DPW or PID but they are not eligible for Medicaid or
CHIP, their applications will be forwarded to the Marketplace.
41
Applying for Health Insurance
• To apply via the Marketplace:
• Online applications are available via:
• www.healthcare.gov
• 1-800-318-2596
• Separate paper applications are available for:
• Individuals who want financial help
• Individuals who do not want financial help
• Households (regardless of whether they want financial help)
• In person assistance (Navigators and Certified Application
Counselors) is available.
42
Applying for Health Insurance
• To apply via DPW or PID:
• There is a new paper application (PA 600 HC) – separate
from applications for SNAP and other benefits.
• COMPASS will not reflect the new rules until December
8, 2013.
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Applying for Health Insurance
• Under the ACA, electronic records are a primary
source of information:
• The Marketplace, DPW, and PID must search federal and
state databases for certain kinds of proof of eligibility,
like income and citizenship information.
• Other kinds of proof, like state residency, can be proved
by self attestation.
• DPW and PID will not have access to some income
information until at least June 2014, so many people will
still have to provide paper documentation of income.
48
Eligibility Determinations
• Written notice of eligibility decisions will be sent.
• Applicants who disagree with eligibility determinations
may appeal and request fair hearings:
• Appeal deadlines vary, but generally will be:
• 30 days for traditional Medicaid.
• 90 days for premium tax credits and cost sharing subsidies.
• 30 or 90 days for MAGI Medicaid and CHIP (rules are forthcoming).
• Because of these variations, it is very important to read
notices and pay attention to deadlines!
49
Renewing Health Insurance
•
For insurance through the Marketplace, MAGI Medicaid, and
CHIP, coverage is renewed once per year:
•
•
Coverage will be automatically renewed unless there are changes
that affect eligibility.
DPW and PID will send pre-populated renewal forms:
•
•
If the information is correct, the forms do not have to be sent back.
If the information is not correct, people must report changes.
•
Medicaid and CHIP recipients still must report substantial
changes in circumstances (e.g., changes in income, household
composition, or residence) throughout the year.
•
Seniors and individuals with disabilities still will be subject to
six-month Semi-Annual Reports under state law.
50
Questions?
51
Contact Us
• John S. Whitelaw:
• [email protected]
• (215) 227-2403
• Kristen M. Dama
• [email protected]
• (215) 981-3782
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