Transcript Cost-sharing reductions

Medicaid & Marketplace Updates
Kyle Fisher
[email protected]
October 2015
Session Topics
2
Medicaid
 Traditional Medicaid Expansion

Transition from Healthy PA to HealthChoices
 New Expansion Category
 Immigrant Coverage Options
Marketplace
 Cost-Sharing Reductions
Medicaid
3
TRADITIONAL
MEDICAID EXPANSION
4
Phase Out of Healthy PA
5
 Gov. Corbett’s alternative Medicaid expansion
created new managed care delivery system


Effective January 1st, 2015
Called the Healthy PA Private Coverage Option (PCO)
 Gov. Wolf moved to a simpler, traditional expansion
under the “HealthChoices” managed care system:
 Two phases: PCO -> MCO


June 1st - 121,000 enrollees transferred
Sept. 1st – 79,000 enrollees transferred
Medicaid Expansion
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 PCO to MCO transition completed September 1st
 Private Coverage Option now defunct
 “Adult” benefit package implemented 4/27/15
 DHS intends to withdraw the Healthy PA 1115
waiver by Sept. 30


Notice given to CMS on March 10, 2015 (6 months req.)
None of the other Healthy PA reforms, such as premiums or
work incentives, go into effect
Delivery Systems
7
What is HealthChoices?
 Long established Medicaid managed care program
 Expanded statewide
 “New West” in fall 2012; “New East” in spring 2013
 Separate physical health & behavioral health systems
 Known as behavioral health “carve-out”
 Single BH MCO in each county
 Covers most adults, not dual-eligibles (on PH side)
 Until, at least, MLTSS proposal implemented
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Medicaid Eligibility
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NEW ADULT/EXPANSION
CATEGORY
10
Newly Eligible Adults
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 Adults age 19-64
 Income under 138% FPL
 Cannot qualify for Medicare
Household
of 1
Household
of 2
Household
of 3
Household
of 4
$1,354
$1,832
$2,311
$2,789
138% FPL
(2015)
monthly
 No asset test
Monthly vs Annual Income
12
 Medicaid uses “point-in-time” eligibility
 Essentially monthly
 Unlike HealthCare.gov, which uses annual income
 But, if monthly income is over 138% FPL, and
 Expected annual income is less than 138%
 Because income expected to decrease or end

Such as unemployment comp. & seasonal employment
 Then CAO should use expected annual income
 See policy clarification PMA17446312 (2/2015)
Medicaid Eligibility Basics
13
 3-step analysis for each person
1)
What category does the person fit in?
2)
What is the person’s household size?
3)
Is the person under the monthly income limit for
that category and household size?
 4th step for immigrants
1)
What is the person’s immigration status and does it
meet the relevant Medicaid standard?
MAWD
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Medical Assistance for Workers with Disabilities
 Underused category
High income & resource limits
 Minimal work requirement
 Many who do not consider themselves “disabled” meet
the MAWD disability standard

 Age 16-64; requires 5% premium

Based on recipient’s income only, after disregards
 see manual on PHLP website
Medicaid Eligibility
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IMMIGRANT COVERAGE
OPTIONS
Immigration Status Overview
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 “Lawfully Present”
 Medicaid standard for:
 Children
 Pregnant women
 “Qualified”
 Plus five year waiting period, for most immigrants
 More narrow than “lawfully present”
 Medicaid standard for:
 Adults
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The 5 year bar
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 Waiting period runs from date the person obtains
“qualified” status
 Does not apply to certain immigration categories
(generally humanitarian):
 Refugees & Asylees (even if later become LPR)
 Persons granted withholding of deportation
 Cuban/Haitian entrants
 Iraqi or Afghan special immigration status
 U.S. veterans or active duty military, spouses, or children
GA-related Medical Assistance
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For very low-income immigrants subject to the ‘5 year
bar’ and still in waiting period. This is state-funded
MA that covers about 4,000 immigrants. GA/MA has
no 5 year bar.
Category:
1. Temporary Disability

Employability Assessment Form– Box 3
2. Health-Sustaining Medications form, or
3. Age 59+
GA/MA Income Limits
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GA-related MA (if disability/need for Rx)
Household
Income Limit
(monthly)
Resource
Limit
HH of 1
$205
$250
HH of 2
$316
$1000
Income limits vary slightly by region, see MAEH 368 Appendix A
GA-related MA (if age 59+)
Household Size Income Limit
(6 months)
Resource Limit
HH of 1
$2,550
$2,400
HH of 2
$2,650
$3,200
HealthCare.gov
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 Special rule for immigrants who do not qualify for
Medicaid because of immigration status

No income floor for PTC - Income: 0 - 400% FPL
 To qualify for premium tax credits
 Normally an income “floor”:
 Income: 138 - 400% FPL
Adults
138% poverty
1 person
2 people
3 people
$16,248
$21,984
$27,310
Emergency Medical Assistance
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What options exist for someone who doesn’t meet the
“qualified” or “lawfully present” standards?
 Emergency Medical Assistance
 no immigration status required
 must be otherwise eligible (meet category & income req.)
 Limited to time period of emergency condition
Emergency Medical Assistance
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 Emergency Medical Assistance
 An emergency medical condition is a medical condition with
acute symptoms of such severity including severe pain, that
without immediate attention, the result may be:
The patient’s health is in serious jeopardy.
 Serious impairment to bodily functions.
 Serious dysfunction of any body organ or part.

 Detailed letter from physician is key
(see MAEH 322)
Marketplace
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COST-SHARING REDUCTIONS
Cost-Sharing Reductions
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 2.2 million 2015 Marketplace enrollees (under 250% FPL)
failed to take advantage of Cost-Sharing Reductions
*Avalere Health Analysis
Marketplace Basics - Subsidies
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Who qualifies?

Premium Tax Credits
Income between 100-400% FPL
 Cannot be eligible for other “minimum essential coverage”
 Cannot be offered “affordable” (<9.5%) employer-based coverage

 Cost-Sharing
Reductions
Income between 100-250% FPL
 Eligible for premium tax credits
 Enroll in Silver-level plan

Cost-Sharing Reductions
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Why would someone forego CSRs?
 Lower premiums!
 Essential that they understand the trade-off:
 Premiums vs Cost-sharing
 CSR harder to understand than APTC
 PTC are a concrete number
 CSR vary by plan, operate in the background
Types of Plans – “Metal Levels”
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 Highest Premiums &
Lowest Cost Sharing
 Lowest Premiums &
Actuarial Value. The percentage of
total average costs that a plan will
cover.
Highest Cost-Sharing
*before CSR
Cost Sharing Reductions
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How do Cost Sharing Reductions work?
Three levels of CSR based on income
 Paid directly to the Silver plan
 Seamlessly reduces enrollee’s out-of-pocket charges

Actuarial
Value
Standard
Silver – no
CSR
100-150%
FPL
151-200%
FPL
201-250%
FPL
70% AV
94% AV
87% AV
73% AV
Cost Sharing Reductions
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 Average cost-sharing at each CSR tier:
Kaiser Family Foundation
Types of Plans – “Metal Levels”
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Resources
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 DHS Medicaid Expansion Website

www.HealthChoicesPA.com
 Medical Assistance Eligibility Handbook

http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm
 Avalere Health Analysis

http://avalere.com/expertise/managed-care/insights/more-than-2-million-exchangeenrollees-forgo-cost-sharing-assistance
 PHLP Helpline: 1-800-274-3258

[email protected]
 PHLP Medicaid Eligibility Manual

http://www.phlp.org/wp-content/uploads/2015/02/Eligibility-Manual-2015.pdf