SYSTEM INTERACTIONS & PATHWAYS TO INSURANCE
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1 SYSTEM INTERACTIONS & PATHWAYS TO INSURANCE
2 Systems & Pathways Desired Outcomes 1 - Develop a basic understanding of the key components and interactions of Colorado s interoperable insurance affordability programs. 2 - Increase familiarity with how ACA elements underpin the system being developed in Colorado. 3 - Be familiar with Real Time Eligibility, how it works, and when it doesn t, what happens. 4 - Be able to explain how members of a given household might enroll in differing programs and receive differing levels of insurance affordability assistance.
3 Opening Doors: Any Door Is The Right Door Community Partners County Staff Service begins at the first point of contact! Medical Assistance Sites PEAK Connect for Health Colorado
4 ACA Requirements No wrong door to enrollment A single streamlined application for insurance affordability programs (IAPs) Regulations require the following: Eligibility determinations to be based on new income and household methodologies for all IAPs Individuals must first be determined ineligible for Medicaid/CHP+ before they are determined for Marketplace financial assistance
5 Medicaid Financial Thresholds PATHWAYS TO INSURANCE & SYSTEM INTERACTIONS
6 Coverage Options by Income PATHWAYS TO INSURANCE & SYSTEM INTERACTIONS
7 Insurance Affordability Program (IAP) Application Doors All applications must be receivable via: Online (PEAK/C4HCO) Telephone In-Person Mail Anywhere with Internet County & MA County & MA County Assistance Sites HCPF Assistance Sites C4HCO C4HCO MAXIMUS
8 Connect 4 Health Colorado
9 ACA Goals for Verification Maximize automation through data sources Minimize need for documentation; reduce administrative burden Simple and transparent process for consumers Ensure program integrity
10 Interoperability Electronic Verification Single Streamlined Application (SSAp) Online PEAK/C4HCO Phone/ In Person Paper Rules Engine State &/or Federal Data Sources Example Electronic Interfaces IRS Internal Revenue Service (income, household size) SSA Social Security Administration (citizenship, incarceration status, identification) SAVE Systematic Alien Verification for Entitlements (residency) DMV Department of Motor Vehicles (identity)
11 Self-Sufficiency & Insurance Affordability Application Types Application for Public Assistance or Single Purpose Application (SPA) Application for Health Coverage & Help Paying Costs or Single Streamlined Application (SSAp) Used to apply for Food, Cash, Adult Financial and any combinations that also include Medical Assistance Programs Used to apply for both Medical Assistance and Marketplace Financial Assistance As of 10/1 includes a one page addendum, Additional Information Needed for use when combination application includes Medical Assistance Program This form is currently available on the HCPF website, along with information for its use
12 PEAK Application
13 What is Real Time Eligibility (RTE)? A client s application for Medical Program Assistance may receive immediate approval or denial when they submit their application via PEAK and it is successfully verified through electronic interfaces for MAGI Programs. RTE will provide online notification and printed correspondence of determination; dating to time of application When interfaces are not able to verify submitted information the application exceptions and moves to manual process When a paper application is submitted, or an online application exceptions, the manual process is activated Electronic interfaces are also used for paper application verifications RTE is not available
14 Real Time Eligibility MAGI Medical Assistance ONLY A Real Time Eligibility determination is only available via submitting an application on PEAK Combination applications may receive RTE for Medical Program and the Food, Cash, Adult Financial and non-magi medical portion will be manually processed by the county of residence Doorways to Real Time Eligibility PEAK New Client New clients submit an application PEAK Manage My Account Existing Client In Report My Changes the client may apply by adding Medical Assistance Program C4HCO Client requesting financial assistance Application will be processed for Medical Assistance eligibility 1 st
15 Real Time Results
16 Medical Assistance Program Denial & Referral to Connect for Health Colorado
17 Newly Eligible 1/1/2014 Communication
18 Application Processing Local County Office Food and Cash Assistance PEAK applications Combination cases that include Medical Assistance that exception to the manual process Paper applications submitted to the county Change Reports) Medical Vendor The majority of Medical Assistance ONLY applications entered through PEAK that exception to manual process Medical only paper applications submitted to the medical vendor
19 Wrap-Up 1 - Develop a basic understanding of the key components and interactions of Colorado s interoperable insurance affordability programs. 2 - Increase familiarity with how ACA elements underpin the system being developed in Colorado. 3 - Be familiar with Real Time Eligibility, how it works, and when it doesn t, what happens. 4 - Be able to explain how members of a given household might enroll in differing programs and receive differing levels of insurance affordability assistance.
20
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