Medical Support & The Affordable Care Act

Transcription

1 Medical Support & The Affordable Care Act

2 Your Presenters Barb Saunders, HMS Kathy Sokolik, OCSE Michael Wright, Jim Fleming, ND Our Moderator Medical Support & ACA Background The judiciary What do we do now?

3 The Affordable Care Act: Medical Support Policy Implications Kathy Sokolik, Sr. Strategist OCSE, Central Office

4 Overview Summary of relevant provisions in the Affordable Care Act Recap of OCSE policy guidance Alignment with the ACA Future considerations

5 Parents and children have access to new, affordable coverage options State marketplaces provide Premium Tax Credits and Cost Sharing Subsidies Larger employers share responsibility for offering health care coverage. State option to expand Medicaid coverage to those with MAGI below 138% of poverty.

6 Parents are responsible for covering themselves and their tax dependents. Parents may meet this responsibility through employer-sponsored coverage, Medicaid, CHIP, Marketplace coverage, TriCare, and other plans. The parent who can claim the child as a federal tax dependent is responsible for demonstrating that the child has coverage. Exceptions and exemptions exist.

7 Parents are exempt from this responsibility if: All coverage options exceed 8% of household MAGI Income is below the federal tax filing threshold Member of an Indian tribe Only 1 gap in coverage that lasts less than 3 months in a year Religious exemptions defined by IRS Hardship as defined by the Secretary of HHS

8 Parents are exempt from this responsibility if: They experience a hardship as defined by the Secretary of HHS. Marketplaces will exempt a child: for whom a party other than the party who expects to claim the child as a tax dependent is required by court order to provide medical support, and who is not eligible for Medicaid and CHIP must show evidence of ineligibility.

9 The Affordable Care Act does not amend Title IV-D. Child support agencies still have the same medical support responsibilities under statute. Employers medical support responsibilities have not changed. However.

10 OCSE Policy Since ACA AT-10-02: Holding States Harmless from Penalties for Failure to Comply with Medical Support Final Rule State Plan Requirements AT-10-10: Increasing State Flexibility to Improve Interoperability with Medicaid & CHIP PIQ-12-02: Partnering with other programs, including outreach, referral, and case management activities IM-14-01: Medicaid Referrals to the IV-D Agency

11 AT-10-02: States Harmless from Penalties State IV-D agencies will not be penalized if OCSE is unable to certify that the state IV-D agency is in compliance with federal medical support rules. Audits of medical support data are temporarily suspended. Must continue to provide medical child support enforcement services in compliance with statutory requirements

12 AT-10-10: Increasing State Flexibility. States Can 1. Update medical support policies to enhance collaboration with Medicaid and CHIP to improve enrollment of eligible children includes the option to define medical support to include private health insurance as well as other health care coverage such as Medicaid, CHIP, and other state coverage plans, and cash medical support; and/or 2. Otherwise update medical support guidelines, including modifying the definition of reasonable cost ; and/or 3. Continue current and planned policies and practices Must continue to provide medical child support enforcement services in compliance with statutory requirements

13 PIQ-12-02: Partnering Some ways Child support programs can increase health care coverage: Provide information about, applications for, and effective referrals to Medicaid, CHIP, and Exchanges/Marketplace Provide information to CHIP and Medicaid to assist in enrollment. Develop Child Support referral policies for families who receive Medicaid, and child support education and outreach for families whose children are on CHIP Train judges, attorneys, and other Child Support staff on health care coverage options

14 PIQ-12-02: Partnering Refer noncustodial and custodial parents to Medicaid, Marketplace, and other health care Collaborate with Medicaid and CHIP to connect children to health coverage Review and modify guidelines regarding medical support

15 IM-14-01: Medicaid Referrals Child support programs in some states may receive more Medicaid referrals overall and in particular may receive more inappropriate referrals; - or receive fewer or no referrals. State child support and Medicaid agencies should work together to define referral criteria to ensure only appropriate Medicaid cases are referred to the child support agency. There is no requirement for the state Medicaid agency to refer all Medicaid cases to the child support program. While establishing or updating Medicaid referral policies, States should consider cost effectiveness, safety, and the desired child support outcomes for the family.

16 Aligning with the ACA

17 OCSE Fact Sheet Series The Fundamentals Who can apply? Medicaid Plan Adequacy Affordability Premium Tax Credits & Cost Sharing Tribal Considerations IRS Considerations Employer Questions To Come: Intergovernmental Considerations

18 Aligning with ACA Assure that the parent who is responsible for providing coverage is the same parent who claims the child as dependent on their federal tax return.

19 Aligning with ACA Define medical support to exclude coverage that is not considered minimum essential coverage under the ACA. State insurance law may already address this.

20 Aligning with ACA Define medical support to include Medicaid, CHIP, and Marketplace coverage. Marketplace will assess eligibility for: Medicaid, CHIP, and premium tax credits. If a child is Medicaid- or CHIP-eligible, their parents can t get subsidies for Marketplace coverage. If a child is Medicaid- or CHIP-eligible, their parents can t get a medical support hardship exemption.

21 Update the definition of reasonable cost. Aligning with ACA Under the Affordable Care Act s individual responsibility requirements, coverage is not considered affordable if the premium is more than eight percent of household income. Marketplaces use a sliding scale to determine what individuals under 400% FPL should contribute for coverage. If income is below the federal tax filing threshold, household is exempt from the requirement to have coverage.

22 What s next? Computer-Based Training Current Medical Support Policy An Overview of the Affordable Care Act Webinar Series: Aligning Medical Support with the Affordable Care Act Order-setting practices Affordability/Reasonable Cost Medical Support Enforcement Medicaid & CHIP considerations Intergovernmental considerations

23 Jennifer Burnszynski, Director Division of Program Innovation Office of Child Support Enforcement (WA DC) Kathy Sokolik, Senior Strategist Division of Program Innovation Office of Child Support Enforcement (CA)

24 ACA, the Courts and Guideline Studies Michael Wright, Supervising Attorney/Program Manager Judicial Council of California

25 ACA and the Courts -Enactment of ACA required courts to immediately deal with order setting practices in a new environment -Courts needed working familiarity with ACA provisions that intersected with existing child support guideline and medical support order laws -Courts needed to be aware of the conflicting provisions of ACA and existing state law and policy -Courts needed to adjust decision-making process to take into account differential impacts of alternative orders in light of ACA/potential for unintended consequences

26 Some Approaches to Make It Happen CSDA Affordable Care Act Workgroup Included representative of the judicial branch Gap analysis Recommendations Judicial Branch Title IV-D Annual Training Conferences ACA and Family Law Webinars for judges Ongoing ACA Judicial Branch Focus Group Ongoing liaison activities with state DCSS and CSDA legal practices workgroups

27 Developing a Consensus on the Court s Role -Need to provide a cogent explanation to parties when ACA and child and medical support do not align (examples: you can t order me to provide health insurance; she has the dependency exemption and the obligation under ACA) -Provide general ACA information and referral to the public using the courts (Covered California brochures with phone numbers/websites) -Develop issues awareness in the private family law bar and expectations of the types of new information/evidence the court needs to make CS and MS orders -Identify areas where judicial branch consensus can be reached on court order setting practice in light of ACA

28 Building on Specific Areas Identified in the Gap Analysis Dependency Tax Exemption Coverage Source ACA Affordability Coverage Gaps Tax Penalty Expanded MediCal Premium Tax Credits & Cost Sharing

29 Key Issues Identified by Judicial Program Partners -How to treat individual shared responsibility payment (tax penalty)? -How to treat any premium tax credit? -Impact of allocating dependency exemption; maximizing support strategies v. aligning with ACA rules. -Availability of information to ensure that actual cost of medical insurance for parents and children is included in the support calculation -Ordering one or both parents to provide health insurance coverage Inquiring and incorporating parent agreements

30 What has worked? Having recognized experts available to provide the ACA overview & provide multiple opportunities for exposure Develop key judicial branch stakeholders with expertise who can provide leadership role Sorting through the enormous volume of materials to find key tool kits to assist judicial decision-making Working through common hypothetical scenarios

31 State Child Support Guideline Review: Setting the Stage for an ACA Policy Discussion Opportunity to assess legislative policy changes to better align ACA and child support guidelines Provide factual information and research in support of the discussion regarding policy changes Provide the ACA background context Delineate interplay between state and federal policy-making Caveat: Don t get ahead of the parade

32 Identify Your Existing Guideline Model Income Shares Model Treatment of Costs for Health Insurance Premiums (Deduction from income vs. allocating costs) Treatment of Unreimbursed Health Insurance Cost Either or both parents may be ordered to provide coverage

33 Identifying Alternatives and Assessing Impacts Presumption that all alternatives have pros and cons Need to Comply with Existing Federal Requirements Current definition of reasonable cost for dependent health care coverage vs. ACA affordable care standard. To align or not align? Cost Recovery, Cost Avoidance, or Who Cares providing research Cash medical options Allocating uninsured health care expenses in Guidelines Consideration of Insurance Premiums in Guidelines Expanded Medicaid and cash medical

34 Conclusions -Assessing the potential intersections and inconsistencies between state CS guidelines and ACA can be beneficial to the program -Even if there are policy changes to Title IV-D s role in medical support, most child support guidelines, under current law, continue to incorporate health insurance related factors -Gap analysis can help to identify limited specific areas where ACA may impact any given guideline -Focus of analysis and impacts may vary depending on the CS guideline model -ACA implementation may present states with opportunity to re-evaluate Guidelines treatment of health insurance related factors and program policy options taken under existing federal medical support regulations -Prepare but don t get ahead of the policy parade

35 A State Perspective What in the Heck do we do now? Jim Fleming, Director North Dakota Dep t of Child Support

36 Three Constants Medicaid Referrals Medical Support Locate Source

37 Pre-ACA Medicaid Referrals Drought or flood, the variety of previous practices Cooperation or the lack thereof Case closure not fast, not easy Gateway to IV-D for poor families Level of automation

38 Pre-ACA Medical Support Employer provided Indeterminate/contingent orders CP carries if, otherwise NCP carries if available through employer or otherwise at reasonable cost Lots of time, little return Shortcomings of cash medical

39 Pre-ACA Locate Source Lots of identifying information easy to match Valuable income data

40 Post-ACA Medicaid Referrals Drought or flood Flood: anonymous referrals Drought: substantial drop in caseload Level of automation Outreach to potential IV-D families?

41 Post-ACA Medical Support Diminished role of employer-provided coverage Establishment stems more from the 1040 than an order by a court or administrative tribunal Enforcement is more a matter for IRS than IV-D Impetus for coverage is found in tax credits and subsidies rather than leverage by IV-D

42 Post-ACA Locate Source How can we have Medicaid expansion and yet get less information? New eligibility systems

43 Time to Revisit Priorities 1. Cost recovery existing collection rates 2. Cost avoidance does a family really have an option to decline Medicaid or CHIP? 3. Get coverage who cares who pays for it?

44 The New Role of IV-D Do we align with the Internal Revenue Code and IRS, or take our own path? Find the path of least resistance We already have enough work to do

45 Ongoing decisions If I could start from scratch, I would How much time to invest in cost recovery? Can lost revenue be offset by savings of time and reallocating resources? The Silver Lining optimal referrals Good information only from those willing to cooperate If child is eligible for CHIP or Medicaid, leave it alone and look at cash medical

46 Ongoing decisions If I could start from scratch, I would Start now or wait for NPRM? Looking ahead to customer service in 2015 and the hardship process Align reasonable cost and affordable coverage Align acceptable coverage with comprehensive and accessible When and how do you allow NCP to apply for Medicaid for the child or make the CP apply?

47 Ongoing decisions If I could start from scratch, I would Who gets the tax deduction, and what is IV-D s role? Priority for CP coverage? Cash Medical or not? How to deal with existing orders compared to new ones?

48 Employer-provided Coverage in a post-aca world The dilemma of 9.5% cost for employee PLUS cost of adding family How much can we avoid employer-provided Still might be the best coverage solution for the child You can use a NMSM if appropriate easier said than done

49 Medical Support Scenario #1 The noncustodial parent is employed, but has no offer of employer-sponsored medical insurance. The custodial parent is employed, and has no offer of employersponsored medical insurance. The child is covered by Medicaid.

50 Medical Support Scenario #1 Analysis Does IV-D want this referral? Cooperation? TANF recipient? Is there an existing court order? Who gets, or should get, the tax exemption for the child? Role of IV-D in deciding who gets the exemption

51 Medical Support Scenario #2 The noncustodial parent is employed and has an offer of affordable employer-sponsored medical insurance for himself and his child. The custodial parent is employed, and has no offer of employersponsored medical insurance for herself or her dependent. The custodial parent claims the child as a dependent for federal tax purposes. The child is covered by a Marketplace plan, purchased by the custodial parent using Premium Tax Credits available to her, based on the size and income of her household.

52 Medical Support Scenario #2 Analysis Look for the status quo how is the child insured right now? Does there need to be alignment with the tax exemption? A NMSN is not helpful or appropriate in all cases What about cash medical from the NCP? Is there an existing order, and if so, what does it require?

53 Medical Support Scenario #3 The noncustodial parent is employed, and has employer-sponsored medical insurance for himself and his child. It is adequate and affordable. The noncustodial parent s household s medical insurance costs are less than 8% of the household s modified adjusted gross income, so they won t be exempt from any shared responsibility payment should they go without coverage. The noncustodial parent claims the child for federal tax purposes. The custodial parent does not have employer-offered medical insurance. The child is ineligible for Medicaid or CHIP. The custodial parent wants to switch the child s medical insurance from the noncustodial parent s employer-sponsored plan, to a Marketplace plan that would be more convenient to use. The support order includes the provision that medical support for the child is to be provided by either or both parents.

54 Medical Support Scenario #3 Analysis Status quo dad is covering the child Dad currently claims the tax exemption Consider the stability of employment for each parent How much do we defer to wishes of CP? If it ain t broke, don t fix it. If the role of IV-D is to get the kid covered, are there services to provide here? Dueling coverage only involves 2 gunfighters, not 3

55 Medical Support Scenario #4 The noncustodial parent is a tribal member. His tribe has purchased medical insurance for him through the Marketplace. He is employed, but does not have access to employer-sponsored medical insurance. The custodial parent and child are both covered by Medicaid. The custodial parent claims the dependency deduction for the child, for federal tax purposes.

56 Medical Support Scenario #4 Analysis Does IV-D want this referral? Is there an existing court order?

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