An Assister's Guide to Helping Adults with Disabilities

Transcription

1 Medicaid An Assister's Guide to Helping Adults with Disabilities Marketplace Medicare Mary Sweet, Outreach and Enrollment Specialist* Elizabeth Larsen, Law Clerk Legal Services of Eastern Missouri January 2016

2 Table of Contents I. Intersections Medicare, Medicaid and the Marketplace... 3 II. The Ins and Outs of MO HealthNet Non-Spenddown/Spenddown... 4 a. Qualifying for Non-Spenddown or Spenddown... 5 b. Non-Spenddown vs. Spenddown Coverage... 6 c. Meeting Your Spenddown... 6 d. Being Spenddown-Eligible vs. Having Spenddown Coverage... 7 III. Spenddown and the ACA... 8 a. Spenddown and Minimum Essential Coverage... 8 b. Choosing between the Marketplace and Spenddown... 9 c. Post Enrollment Documentation IV. Conclusion *Contact information: Mary Sweet, J.D., Outreach and Enrollment Specialist Marketplace Assistance Program Legal Services of Eastern Missouri (314) mcsweet@lsem.org 2

3 Although Missouri has not expanded its Medicaid program, low-income adults with disabilities have coverage options: Medicaid Marketplace Medicare This guide is for assisters to use when helping adult consumers with disabilities. The ADA defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity. The guide describes the Missouri Medicaid (MO HealthNet) Non-Spenddown and Spenddown programs as they apply to adults with disabilities. 1 The guide shows how these programs relate to Medicare and to the rules for health insurance under the Affordable Care Act (ACA). The guide offers tips for assisters to help consumers with disabilities sort through their coverage options in Missouri. I. Intersections Medicare, Medicaid and the Marketplace Adults with disabilities may not know how the rules for Medicare, Medicaid, and Marketplace eligibility work together. As assisters, it is important to clarify these relationships for consumers. 1 Children with disabilities are eligible for MO HealthNet for kids until they turn 19. Young adults 19 and over on Medicaid spenddown receive Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services up to age 21. 3

4 Medicare Consumers determined disabled by the Social Security Administration (SSA) are eligible for Medicare 2 years after they start receiving benefits Medicaid Consumers waiting for a disability determination or in the 2 year waiting periodfor Medicare may be eligible for Medicaid during that time Consumers can keep Medicaid (if they're still eligible) after they get Medicare Marketplace Consumers who are Medicare eligible cannot purchase insurance through the Marketplace or receive tax credits or cost-sharing reductions. Consumers who have Medicaid coverageare not eligible for tax credits or cost-sharing reductions through the Marketplace. II. The Ins and Outs of MO HealthNet Non-Spenddown/Spenddown MO HealthNet offers coverage to low-income adults who are elderly or blind, or have disabilities. Coverage for these groups is divided into two programs: Non-Spenddown and Spenddown. A spenddown is the amount of out- of- pocket medical expenses a Spenddown-eligible consumer must pay or incur each month before their coverage becomes effective for that month. Joe is 40 and single. He recently started getting $13,000/year in Social Security Disability (SSD) benefits. Joe has diabetes that went untreated and has some nerve damage in his hands, a recurring foot problem, and kidney problems. Joe has come to you for assistance in understanding his coverage options. Meet Joe 4

5 a. Qualifying for Non-Spenddown or Spenddown The first step is for the consumer to be determined to have a disability. If a consumer has already been determined disabled by the SSA when they apply for MO HealthNet, then they meet the definition of disability for MO HealthNet. MO HealthNet will determine if a consumer is disabled if the SSA has not made a determination. MO HealthNet follows the same standard for disability as the SSA. Consumers also must be under the resource limit to qualify for Non-Spenddown or Spenddown. Resources are property like a bank account, a home (other than the home the consumer lives in), or a retirement account. Finally, consumers must have income at or under 85% of the Federal Poverty Level (FPL) ($834 for 2015) to qualify for Non-Spenddown. If the consumer s income is over 85% FPL, they qualify for Spenddown. Meet definition of disability Decided by Social Security Administration (SSA) OR MO HealthNet Resources under program limits Single -Less than $1000; Married -$2000 or less Income at or under $834 (for 2015) Qualify for Non-Spenddown Income over $834 (for 2015) Qualify for Spenddown Joe is receiving SSD benefits, so he meets the definition of disability. Joe has $800 in his checking account and no other assets. With his SSD income, he is above 85% FPL. Joe is eligible for Spenddown. 5

6 b. Non-Spenddown vs. Spenddown Coverage Consumers with coverage through Non-Spenddown and Spenddown get the same adult Medicaid coverage. However, consumers in the Spenddown program must meet their spenddown amount each month before their coverage becomes active. Consumers in the Non- Spenddown program do not have to meet this out-of-pocket cost to receive coverage. The amount of the spenddown is basically the difference between the consumer s income and the Non-Spenddown income limit (Consumer income income limit). 2 Joe s monthly income is $1, For 2015, the Non-Spenddown income limit for adults with disabilities is $834. He is over the income limit for Non-Spenddown, so he has a Spenddown. His Spenddown is $249.33/month (1, = ). c. Meeting Your Spenddown There are two ways for a Spenddown-eligible consumer to meet their spenddown: Pay-In Consumer pays full amount of spenddown on the 1st of each month - like an insurance premium. Medicaid coverage starts on the first day of the month. Incurred Expenses Consumer incurs medical expenses and sends bills or receipts to MO HealthNet. Coverage starts the day of the month the incurred or paid medical expenses equal the spenddown. 2 Some income disregards apply. For simplicity, this guide will use just the basic calculation without disregards. 6

7 In February, Joe receives a tax refund and uses it to pay his March spenddown. On March 1st he pays $ to the State and he has coverage as of that date (Pay-in method). In April, Joe can t afford to pay his spenddown at the beginning of the month. He goes to the doctor on April 1st and pays $150 out-of-pocket for the cost of the visit. On April 10th, he has some tests done and pays $99.33 out-ofpocket. These two payments meet his spenddown for the month. Joe sends in the bills that he paid to the State and he has Spenddown coverage as of April 10 th (Incurred expenses method). For the incurred expenses method, even though Joe s coverage did not start until the 10 th of the month, he is considered to have coverage for the whole month. 26 CFR A-1(b)(1). d. Being Spenddown-Eligible vs. Having Spenddown Coverage Eligible Coverage Any month a consumer's income is above the Non-Spenddown Limit Any month an eligible consumer meets their spenddown amount It is therefore possible for an eligible consumer to have Spenddown coverage one month, but not the next. In May, Joe needs an expensive procedure, so he pays his $ spenddown to MO HealthNet on May 1st. Joe then has Spenddown coverage. In June, however, Joe cannot afford to pay his spenddown at all. Joe is eligible for Spenddown in June, but he does not have coverage for that month. 7

8 III. Spenddown and the ACA a. Spenddown and Minimum Essential Coverage The ACA requires that most people have Minimum Essential Coverage (MEC) or pay a penalty on their taxes (Shared Responsibility Payment). When a consumer has MEC from a source outside of the Marketplace, they are not eligible for financial help - Advance Premium Tax Credits (APTC) or Cost-Sharing Reductions (CSR) - through the Marketplace. If an individual loses MEC, they qualify for a Special Enrollment Period (SEP) to enroll in coverage through the Marketplace. Just because a person is eligible for the Spenddown program does not mean they have MEC. Spenddown is considered MEC when a Spenddown-eligible consumer meets their spenddown and receives coverage. Simply being eligible for Spenddown does not give someone MEC. Consumer pays or meets spenddown in a month Consumer has coverage that month Consumer has MEC for that month Helping consumers with Spenddown decide if they have MEC is an important job for assisters. APTC/CSR Shared Responsibility Payment (Tax Penalty) Special Enrollment Period (SEP) Consumer has Spenddown Coverage (MEC) Consumer is not eligible for APTC or CSR through the Marketplace. Consumer does not have to pay a tax penalty. When a consumer loses Spenddown coverage (MEC), consumer qualifies for a SEP. Consumer is Spenddown Eligible (no MEC) Consumer is eligible for APTC and CSR through the Marketplace. Consumer has to pay a tax penalty if they don't qualify for an exemption. Consumer does not qualify for a SEP. 8

9 Building from the last example, in May, Joe had MEC because he met his Spenddown. He will not have a penalty for that month. In June, Joe did not meet his Spenddown. He did not have MEC, so he may have to pay a penalty unless he qualifies for an exemption. Since Joe lost his MEC coverage at the end of May, Joe would have a SEP to enroll in coverage through the Marketplace. b. Choosing between the Marketplace and Spenddown Non-Spenddown coverage has no out-of-pocket costs for covered services, making it affordable for most consumers unless they need a service that is not covered. For Spenddown coverage, once a person has met their Spenddown, they don t have out-of-pocket costs for covered services. However, meeting the spenddown can be a struggle for consumers. The higher a consumer s spenddown gets the less likely it is they will be able to pay it. If a Spenddowneligible consumer does not pay their spenddown, they will not have coverage. 86% FPL $10 spenddown 1% of income 120% FPL $343 spenddown 29% of income The Affordable Care Act (ACA) has created new coverage options through the Health Insurance Marketplace (Marketplace) for many adults with disabilities in Missouri. These options may be more affordable than Spenddown. 9

10 Income Level MO HealthNet Eligibility Marketplace Eligibility Up to 85% FPL Non-Spenddown Program Not eligible for APTC or CSR % FPL Spenddown Program Not eligible for APTC or CSR Eligible for exemption from the tax penalty % FPL Spenddown Program Eligible for APTC and CSR % FPL Spenddown Program Eligible for APTC Assisters should explore Marketplace options with Spenddown-eligible consumers. With APTCs and CSRs, Marketplace coverage can be much more affordable for consumers than Spenddown. Based on his monthly income ($ ) and household size, Joe is at 100% FPL. His $ spenddown is 23% of his monthly income. Joe wants to look into his coverage options through the Marketplace. As long as he does not meet his spenddown, Joe is eligible to purchase coverage through the Marketplace. Joe is eligible for APTC and CSR through the Marketplace. He is also eligible for an exemption from the tax penalty (SRP) for any months he did not meet his spenddown before enrolling in Marketplace coverage. Spenddown-eligible consumers generally have complex health issues that assisters should keep in mind when helping them choose between Spenddown and Marketplace plans. To help consumers make the best coverage decision, ask about specific service, physician, and medication needs when looking at plans. Take the time to calculate predictable out-of-pocket costs among different Marketplace plans as compared to their Spenddown amount. When helping consumers with the decision between Spenddown and the Marketplace, assisters should consider the following: 3 A Spenddown consumer with income between % FPL is eligible for Marketplace coverage with APTC and CSR. However, if they choose not to purchase a Marketplace plan, that consumer would still be eligible for a hardship exemption for being in the Medicaid gap. 10

11 Spenddown-eligible consumers may use more services. This might mean more out-of-pocket costs in the Marketplace. In Spenddown, once a person meets their spenddown, there are no out-of-pocket costs for covered services. Find out what kinds of services a consumer uses most often. Calculate out-of-pocket costs for those services among the available Marketplace plans and compare to the consumer's spenddown amount. Provider networks may be important to Spenddown-eligible consumers. Spenddown eligible consumers may have established relationships with their providers. Help consumers check provider networks among the available Marketplace plans to avoid out-of-network costs. If a consumer cannot find a plan that has all of their providers in-network, help the consumer prioritize which providers are necessary to keep. If a consumer chooses a Marketplace plan over Spenddown, give them resources to be able to find in-network providers and hospitals on their own. Spenddown-eligible consumers may have multiple prescriptions. Help consumers look through formularies to check availability of their prescribed drugs and calculate out-of-pocket costs for prescriptions among different plans. If a consumer chooses a Marketplace plan over Spenddown, make sure they understand how to use the formulary to calculate out-of-pocket costs for new prescriptions they might get. Joe finds affordable plans on the Marketplace with premiums between $0 $40/ month. Joe tells you he has had the same primary care provider (PCP) who helps him manage his diabetes. He just started seeing specialists for his kidney problems and feet. You check the provider lists for the plans Joe can afford, but you can t find one that has all of his doctors. Joe wants to keep his PCP but is willing to get different specialists. Most of the services he needs are covered, except routine foot care. With his CSR, Joe s out-of-pocket costs will average $90/month between prescriptions and services. 11

12 c. Post Enrollment Documentation Once a Spenddown-eligible consumer enrolls in Marketplace coverage with APTC and CSR, the Marketplace usually asks the consumer to send in proof that they are not eligible for Medicaid coverage. If the consumer does not send in this documentation, then the Marketplace may remove the consumer s APTC and CSR. The consumer should send in some proof that they are eligible for the Medicaid Spenddown program. This might be their original Spenddown approval letter, or the monthly letter the State sends the consumer to remind them that they need to pay their spenddown in order to get coverage. The consumer should also show that they have not met their spenddown. The Marketplace has accepted consumer attestations of this fact, or a printout from the State showing that they have not met their spenddown. It is important for assisters to encourage consumers to send in this information so that they can keep their APTC and CSR. IV. Conclusion The ACA has increased access to affordable health for millions of Americans. Assisters in Missouri can now help the Spenddown-eligible population, many of whom have struggled to pay their spenddown or have gone without coverage, explore more affordable options through the Health Insurance Marketplace. An assister s role is to give consumers objective information on their coverage options. For Spenddown-eligible consumers, this means showing them their options in the Marketplace as compared to Spenddown. Assisters should take all of a consumer s needs from premiums and out-of-pocket costs to provider networks and covered services into account in both programs to help the consumer make the most informed decision. 12