Marketplace/AHCCCS Scenarios: Complex Scenarios

Transcription

1 Marketplace/AHCCCS Scenarios: Complex Scenarios MORNING SESSION KidsCare Prescreening... 2 SCENARIO... 2 Medicaid Denials... 3 SCENARIO... 3 Lesbian, Gay, Bisexual, Transgender... 4 SCENARIO SCENARIO Health Coverage for American Indians & Alaska Natives... 6 SCENARIO... 6 AFTERNOON SESSION Mixed Immigration Status... 7 SCENARIO SCENARIO Unmarried Couples with Common Children... 9 SCENARIO Projected Income and Supportive Documents SCENARIO SCENARIO Eligibility/Household/Tax Dependents SCENARIO SCENARIO SCENARIO Marketplace/AHCCCS Scenarios 1

2 Complex Issue: KidsCare- Prescreening income KidsCare Prescreening Background: The Children s Health Insurance Program known as KidsCare is a joint Arizona and Federal initiative designed to help families who earn above the AHCCCS (Medicaid) income limit whose earnings are too low to pay for health insurance for their children. To be eligible for KidsCare a child must be under 19 years old, US citizen or a qualified immigrant and an Arizona resident with family income between 133%-200% of the Federal Poverty Limit (FPL). They must not be eligible for AHCCCS coverage and must not have other health insurance. KidsCare premiums will depend on household income and number of children enrolled in the program. Native Americans and certain Alaskan Natives enrolled with a federally recognized tribe do not have to pay a premium. Scenario: Jesus and Maria are lawful permanent residents under 5 yrs. They have two common children, Saul (6 yrs) and Sofia (8 yrs) who are both U.S. citizens. Jesus is employed earning $3,160 monthly. At this time, Jesus and his household are enrolled in a health plan through the Marketplace. 1. Who is presumptively eligible for KidsCare? a. Everyone b. Maria and Sofia c. Saul and Sofia 2. What is the minimum and maximum FPL % for KidsCare? a. 0% to 133% b. 133% to 200% c. 100% to 200% 3. Who is eligible for continuing health coverage in the Marketplace? a. Jesus and Maria b. Everyone c. Saul and Sofia Marketplace/AHCCCS Scenarios 2

3 Medicaid Denials Complex Issue: Medicaid Denials Background: Denials from Medicaid are important when you are assisting a consumer apply for benefits through the Marketplace. The Marketplace now requires verification of denial from the state Medicaid program. Failure to provide verification information could result in the consumer not being able to enroll into the Marketplace. Scenario: Tammy and Jerry are married and have two common children; Sarah and Tom (ages 11 and 13). They are currently enrolled in AHCCCS/Medicaid. Tammy is currently employed and Jerry recently reported that he started a new job. Tammy received a letter from AHCCCS stating that the family is no longer eligible for AHCCCS/Medicaid because they are now over income. Tammy meets with a local Navigator to assist her with a Marketplace application through Healthcare.gov to apply for health insurance for her family. Tammy receives an eligibility determination and selects a health plan for her family. 1. After Tammy enrolls into a health plan she is required to verify termination of her health coverage with AHCCCS/Medicaid, which document must Tammy provide? a. Verification of income b. Proof of residence c. AHCCCS/Medicaid Denial letter showing the family was denied for being over income. d. AHCCCS/Medicaid Denial letter showing the family was denied for failure to provide documents 2. At what point in the application process is it best to submit the denial letter from AHCCCS/Medicaid? a. After creating an account in Healthcare.gov b. After receiving an eligibility determination in Healthcare.gov c. Before starting the application in Healthcare.gov d. After enrolling in a qualified health plan in Healthcare.gov. Marketplace/AHCCCS Scenarios 3

4 Complex Issue: LGBT Clients Lesbian, Gay, Bisexual, Transgender Background: Historically discrimination and exclusion based on sexual orientation and gender identity was acceptable practice among insurance and healthcare providers. Many lesbian, gay and bisexual individuals would prolong treatment due to fear of being denied service from their provider. Transgender people are more likely to be uninsured and less likely to have employer-based health insurance than the general population. Section 1557 prohibits discrimination on the grounds of race, color, national origin, sex, age, or disability under any health program or activity, any part of which is receiving Federal financial assistance or under any program or activity that is administered by an Executive agency or any entity established under [Title I of ACA]. Section 1557 is the first Federal civil rights law to prohibit sex discrimination in health care. To ensure equal access to health care, Section 1557 also applies civil rights protections to the newly created Health Insurance Marketplaces established under the Affordable Care Act. NOTE: Insurers cannot deny medically necessary services, as determined by a person s medical provider, if the service is provided based on current standards of care if they provide that service to another individual without regard to their sexual orientation or gender identity. Scenario 1: Rebecca is 27 years old and works two part time jobs. One at Macy's and the other at a local coffee shop. She is not eligible for employer-based health insurance. When Rebecca presents her identification the name stated is Michael and the gender question response is as male. Rebecca explains that she identifies as a transgender woman and is currently in the process of having her identification and gender updated. She knows it s important to have health coverage and needs assistance to cover her transitional healthcare needs. 1. How would you refer to Rebecca, knowing that her identification states Michael with a male gender marker? a. Refer to Rebecca by birth name b. Refer to Rebecca by birth name and as a male c. Refer to Rebecca using pronouns (he, him, and his) d. Refer to Rebecca as her preferred name using pronouns (she, her, and hers) 2. How do you proceed through the application? a. Inform Rebecca that in the application process you will be using her preferred name and gender. b. Don t inform Rebecca and just complete the application using her preferred name and gender. c. Inform Rebecca that in the application process you will be using her legal name and gender. d. Inform Rebecca that you will complete the application once she legally changes her name and gender. Marketplace/AHCCCS Scenarios 4

5 Scenario 2: On 4/14/16 Rebecca and Patricia were married. Rebecca is currently employed and has employer sponsored health coverage for herself and her son Michael. On 6/12/16 Patricia wanted to apply for health coverage through the Marketplace because she missed the deadline to enroll under Rebecca s employer sponsored health insurance. 1. Patricia is potentially eligible for APTC/CSR. a. TRUE b. FALSE 2. Patricia meets the Special Enrollment Period. a. TRUE b. FALSE 3. What was Patricia's deadline to enroll under the Special Enrollment Period through the Marketplace? a. 6/14/16 b. 6/30/16 c. 7/1/16 d. 7/30/16 Marketplace/AHCCCS Scenarios 5

6 Health Coverage for American Indians & Alaska Natives Complex Issue: Special Marketplace protections and benefits for Americans Indians and Alaskan Natives Background: If you re an American Indian or an Alaska Native you may have new health coverage benefits and protections in the Marketplace. Members of federally recognized Tribes (Tribal members), include, Alaska Natives and ANCSA corporation shareholders: Tribal members who purchase health insurance in the Health Insurance Marketplace and who have incomes at or above 100 percent or below 300 percent of the federal poverty level can enroll in a zerocost sharing plan. However, they must also pay premiums and be eligible to receive advanced premium tax credits to receive zero-cost sharing. If household incomes are below 100 percent or at or above 300 percent of the federal poverty level, they can enroll in a limited cost-sharing plan. Tribal members can enroll in a Marketplace plan at any time, not exclusively to open enrollment. Tribal members can also change Marketplace plans up to once a month. Consumers should be advised that if they select a plan after the 15th of the month the new plan will not start until the month following the next month, however, the current plan will remain in effect. For example, coverage elected on March 16th would not begin until May 1st and the current coverage would end April 30th. If a plan is selected before or on March 15th, coverage would begin April 1st. Tribal members and those eligible for Indian Health Care Services can apply for an exemption from the individual shared responsibility requirement through the Marketplace or they can self-attest to their eligibility on their tax forms. If they receive this exemption, they will be exempt from the Minimum Essential Coverage penalty. Scenario: George and his six year old son Landon, live on a tribal reservation in Montana. He works for his family s lumber company and earns around $40,000 annually. George and Landon use the Indian Health Service (IHS) for all of their health care needs. Luckily, there is an IHS hospital and health center close by that they can go to for health care. George is satisfied with the care they receive and does not want to enroll in a Marketplace QHP. George is afraid that he will have to pay the individual shared responsibility penalty for himself and his son since he does not have minimum essential coverage. 1. George and Landon are receiving medical care from an IHS provider. This satisfies the minimum essential coverage requirement. 2. George and his son are members of a federally recognized tribe. They do not have to apply for an exemption from the individual shared responsibility requirement. Marketplace/AHCCCS Scenarios 6

7 Complex Issue: Mixed Immigration Mixed Immigration Status Background: Many immigrant families are of mixed status ; family members have different immigration and citizenship status. For example: A family of four can have a U.S citizen, lawfully present resident and two undocumented immigrants. Members maybe Marketplace, CHIP and FES eligible. Mixed status families can have eligible dependents apply for advance premium tax credits (APTC) or lower out-of-pocket costs (CSR) for private insurance through the Marketplace. They may also apply for Medicaid and CHIP coverage for eligible dependents. NOTE: Family members who aren t applying for health coverage for themselves won t be asked if they have eligible immigration status. Scenario 1: Alejandra is an undocumented immigrant who is married to Brian who is a U.S citizen. Alejandra s two daughters Brittany (8 yrs.) and Sofia (21 yrs.) are U.S. citizens. Brian claims head of household and claims Brittany, Sofia, and Alejandra as tax dependents. 1. Who is eligible to obtain health coverage and potential, premium tax credits and other savings through the Marketplace? a. Brittany and Sofia b. Alejandra, Brittany, and Sofia c. Alejandra, Brian, Brittany, and Sofia d. Brian, Brittany, and Sofia 2. Federal Marketplaces and state Medicaid agencies can require applicants to provide information about the citizenship or immigration status of any household members who aren t applying for coverage. 3. States can t deny benefits to an applicant because a household member who is applying hasn t disclosed his or her citizenship or immigration status. Marketplace/AHCCCS Scenarios 7

8 Scenario 2: Guadalupe is an undocumented immigrant who wants to apply for her daughter Jessica who is a U.S citizen. Guadalupe is married to Fernando who is also an undocumented immigrant. Jessica is a 17 year old high school student and unemployed. Guadalupe earns income of $2,000 each month by cleaning houses and taking care of her relative s children. Fernando cleans yards and earns $1,500 a month. 1. Who is eligible to apply for the Marketplace? a. Jessica b. Guadalupe and Fernando c. Guadalupe, Fernando, and Jessica d. Fernando and Jessica 2. Guadalupe and Fernando s income is counted to determine eligibility for APTC and CSR for a family of three. 3. Guadalupe and Fernando have to provide their legal status in Healthcare.gov. Marketplace/AHCCCS Scenarios 8

9 Unmarried Couples with Common Children Complex Issue: Unmarried couples with common children. Background: Many consumers who we assist are couples that have children together but are not married. Eligibility for a program depends on who is earning income and how much. Is it not uncommon to have various household members qualify for different programs? Scenario 1: Jackie and Tommy are a couple who live together with their common child Jason who is three years old. Jackie is working at Target and Tommy is a domestic engineer who takes care of Jason full time. Jackie works 35 hours per week and earns $15.00 per hour. Jackie gets paid every two weeks. Jackie, Tommy and Jason are US citizens. Jackie is applying for a qualified health plan for herself and Jason. 1. How many household members must be included on the application? a. Household of one b. Household of two c. Two different households of two d. Household of three 2. If Jackie claims Tommy as a tax dependent then her income counts towards Tommy s APTC and CSR. 3. Jackie and Jason will be able to select one health plan in the Marketplace. Marketplace/AHCCCS Scenarios 9

10 Projected Income and Supportive Documents Complex Issue: What do you do when income verification does not match projected income? Background: The Marketplace can re-determine consumers APTC and CSR due to discrepancies in their projected income and verified income. A consumer may need to submit an explanation as to why projected income is less than the verified income to avoid from losing or reducing their APTC and CSR. Consumers may have to verify all income projected for the household members in the application with an exemption of uncountable income (Gifts, Child Support, and SSI). Scenario 1: Juan and Alejandra are married and are both U.S. citizens. Their two daughters Brittany (8 yrs.) and Sofia (13 yrs.) are also U.S. citizens. Juan is self-employed and projected his income will be $25,000 in 2016, which is $10,000 less than Alejandra receives SSDI of $1650 monthly and is not Medicare eligible. Her daughter Brittany, receives $733 a month from SSI. Juan applied for health coverage for himself, Alejandra, and Sofia. After Juan chose a health plan the Marketplace requested income verification. 1. Whose income is the Marketplace requesting verification for? a. Juan and Brittany b. Juan, Alejandra, and Sofia c. Juan and Alejandra 2. Juan provides his 1040 tax forms for 2015, and other income verification. What other supportive document MUST Juan provide to the Marketplace? a. Verification of residence b. An explanation of any income discrepancies c. Verification of Brittany s SSI 3. Does the Navigator include Brittany and her SSI payments in the application? a. Yes, but not her SSI payments b. No c. Yes, only if Juan applies for her in his application Marketplace/AHCCCS Scenarios 10

11 Scenario 2: Juan and Joanna are an unmarried couple who are both U.S. citizens. Their two children Brenda (8 yrs.) and Vicente (13 yrs.) are also U.S. citizens. Juan is self-employed and projected his income to be $45,000 in 2017, which is $15,000 less than Joanna receives $733 a month from SSI. Juan applied for health coverage for himself, Brenda, and Vicente. After Juan chooses a health plan the Marketplace is requesting income verification. 1. Calculate the total countable household income for a. $15,000 b. $60,000 c. $45, Juan provides his 1040 tax forms for 2016, and other income verification. What other supportive document MUST Juan provide to the Marketplace? a. Verification of residence b. An explanation of any income discrepancies c. Verification of Joanna s SSI 3. The Navigator includes Joanna and her income in the Marketplace application. Marketplace/AHCCCS Scenarios 11

12 Complex Issue: Eligibility and Household Eligibility/Household/Tax Dependents Background: For the Health Insurance Marketplace a household includes the tax filer, their spouse if they have one, and their tax dependents. Tax filer + spouse + tax dependents = household Follow these basic rules when including members of your household: Include your spouse if you re legally married. If you plan to claim someone as a tax dependent for 2016, do include them on your application. If you won t claim them as a tax dependent, don t include them. Include your spouse and tax dependents even if they don t need health coverage. Who to include in your household Relationship Dependent children, including adopted and foster children Include in household? Yes Notes Include any child you ll claim as a tax dependent, regardless of age. Children, shared custody Sometimes Include children whose custody you share only during years you claim them as tax dependents. Nondependent child under 26 Sometimes Include them only if you want to cover them on your Marketplace plan. Children under 21 you take care of Yes Include any child under 21 you take care of and who lives with you, even if not your tax dependent. Unborn children Dependent parents No Yes Don t include a baby until it s born. You have up to 60 days after the birth to enroll your baby. Include parents only if you ll claim. Dependent siblings and other relatives Yes Include them only if you ll claim. Marketplace/AHCCCS Scenarios 12

13 Relationship Include in household? Notes Spouse Yes Include your legally married spouse, whether opposite sex or same sex. In most cases, married couples must file taxes jointly to qualify for savings. Legally separated spouse No Don t include a legally separated spouse, even if you live together. Divorced spouse No Don't include a former spouse, even if you live together. Spouse, living apart Spouse, if you re a victim of domestic abuse, domestic violence, or spousal abandonment Yes Not required Include your spouse unless you re legally separated or divorced. (See next row for an important exception.) In these cases, you don t have to include your spouse. See rules for victims of domestic abuse, domestic violence, or spousal abandonment. Unmarried domestic partner Sometimes Include an unmarried domestic partner only if you have a child together or you ll claim your partner as a tax dependent. Roommate No Don t include people you just live with unless they re a spouse, tax dependent, or covered by another exception in this chart. Marketplace/AHCCCS Scenarios 13

14 Scenario 1: Rosemary and Dominic are domestic partners and U.S. citizens. Rosemary and Dominic have been living together in Arizona for the last five years. They file their taxes separately. They have two children Mia who is five years old, and Donovan who is two years old. Dominic claims both children as dependents on his tax returns. Dominic works as a manager at a restaurant and earns $40,000 annually. Rosemary runs a child care service, and she has no employees. She earns $19,000 annually. 1. How should Rosemary and Dominic apply for health coverage? a. Submit one application: List Dominic as the applicant and apply for coverage for Mia, and Donovan, and include Rosemary as a tax filer. b. Submit one application: List Rosemary as the applicant and tax filer applying for coverage for Dominic, Mia and Donovan. c. Submit two applications: One application with Dominic as the applicant; and tax filer applying for coverage for himself, Mia, and Donovan. Include Rosemary as a nonapplicant. The second application with Rosemary as the applicant and tax filer who is applying for coverage. Include Dominic, Mia, and Donovan as non-applicants. 2. Are Rosemary and Dominic both eligible for financial assistance to make health coverage more affordable? a. No. Based on their incomes and respective household sizes, only the applicant who has tax dependents and is applying for coverage for them should qualify for advance premium tax credits (APTC). This is because, they meet all other eligibility criteria; their income is between 133% to 400% of the federal poverty level, and they aren t eligible for Medicaid or the Children s Health Insurance Program (CHIP). b. Yes. Based on their incomes and respective household sizes, both Rosemary and Dominic should qualify for advance premium tax credits (APTC). This is because they meet all other eligibility criteria, their income is between 133% to 400% of the federal poverty level, and they aren t eligible for Medicaid or the Children s Health Insurance Program (CHIP). Scenario 2: Ashley is a 23-year-old single mother. Ashley is a recent college graduate. She works at a physical therapy office in Arizona and earns $33,000 a year. Ashley has an 18-month old son, Victor, whom she claims as her tax dependent. Ashley lives in the same state as Victor s father, Carlos. As part of their custody agreement, Carlos must buy health insurance for Victor. Carlos doesn t have access to employer-sponsored insurance, so he is planning to enroll himself and Victor in Marketplace coverage. 1. Can Carlos purchase a Marketplace plan for Victor, even though he doesn t claim his son as his tax dependent? a. Yes. Carlos can apply for insurance on Victor s behalf, but will have to pay full cost for his son s coverage. b. No. Carlos can t apply for insurance on Victor s behalf, because he doesn t reside with him and does not claim him as his tax dependent. c. Yes. Carlos can apply for insurance on Victor s behalf as long as he claims him the year he receives coverage for him. Marketplace/AHCCCS Scenarios 14

15 Scenario 3: Enrique has been a lawful permanent resident for five years and is married to Brian who is a U.S citizen. Enrique has two daughters Brittany who is eight years old and Sofia who is 21 years old. Both are U.S citizens. Sofia works part time. Enrique and Brian also care for Brian s mother Betsy a U.S. citizen who has been living in their residence for the past two years. Enrique and Brian file their taxes jointly and claim Brittany, Sofia, and Betsy as tax dependents. 1. On the Marketplace application who can Enrique apply for health coverage? a. Enrique and Brian b. Brian, Brittany, and Sofia c. Enrique, Brian, Brittany, Sofia, and Betsy d. Betsy, Brittany and Sofia 2. On the Marketplace application who can Enrique claim as a tax dependent? a. Enrique and Brian b. Betsy, Brittany, and Sofia c. Enrique, Brian, Brittany, and Sofia d. Brittany and Sofia Marketplace/AHCCCS Scenarios 15