About These Materials

Transcription

1 About These Materials Families USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for a training program for DC eligibility workers. These workers determine eligibility for Medicaid and other benefit programs (including SNAP and TANF). They will help consumers apply for coverage and financial assistance, report changes, renew coverage, and verify the information that is needed to determine eligibility. These workers will not be responsible for helping consumers select health plans. These training materials are posted here as an example that can be adapted for other training programs. They contain information that is specific to the District of Columbia, which would have to be changed if used in another state. Contact Families USA at stateinfo@familiesusa.org for assistance with adapting these materials.

2 Training Day 2 Speaker Notes Slide 1: ESA Policy Training Day 2 Slide 2: MAGI, non-magi, and Eligibility Categories Yesterday, we started to talk about the new system for determining eligibility and some of the new rules that this system uses to figure out if a person is eligible for Medicaid, the new premium tax credits, and DC Health Link plans. These new rules and the new system will be used to determine eligibility for most people. However, there are some groups that will not be included in this new system right away. We want to begin today by talking about whose eligibility will and will not be determined by the new system, and what the Affordable Care Act does to simplify eligibility categories. Slide 3: What is MAGI? Let s start out with a little review from yesterday. The Affordable Care Act defines how eligibility will be determined for - most Medicaid beneficiaries - everyone who will get premium tax credits and cost-sharing reductions MAGI stands for Modified Adjusted Gross Income. It s a new way of determining eligibility for people who qualify for Medicaid or premium tax credits. It includes new rules for determining income and household composition, which we will talk about tomorrow. The new system will use MAGI. While the health care law changes eligibility determinations for most people, the current Medicaid rules will still be used for a few populations. We call these the non-magi populations. These populations are primarily people who are aged, blind, or disabled, or people who need long-term care. Unless it is clear that they will be immediately eligible based on a non-magi factor, all applicants will need to fill out the DC Health Link application. For the first year of the new DC Health Link system, ESA will still do eligibility determinations non- MAGI Medicaid As we talk through the changes made by the health care law, we will discuss which of the changes apply only to the MAGI population, which apply to everyone, and which apply differently to MAGI and non-magi populations. Slide 4: Who are the MAGI groups? The Affordable Care Act takes many of the previous eligibility categories for Medicaid and simplifies them into four categories. These are the MAGI populations: 1. Parents and caretaker relatives 2. Children under age Pregnant women 4. Adults ages without dependent children Most people with Medicaid in the District are in one of these four groups (a total of 158,000 people).

3 These individuals eligibility for Medicaid will depend exclusively on what their household Modified Adjusted Gross Income is. DC Health Link will be able to determine whether people are eligible for Medicaid under this category based on the information they provide on the DC Health Link application. Let s talk briefly about who is included in each of these categories and what changes the health care law makes to eligibility for these categories. Slide 5: Parents and Caretaker Relatives Parents and caretaker relatives are eligible based on their relationship to a dependent child who lives in their home and for whom they have primary responsibility. In the system you use now, there are several different categories of parents. You check to see if parents have TANF or are TANF-eligible, if they might qualify as medically needy, or if they qualify because their income is below 200 percent of the federal poverty level. You have to figure out which category a parent fits in and enter the correct code. Things will be much easier with the new system. The Affordable Care Act takes all these categories for parents and caretaker relatives and combines them into one category: 1931 Low-Income Families. And you won t need to plug codes in for this group because the application figures this out automatically! People in this category with household incomes of up to 221 percent of poverty are eligible for Medicaid. People over age 65 who meet the definition of a parent or caretaker relative can also be included in this category. While people over age 65 generally fall into the non-magi category, they can qualify for Medicaid as parents or caretaker relatives because there is no age limit on this category. Slide 6: Who is a caretaker relative? Let s take a closer look at the definition of caretaker relative. A caretaker relative is a relative of a dependent child with whom the child lives and who is taking primary responsibility for the child s care. The person must be related to the child by blood, adoption, or marriage. The spouse of any one of the people just listed can also be considered a caretaker relative. This is true even when the spouse is no longer married to the person who is related to the child, even if this is the result of death or divorce. Slide 7: Children In DC, children under age 19 with household incomes up to 324 percent of poverty are eligible for Medicaid. Young adults ages 19 and 20 are also considered children and have access to the same benefits as younger children. However, 19 and 20 year olds are eligible only if they have incomes below 221 percent of poverty. When doing Medicaid eligibility determinations for children today, you have to figure what category the child should be in for the matching rate that DC gets from the federal government. The new name for the CHIP kids who receive a higher matching rate is Targeted Low-Income Child. Just like we saw with parents and caretaker relatives, the new system will automatically determine who is and isn t a Targeted Low-Income Child, and you will not have to code anything when filling out the application. Slide 8: Continuous Eligibility for Children DC has special protections to make sure children can keep their Medicaid coverage even when their circumstances change. This is called continuous eligibility. DC has two types of continuous eligibility for children.

4 The first applies to all kids with Medicaid in the District. Beginning this October, children in Medicaid will be able to stay in Medicaid for a whole year even if their situation changes and their household income increases enough that they would no longer be eligible for Medicaid. We will look at an example of how this works in a minute. The second type of continuous eligibility is continuous eligibility for hospitalized children. A child who turns 21 (and is therefore no longer eligible for Medicaid as a child) while hospitalized continues to be eligible as a child until the end of the hospital stay. You will not need to worry about figuring out who gets continuous eligibility. The system will do this for you by disregarding mid-year changes that would make a child ineligible for Medicaid. Slide 9: Example: Continuous Eligibility Let s take a look at a quick example of continuous eligibility. Marika and her nine-year-old daughter, Chloe, have a family income of 275 percent of poverty. Marika has a DC Health Link plan and gets premium tax credits, and Chloe has Medicaid. Marika s work hours increase over the summer, and their income rises to 350 percent of poverty. Marika reports the change to DC Health Link. Slide 10: Example: Continuous Eligibility (cont d) DC Health Link updates Marika s premium tax credit amount to reflect the change. Now that her income is higher, the amount of premium tax credits she can get will be a bit smaller. Chloe s eligibility for Medicaid does not change, even though her income has risen above 324 percent of poverty, because she has continuous eligibility. Marika s work hours return to normal at the end of the summer. She reports the change, and DC Health Link adjusts her premium tax credit amount. As we see in this example, Chloe stays in Medicaid the whole time even though her family income fluctuates. However, without continuous eligibility, Chloe would have had to move into a DC Health Link plan when her mother s income went up and then switch back to Medicaid when her mom s income went back down. This could make it hard for Marika to keep seeing the same doctor. Slide 11: Pregnant Women Now let s talk about our third MAGI category, pregnant women. Pregnant women with household incomes up to 324 percent of poverty are eligible for Medicaid. However, eligibility for Medicaid as a pregnant woman ends at the end of the month in which the 60 th day postpartum falls. The new application will make it easier to determine eligibility for a pregnant woman because the system will automatically determine what match rate a pregnant woman qualifies for. The new name for pregnant women for whom DC receives a higher match rate is Targeted Low-Income Pregnant Woman. DC Health Link will determine whether or not a pregnant woman is a Targeted Low-Income Pregnant Woman without your having to code anything. Slide 12: Continuous Eligibility for Pregnant Women DC also uses continuous eligibility to make sure pregnant women do not have to leave Medicaid and find a new doctor if their income goes up while they are pregnant or within the first few months of giving birth. Pregnant women continue to be eligible for Medicaid until the end of the post-partum period even if their income rises above 324 percent of poverty.

5 Slide 13: Adults Ages without Dependent Children Adults between the ages of 21 and 64 who are not pregnant and are not parents or caretaker relatives can receive Medicaid if they have household incomes up to 215 percent of poverty. You may already have heard in the news about states choosing to expand or not expand Medicaid. DC is one of the few states that expanded Medicaid early, providing Medicaid to childless adults with incomes up to 200 percent of poverty. We did this in The eligibility level for this group goes up slightly (to 215 percent of poverty) because we will no longer be using income disregards. We will talk more about this later. The important thing to know is that DC has already expanded Medicaid for the childless adult population, so coverage for this group will remain the same. The new application system simplifies eligibility categories for this group too. Right now, you must distinguish between the CAM group and the group that uses Program Code 775. Just like with the three other MAGI groups, the new system will sort out who goes in what group for you, so you will not need to do any coding for this group. Slide 14: Presumptive Eligibility for Pregnant Women Before we move on to talk about the non-magi population, we want to talk briefly about another special enrollment situation you may encounter. As you know, DC provides a special accelerated eligibility process for pregnant women. Certain medical providers can use basic information about pregnancy, family size, and income to make a determination of presumptive eligibility for outpatient services. A pregnant woman must have income below 324 percent of poverty to be found eligible for this limited coverage. Once a pregnant woman is determined to be eligible, she has 60 days to complete a regular application for Medicaid or she will lose her coverage. Presumptive eligibility for pregnant women does not change under the new rules. Slide 15: Hospital Presumptive Eligibility The Affordable Care Act makes all Medicaid provider hospitals eligible to do these presumptive eligibility determinations. Presumptive eligibility is also no longer limited to pregnant women. Anyone in a MAGI category who appears to meet the income limits for Medicaid can receive presumptive eligibility from a Medicaid hospital. When a clinic determines presumptive eligibility for a pregnant woman, she is eligible only for outpatient services. Hospital presumptive eligibility is different from the kind of presumptive eligibility a clinic can do: Anyone a hospital determines to be presumptively eligible (including pregnant women) is eligible for all Medicaid services. Just like with pregnant women, anyone who is determined to be presumptively eligible for Medicaid needs to fill out an application within 60 days to continue to receive Medicaid. Slide 16: Non-MAGI Populations Now that we ve reviewed the different populations that are a part of the four MAGI categories, let s take another look at those who are eligible for Medicaid on a non-magi basis. Remember, people who do not already receive Medicaid and seem like they might be eligible on a non-magi basis will still need to fill out the DC Health Link application first. Later, they can continue on to provide information that would be used by ESA to determine their eligibility for non-magi Medicaid.

6 The populations listed on this slide and the following slide are exempt from the new MAGI method of counting income that was established by the Affordable Care Act. The populations listed on this slide do not use MAGI rules because eligibility for these categories is not based on a person s income. - SSI recipients - Deemed newborns: Deemed newborns are granted Medicaid eligibility automatically based on their mother s eligibility - Foster care youth - Project Wish beneficiaries: As you probably know, Project Wish is a special program for women with breast and cervical cancer. - Former foster care youth up to age 26 Slide 17: Non-MAGI Populations (cont d) The categories listed on this slide are eligible for extra benefits or fee-for-service Medicaid. MAGI rules are not used for these populations because additional information is needed to determine their eligibility. Eligibility for these categories will be determined by ESA: - Those who are aged, blind, or disabled - Those seeking long-term services and supports (nursing home and home- and community-based services) - Medicare savings program beneficiaries - Dual eligibles - Medically needy/spend-down beneficiaries Former foster care youth is the only new population that is included in the non-magi category. The rest of these populations are already eligible for Medicaid. The method used today to determine eligibility for these populations will not change. Slide 18: Former Foster Care Youth The Affordable Care Act allows young adults to stay on their parents health insurance plans up to the age of 26. However, young adults who have aged out of foster care while receiving Medicaid do not have the same protection. This new eligibility category provides coverage for these young adults. So what are the qualifications for this category? The young adult Must be under age 26 Must have been in foster care in DC and in Medicaid on his or her 18 th birthday (or emancipation date) or when he or she left foster care (after age 18) This eligibility category is a non-magi category because the income of young adults in this category is not a factor in their eligibility. DC just needs to know that these young adults had Medicaid when they aged out of DC foster care or were emancipated and that they are still residents of the District. Slide 19: Why is the distinction between MAGI and non-magi important? Now that we ve talked about what the different MAGI and non-magi eligibility categories are, let s take a step back and discuss why these categories matter and what they mean in practical terms. In some cases, people who qualify as part of a non-magi category can get additional benefits. Non-MAGI categories are also important for determining whether a person should be enrolled in fee-for-service Medicaid or Medicaid managed care. Determining eligibility for non-magi people sometimes has extra requirements. For example, getting a disability determination can be a long and difficult process. Some applicants who might be eligible for a non-magi category may not want to go through this process.

7 It is important that you help applicants understand why a non-magi determination might help them and what the process is like. Slide 20: How will you know if someone is in a non-magi category? There will be screening questions on the application that will help identify who is potentially eligible on a non-magi basis. People who answer yes to these questions will be flagged for further follow-up by ESA. Once applicants get their eligibility results, they can request a full examination of their eligibility if they have been determined to not be eligible for Medicaid or if they think they may qualify for additional benefits. This might apply to someone who completes the online application and is found to be eligible for Medicaid for reasons other than income. For example, the notice of an eligibility determination includes a question like, Do you want to request a determination for Medicaid as conducted by ESA on the basis of disability, blindness, or recurring medical needs and bills? and gives instructions on how to request a full eligibility determination. All applicants will need to fill out the DC Health Link application. Some non-magi groups will also need to fill out supplemental application forms. Receiving these supplemental forms lets us know that someone wants to be evaluated for non-magi eligibility. ESA may also have information about some applicants besides what they have provided on their application that would identify those applicants as potentially eligible on a non-magi basis. People can choose whether or not to go forward with a non-magi determination. Slide 21: What happens to non-magi applications? What happens after an applicant has been flagged as potentially eligible on a non-magi basis depends on how easy or hard it is to for ESA to make a non-magi determination. The goal is to get the applicant enrolled in coverage as soon as possible. For some groups, like former foster care youth, the application will have already captured all the information needed to make a non-magi determination. For these applicants, it makes the most sense to determine their non-magi eligibility so they can enroll in non-magi coverage right away, since this can be done quickly. However, for other categories, determining eligibility is a more complicated process and ESA will be doing these determinations for the first year. For example, determining eligibility on the basis of a disability can take longer than a regular Medicaid determination, and we want to make sure that these applicants do not have to go without coverage while their eligibility is being evaluated on a non-magi basis. In these cases, the applicant should have his or her eligibility determined based on MAGI. Depending on income, the applicant can get Medicaid or a DC Health Link plan (with or without premium tax credits) until the final non-magi eligibility determination is made. Slide 22: Example: Ron Let s see how this might work using an example. Ron is 49 years old and has a part-time job that pays $15,000 a year. He has some medical conditions that make it difficult for him to do certain daily tasks. When he fills out the application, he answers yes to the non-magi screening questions. Slide 23: Ron s Application It looks like Ron might be eligible for coverage of several personal care services to help with some of his medical needs based on having a disability. But the application process for these services takes longer than the MAGI Medicaid application.

8 In the meantime, Ron is income-eligible for Medicaid as an adult under age 65 with no dependent children. You should determine his eligibility using the childless adult category until his application for additional services from ESA is finished. When he is found to be eligible for additional services, he should be moved into the relevant non-magi eligibility category. We will talk more about applications like Ron s later in the training. Slide 24: Review: Question #1 Now let s do a little review of what we learned. Martin is 21 years old. His income was at 175 percent of poverty when he applied and got Medicaid. Three months later, he got a second job, and his income went up to 230 percent of poverty. True or False: Because this change happened during the year, Martin can keep his Medicaid through continuous eligibility. Slide 25: Answer: Question #1 False Only children and pregnant women have continuous eligibility. Slide 26: Review: Question #2 ESA will still determine eligibility for which of the following groups in 2014? a. Childless adults ages b. People with disabilities c. Pregnant women d. Dual eligibles e. The medically needy/spend-down beneficiaries Slide 27: Answer: Question #2 B, D, and E In 2014, ESA will still determine eligibility for non-magi populations, which includes people with disabilities, people who are dually eligible for Medicare and Medicaid, and those who are medically needy. Pregnant women and childless adults ages are MAGI populations and will use the new system. Slide 28: Review: Question #3 True or False: If an applicant might be eligible for Medicaid on a non-magi basis, she must wait until her non-magi eligibility has been determined to get coverage. Slide 29: Answer: Question #3 False Applicants who are waiting for a non-magi determination should be enrolled in Medicaid or a DC Health Link plan based on their income. Slide 30: Recap of Eligibility Categories

9 To wrap up this section, we want to review what you as ESA workers will be doing and what the new system will do for you. You will need to: Enter the applicant s information into the DC Health Link application Enter any changes the applicant reports into the system DC Health Link will: Determine the eligibility category for each applicant automatically. This means you will not have to figure out the person s eligibility category and code it in. Slide 31: Overview of Eligibility Factors Several key factors will affect someone s eligibility for Medicaid, premium tax credits to help buy a plan through DC Health Link, or eligibility to buy a DC Health Link plan without the tax credits. In this section, we are going to provide an overview of what the core eligibility requirements are and how they are different for the different types of coverage. Some of these requirements are pretty straightforward, like whether you are a resident or not. However, some eligibility requirements, such as income, are much more complicated to determine. We are going to spend tomorrow talking about household composition and income, since these are the eligibility factors that involve more complicated processes and rules. Working with the current ACEDS system, you have to do many things yourself, like figuring out who is included in an applicant s household. The new DC Health Link system will do most of this work for you. The purpose of today s training is to help you understand how DC Health Link will evaluate eligibility. This is both for your own knowledge and so you can explain this to applicants. You won t have to memorize all these new policies, because DC Health Link will do the hard work for you. Slide 32: Eligibility Factors at a Glance Let s start with the broad eligibility requirements for Medicaid, the premium tax credits for DC Health Link coverage, and buying a DC Health Link plan without financial assistance. In order to be eligible for full Medicaid in DC, you must: Be a U.S. citizen, a qualified alien, a lawfully residing child under 21, a lawfully residing pregnant woman, or a victim of trafficking and certain of their relatives. This not a change from current Medicaid rules. The types of immigration status that are included in the qualified alien category will stay the same as they are today. Many adult immigrants who are considered qualified aliens become eligible for Medicaid only after five years of residence in the United States. As you know, children and pregnant women who have a lawful immigration status can also qualify for Medicaid and are not subject to the five year bar. (Immigrants who are not qualified aliens may still qualify for Medicaid coverage of emergency services, just as they do under current rules.) Be a resident of the District of Columbia Have a household income below the limit for the MAGI Medicaid category they qualify as part of (for example, children with family incomes up to 324 percent of poverty) You may notice in the chart that incarceration is not an eligibility factor for Medicaid. When someone who receives Medicaid is incarcerated or in a transitional reentry program that is considered an institution, DC

10 will now suspend that person s eligibility rather than terminating it. This makes it easier for people who are leaving jail, prison, or a transitional institution to keep their health coverage and get the help they need right away when they are released. Just like today, how you file your taxes and whether or not you can get coverage from an employer does not matter when determining eligibility for Medicaid. In order to be eligible for premium tax credits and for cost-sharing reductions, you must: Be a U.S. citizen or lawfully present. Be a resident of the District of Columbia Not be incarcerated unless pending disposition (that is, not yet charged, or not yet convicted or acquitted.) Have a household income between below 400 percent of poverty and above the MAGI Medicaid income eligibility limits for your eligibility category. People who are subject to the five-year bar can get premium tax credits at any income level below 400 percent of poverty, since they are not eligible for Medicaid. We will talk more about this in a minute. Agree to file taxes in the upcoming year, and agree to file jointly if married. Not have an offer of affordable coverage through an employer or government-sponsored coverage, like Medicare, Medicaid, CHIP, or certain veterans benefits There is also a third category that we haven t spent much time talking about: those who qualify to buy a DC Health Link plan without financial assistance. There will be people with incomes above 400 percent of poverty who do not have coverage from an employer or other source and who need to be able to buy plans through DC Health Link. There may also be people who have an offer of coverage through a family member s employer that disqualifies them from being eligible for premium tax credits, but that coverage is nonetheless unaffordable, and those people would therefore be able to enroll in a health plan through the DC Health Link without premium tax credits. These DC Health Link plans come with the same set of benefits and consumer protections that we talked about earlier, but enrollees would not get any financial assistance to pay for the plans. There are still certain criteria a person needs to meet to qualify to buy a DC Health Link plan. Like people who will receive premium tax credits for a DC Health Link plan, people in this category need to: Be a U.S. citizen or lawfully present Be a resident of the District of Columbia Not be incarcerated (except pending disposition) As we mentioned yesterday, there will be a separate, shorter application for unsubsidized coverage in DC Health Link for people who do not want to apply for financial assistance. This application will be shorter because it does not have to cover the more complicated aspects of eligibility like income. As we talked about yesterday, deciding whether to apply for financial assistance will be very important. Many people do not know about the premium tax credits and may assume that, because their income is too high to qualify for Medicaid, no help is available for them. You should encourage people to fill out the full application for financial assistance because of the new options that are available. Today, we will talk about most of these eligibility factors and what has changed and what hasn t changed under the new rules. Household composition and income are more complicated, so we will go over those briefly today and spend all day tomorrow on these two important factors. Slide 33: Household Composition

11 As we talk about the new rules, you may be noticing a theme: Because premium tax credits are administered through taxes, the rules for determining eligibility in the new system are based on tax rules. This is also true for the way we determine household composition. The new rules are based on the tax household the people who are on the same tax return together. For example, a single mom who claims her two children would have a household consisting of herself and her two children. There are some exceptions in certain family situations and a different set of rules for families that do not have to file taxes, which we will talk about more tomorrow. Slide 34: Income Once the system has figured out who is in which household, it can add up their incomes to start determining their eligibility. However, the rules for what counts as income are changing somewhat. Instead of the current system, where we add up all types of income and then subtract income disregards and deductions, the new rules look at income almost the same way the IRS does. This means certain types of income (like child support) will not be included anymore, there will be changes to income disregards, and there will be no more deductions. We will talk more about this tomorrow. Slide 35: Citizenship and Immigration Status Citizenship and immigration status is the first eligibility factor that we will cover completely today. The rules for Medicaid regarding immigration status are not changing. We will review these rules, but then we will spend more time talking about immigration status for DC Health Link and about how the DC Alliance fits into everything. Laws and rules about how immigrants are classified and treated by government programs frequently change. For example, you probably know that the United States recently decided not to deport some people who arrived in this country as children and who have finished high school or served in the military (they are sometimes called Dreamers in the media, and their immigration status is now referred to as deferred action childhood arrivals ). The federal government has said that this group is NOT eligible for either premium tax credits or Medicaid. You will not need to remember which immigration status makes a person eligible for Medicaid or DC Health Link. All you will need to do is ask applicants what their immigration status is (if they are not citizens), enter this information, and evaluate the documentation of immigration status (if applicants need to submit documentation in order for DC Health Link to verify their immigration status). Slide 36: Immigration Status and Medicaid Citizens are eligible for Medicaid, as are many types of immigrants. However, certain adults with an immigration status that makes them part of the current qualified alien category are subject to a five-year waiting period before they can receive Medicaid. Pregnant women and children who are lawfully present are exempt from the five year bar. The lawfully present category includes more types of lawful immigration status than are included in the qualified alien category. The Affordable Care Act did not change anything about the five-year bar. DC Health Link will determine whether or not the five-year bar prevents an applicant from getting Medicaid. Slide 37: Immigration Status and DC Health Link Coverage Just like in Medicaid, an applicant must be a citizen or have an eligible immigration status to qualify for DC Health Link coverage. All individuals who are lawfully present can qualify to enroll in a DC Health Link plan, for premium tax credits and for cost-sharing reductions, as long as they are not currently eligible to enroll in Medicaid and they meet other eligibility criteria, including residency. Since the lawfully present category includes people with types of immigration status that are not included in the qualified

12 alien category, this means that more people will qualify for DC Health Link based on their immigration status than will qualify for Medicaid. Unlike Medicaid, there is no five-year bar for enrolling in a DC Health Link plan, for getting premium tax credits, or for getting cost-sharing reductions. During the five-year bar period, a person who would otherwise be eligible for Medicaid will be able to enroll in a DC Health Link plan and receive premium tax credits and cost-sharing reductions. Slide 38: DC Alliance In DC, the Alliance covers people with incomes under 200 percent of poverty who do not qualify for Medicaid, either because they are subject to the five-year bar or because they do not have an eligible immigration status, such as deferred action childhood arrivals (DACA). DC Alliance has a limited network of providers, and the benefits it covers are also limited, but no premium payments are required. It is important to know that the Alliance does not count as minimum essential coverage. People who are in the five-year bar period who choose Alliance coverage may have to pay the individual responsibility payment if their income is high enough that they are required to file taxes. People who are not lawfully present are exempt from individual responsibility payments. For now, DC Health Link will not determine eligibility for the Alliance. People who want to apply for Alliance coverage will need to fill out a separate application and do a face-to-face interview with ESA. Slide 39: Immigrants Have a Choice during the Five-Year Bar Period Immigrants who are subject to the five-year bar and have incomes below 200 percent of poverty will have a choice between whether they want to have DC Alliance coverage or buy a DC Health Link plan with the help of premium tax credits and cost-sharing reductions. DC Alliance coverage differs substantially from DC Health Link coverage. In DC Health Link, people are in private health insurance plans. They will have to pay monthly premiums that will follow a sliding scale. For example, premiums might be as low as $19 a month for a single person or be as high as $120 a month for someone with an income at about 200 percent of poverty. The network of doctors and other health care providers and the benefits will include all of the required benefits for DC Health Link plans, any additional benefits provided under the plan they choose and will have a larger provider network, like other people with private insurance have. The benefits and the network of doctors are more limited in the DC Alliance, but there are also no premiums and no copayments. DC Alliance does not provide enough coverage to count as minimum essential coverage. People in the five-year bar period should know that if they choose Alliance coverage and their income is high enough that they are required to pay taxes, they may be required to pay the individual responsibility payment when they file their taxes because they did not have minimum essential coverage. You should tell applicants who fall in the five-year bar period about these differences to help them make good choices about whether to get DC Alliance coverage or a DC Health Link plan. Slide 40: Including Non-Applicants There are a variety of reasons that people may be listed as non-applicants on an application. The most common reason will be if some members of a household already have coverage from a job or government program.

13 Another reason is if they do not qualify for coverage based on their immigration status. People who do not have a qualifying immigration status should still be included as non-applicants on the applications of family members who are lawfully present if they are in the same tax household. The application system will consider these people as it determines household size and income. Slide 41: Verifying Citizenship and Immigration Status You won t need to keep track of what types of immigration status allow a person to get Medicaid or DC Health Link coverage. Applicants will give you information about their immigration status that you will enter in the DC Health Link application. DC Health Link will automatically check to see if this information matches the information that the federal government has about their immigration status. If it matches, there is nothing more you need to do, and applicants do not need to show you proof of what they have told you. If the DC Health Link system cannot confirm what an applicant has told you: The applicant has 90 days to provide documentation. During the 90 days, applicants who have attested to having an eligible immigration status will be considered conditionally eligible and can be covered by Medicaid or a DC Health Link plan with or without premium tax credits if they meet other eligibility requirements. (Note that for other eligibility factors, there are differences in what needs to be confirmed for Medicaid and for DC Health Link before someone can be made conditionally eligible. For Medicaid, all other factors must be verified for the applicant before eligibility begins. For instance, until a Medicaid applicant has verified income, they cannot be found eligible for Medicaid even if they attest to eligible immigration status. This is different in DC Health Link, and we will talk about that more in our unit on verification. For DC Health Link, a person can be made conditionally eligible based on selfattestation for 90 days while verification of other factors, such as income, is pending as well as when verification of immigration status is pending.) Slide 42: Documenting Citizenship and Immigration Status If there is not enough information to verify an applicant s citizenship or immigration status in the electronic data sources, the applicant will need to provide documentation. Your job will be to tell applicants what documentation can be used and look at documents when applicants bring them in to ensure they are acceptable forms of documentation. There are two types of documents applicants can provide if they need to verify their citizenship: 1) primary documentation and 2) secondary documentation. 1. Primary documentation is the strongest form of proof. You need to see only one piece of primary documentation to confirm a person s citizenship or immigration status. 2. Secondary documentation is not as strong as primary documentation. An applicant who is documenting his citizenship and/or immigration status will need to provide ID along with a secondary form of documentation. The ID must have: o A photo or o Other identifying information A list of what counts as primary and secondary documentation for citizenship, as well as a list of o government documents that will be accepted as proof of lawful immigration status is in your handouts. Remember, applicants will need to provide this documentation only when DC Health Link cannot confirm their citizenship or immigration status. We will talk more about verification for all the different eligibility factors on Thursday. Slide 43: Working with Immigrant Applicants Immigrants and their family members are disproportionately uninsured, and there are a number of barriers that can prevent immigrant families from getting the coverage they qualify for. Language barriers can be a

14 key challenge, along with fears of how applying for coverage might affect family members who are not citizens or who are undocumented. Let s go over some important things to remember about working with immigrant applicants. Applying for health coverage does not make someone a public charge. o Immigration law allows the United States to deny a person entry to the country or deny a person the opportunity to adjust his or her immigration status if the person is likely to become dependent on the U.S. government for their subsistence (sometimes called a public charge ). Immigration authorities can look at someone s past use of certain public benefits (for example, use of Medicaid for institutionalized long-term care) when making the determination of whether or not someone is likely to become a public charge. o Receiving most public benefits, including regular Medicaid, does not make someone a public charge. However, there is a high level of fear in many immigrant communities that receiving any sort of assistance could jeopardize their immigration status. That is why it is important to reassure immigrants that applying for health coverage will not affect their immigration status. Be clear about how information will and won t be used. o The application asks for lots of personal information, like address and employment. Families that include members who do not have eligible immigration status may be afraid that information they share with a government agency like ESA will be used to enforce immigration laws. o The Affordable Care Act is very clear that the information provided will be used only to determine eligibility for health coverage. Be sure that applicants understand which information is optional. o Some information, like income, is needed for everyone in the family, whether they are applying for coverage or not. o Other information not required for non-applicants. For example, non-applicants do not need to provide information on their immigration status or their Social Security numbers, although if this information can be provided it will be helpful when verifying eligibility using electronic data sources. o Making sure families understand that family members who are not applying for coverage will not have to provide sensitive information will help them feel more comfortable with completing the application. Finally, remember that if the application system cannot verify the person s immigration status right away, he or she has 90 days to provide documentation. During that 90 days, the person gets coverage. Slide 44: Review: Question #1 Which of the following groups with incomes below 200 percent of poverty have a choice between coverage through DC Alliance and DC Health Link? a. A lawfully present child b. A lawfully present adult who is subject to the five-year bar c. A U.S. citizen d. A Deferred Action Childhood Arrival Slide 45: Answer: Question #1 B. a lawfully present adult who is subject to the five-year bar

15 A lawfully present child can get Medicaid. A U.S. citizen adult can get Medicaid. A Deferred Action Childhood Arrival can get DC Alliance coverage. Slide 46: Review: Question #2 True or False: Applicants who attest to having eligible immigration status and are eligible for coverage based on other factors have 90 days to provide documentation of their immigration status if it cannot be verified electronically, but they do not receive coverage until their immigration status has been verified. Slide 47: Answer: Question #2 False Immigrant applicants do have 90 days to document their immigration status if documentation is needed, but during this time, they can get coverage, if they qualify based on other eligibility factors. Slide 48: Residency Requirements Now we ll move on to talking a bit about the residency requirements for health coverage in DC. As you know, verifying residency is important for us in the District, since neighboring states Maryland and Virginia do not provide the same levels of coverage that we do. Slide 49: Medicaid Residency You are already familiar with residency requirements for Medicaid. Applicants have to be a resident of the District of Columbia. People are considered District residents if: They live in the District and intend to continue living in the District o Applicants don t have to have a fixed address to be considered residents people who are homeless can qualify. There is no amount of time that applicants have to live in the District before qualifying. For as long as someone lives in the District, he or she is considered a resident for Medicaid purposes. These things haven t changed. People who enter the District with a job commitment or who are searching for employment are also considered residents. Slide 50: Medicaid Residency for People under Age 21 In general, people who are under age 21 can be considered residents either: of the place they live, including without a fixed address or of the state where they live with a parent or caretaker For example, a young person who leaves DC for college may or may not be considered a resident of the District. You cannot assume that a child resides with his or her parent if the applicant lists a different residence for that child: The parent and child can be considered residents of different places. Slide 51: Special Situations for Residency There are a few special situations about Medicaid residency, and these are rules you already know. When DC places someone in an out-of-state institution, such as a nursing home or mental health facility, the person is still considered a DC resident.

16 When a person decides on her own to move to a different state and enter an institution, that person will be considered a resident of that state. People who get the District s SSI supplements are automatically eligible for DC Medicaid. Slide 52: Residency Requirements for DC Health Link In general, residency rules are the same for DC Health Link as they are for Medicaid. Those over age 21 must: Live in DC, or intend to continue living in DC, including: o People with no fixed address o People who have a job commitment or are looking for a job In order to be eligible for a DC Health Link plan, children under age 21 must either: Live in DC or Have a parent or caretaker relative who lives in DC Slide 53: What if a household includes someone who lives in a different state? As we mentioned earlier, the rules about household composition are changing. For most people, household composition will be based on who is in the same tax household rather than who lives together. There are some families who file taxes together who live in different states. For example, a woman might claim her mother as a tax dependent even though her mother lives in a different state. Or spouses may live in different states because of their jobs. Families like these will have to get different health plans, since they do not all live in the District. When you are filling out an application for a resident, you will need information for all household members, even if they live in a different state. The application will consider the information for the whole household when figuring out what the DC residents are eligible for. Slide 54: Example This example illustrates what happens when family members live in several service areas. Jim (26) and Liz (28) are married and have a child, Sam (5). Jim and Sam live in the District. This year, Liz will live in North Carolina for a job. Jim has a DC Health Link plan, and Sam qualifies for Medicaid. Liz is in a separate plan in North Carolina. Jim and Liz s combined income is just under 250 percent of poverty, so they are eligible for premium tax credits and cost-sharing reductions, and Sam is eligible for Medicaid. Liz gets a premium tax credit and cost-sharing reductions in her plan, and Jim gets a premium tax credit and cost-sharing reductions in his plan. Families with incomes between 200 and 250 percent of poverty are eligible for some cost-sharing reductions. Even though Liz is living in a different state, DC Health Link will still look at the entire family income and family size to decide whether the family is eligible for premium assistance and cost-sharing reductions. Slide 55: Verifying Residency As you are filling out the application, DC Health Link will check to see if what the applicant is telling you about his or her residency can be confirmed using electronic data sources. If this information can be confirmed, the applicant does not need to show any proof of residency.

17 If the information the applicant provides cannot be confirmed, you can accept one of these documents as proof of residency: Current driver s license Current lease (signed within the last year) Current rent receipt Current utility bill Current letter from a landlord Homeless applicants do not need to provide documentation, they just need to indicate their intent to continue living in the District. Slide 56: Incarceration Incarceration is another important eligibility factor. Medicaid and DC Health Link plans treat incarceration differently. Today, if someone who is receiving Medicaid is incarcerated, his or her Medicaid case is terminated. That will change in October. Instead of closing an incarcerated person s case, DC will suspend it. People who are in prison or jail will still not be able to get benefits or services from Medicaid while they are incarcerated. The change simply means that people who are incarcerated will not have to fill out a new application when they leave, since their case was not closed. Those who are incarcerated cannot get coverage from DC Health Link or receive premium tax credits unless they are incarcerated pending disposition of charges. Pending disposition of charges means that the person has been charged but not convicted or acquitted. This generally applies to people who cannot afford their bail. People who are incarcerated may not receive coverage themselves, but they may apply for health coverage for others and be included in the households of those who can properly include someone who is incarcerated on their tax return. Slide 57: Pregnancy Knowing the pregnancy status of members of a household is important because: Pregnant women are eligible for Medicaid at higher income levels Pregnancy can affect household size The application will ask questions about pregnancy. You just need to fill in this information. DC will be relying on self-attestation for pregnancy, so you won t need to ask for any sort of documentation for pregnancy. Slide 58: Job-Based Coverage Next we are going to take a closer look at an eligibility factor that affects only those who might be able to get premium tax credits to buy a DC Health Link plan: job-based coverage. Applicants who have an offer of coverage through their own employer or through a family member s employer may not be able to get premium tax credits in some cases. Slide 59: Why does job-based coverage matter? Just to recap, if an applicant has an offer of coverage through an employer, he or she is NOT eligible for premium tax credits if that coverage meets two criteria: 1) It has to be comprehensive enough to be of minimum value. This is defined as the plan covering, on average, at least 60 percent of an enrollee s medical expenses.