Affordable Care Act. (ACA) Implementation

Transcription

1 Affordable Care Act (ACA) Implementation 1

2 Overview of the Affordable Care Act (ACA) 2

3 Objectives By the end of this session, participants will: Review changes due to ACA Explain what ACA is at a high level Define MAGI Methodology 3

4 The Affordable Care Act (ACA) The federal laws and regulations contained in the Patient Protection and Affordable Care Act and the subsequent Health Care and Education Reconciliation Act have come to be called the Affordable Care Act (ACA) The main goal of the ACA is to provide insurance coverage, both public and private, to reduce the number of Americans who are uninsured 4

5 The Affordable Care Act (ACA) Continued ACA streamlines eligibility and enrollment: Consolidates Medicaid categories Simplifies eligibility determination using Modified Adjusted Gross Income (MAGI) methodology 5

6 The Affordable Care Act (ACA) Continued Medicaid eligibility for children, pregnant women and families used to be based on the rules of Aid to Families with Dependent Children (AFDC) and then, in 1996, on the rules of Temporary Assistance for Needy Families (TANF) The ACA replaces almost all of the former eligibility rules with financial methodologies from the Tax Code 6

7 ACA Expands Medicaid Coverage For Colorado, beginning January 2014, individuals under 65 years of age with income below 133 percent of the federal poverty level will be eligible for Medicaid This new coverage ends the long time exclusion of low income adults from Medicaid coverage 7

8 MAGI versus Non-MAGI WHAT IS MAGI? Methodology for how income is counted and how household composition and family size are determined for family and children s programs (Medicaid and CHP+) WHAT IS NON MAGI? Medicaid categories exempt from applying the MAGI methodology 8

9 MAGI & Non-MAGI at a Glance Coverage up to age 65 IRS MAGI methodology for household composition and income calculation MAGI groups up to 133% FPL Medicaid Pregnant Women to 185% FPL CHP+ (children and pregnant women) up to 250% FPL No Asset Test 5% Income Disregard Cannot receive or be eligible for Medicare (for expansion populations) MAGI No change to household composition and income calculation Age varies by category Disability Determination, if under age 65 Asset Test Clients awaiting a disability determination or other verification may qualify to receive MAGI benefits in the interim NON MAGI 9

10 MAGI Eligibility Category Consolidation 1931 Family Parent and Caretaker Relatives CHP+ AwDC Eligible Newborn Current Medicaid Categories Qualified/ Expanded Child CHP+ New MAGI Medicaid Categories Pregnant Women Ribicoff Child Qualified/ Expanded Pregnant Women Children Adult 10

11 Non-MAGI Eligibility Categories Children s Buy In Long Term Care Aged, Blind Disabled Non MAGI Categories Adult Buy In Medicare Savings Program Low Income Subsidy 11

12 CHP+ Pregnant Women 12 Current FPL MAGI FPL Children Parents Adults CHP+ Pregnant Women Children Parents Adults

13 Modified Adjusted Gross Income Financial eligibility for the consolidated Medicaid and CHP+ programs will be determined using methodologies based on Modified Adjusted Gross Income (MAGI), as defined at USC 26 36B(d)(2)(B) of the Internal Revenue Code MAGI for most taxpayers is equal to their Adjusted Gross Income as figured on their personal income tax return. It may also include: Any foreign earned income excluded from taxes Tax exempt interest Tax exempt Social Security income 13

14 Countable Income CURRENT Earned Employment Self employment Unearned Alimony Child Support In Kind Veterans Benefits Social Security Benefits MAGI Counts taxable income: Salaries, Wages, Tips Capital Gains Unemployment Benefits Minus allowable tax deductions: Retirement Plan Contributions Child Care Mortgage Interest Does not count non taxable income: Social Security Title XVI Child Support 14

15 Income Disregards Medicaid: $90 Each working adult $50 Child support Childcare: Child under 2 years = $200 Child over 2 years = $175 CHP+ attested amount for: Daycare Child support Alimony CURRENT Medical Expense MAGI 5% across the board disregard for both Medicaid and CHP+ 15

16 Household Composition Current Household and Medical Benefit Unit is based on Financial Responsibility Self to Self Spouse to Spouse Parent to Child May include Caretaker Relatives MAGI Tax Filer Household based on tax dependency Tax Filer and Spouse if living together Biological, Adopted or Step Children under 19 years if tax dependents Anyone else who is claimed as a taxdependent MAGI Non Tax Filer Parallel Tax Filer to extent possible Household Includes: Individual, Spouse is living together Biological, Adopted or Step Children AND if under 19 years old: Biological, Adoptive or Step Parents Biological, Adoptive or Step Siblings 16

17 Questions? 17

18 Program Rules for Medicaid and CHP+ 18

19 Objectives Identify the difference between old & new Medicaid and CHP+ program rules By the end of this session, participants will: Recall and recite new FPL & disregard percentages Name all MAGI programs 19

20 Medicaid Family Programs Prior to ACA After ACA 1931 Transitional Medicaid 4 Month Extended Psych < 21 Baby Care Kids Care (BCKC) Qualified Child Expanded Child Ribicoff Qualified Pregnant Expanded Pregnant Legal Immigrant Pregnant Needy Newborns Children Needy Newborns Psych < 21 Parents/Caretaker Relatives Transitional Medicaid 4 month extended Pregnant Women Legal Immigrant Prenatal Adults 20

21 CHP+ Family Programs No Changes in CHP+ Family Programs after ACA Prior to ACA CHP+ Children CHP+ Pregnant Women CHP+ Needy Newborns After ACA CHP+ Children CHP+ Pregnant Women CHP+ Needy Newborns 21

22 Medicaid Children Volume 8 Rules at 10 CCR G.2 MAGI Covered Groups (children) G.7 MAGI Covered Groups (needy newborn) D. MAGI Methodology for Income Calculation D. Income Disregard E. Determining MAGI Household Composition H. Needy Persons Under 21 Effective 10/1/2013, MAGI methodology for income calculation, disregard, and household composition: Up to 133% FPL Under age 19 Child will continue to pass as a Newborn when Mom is no longer on the case or in the home Needy persons under 21 continue to be covered o Foster care Title IV E extend to age 26 22

23 CHP+ Children Volume 8 Rules at 10 CCR D Eligible Persons Calculation of Household Income Disregards Household Enrollment Date 300 Enrollment Fees and Copays Effective 10/1/2013, MAGI methodology for income calculation, disregard, and household composition: Greater than 133% FPL but less than 250% FPL o Enrollment fee still applies between % FPL o With additional 5% disregard Under age 19 Newborns covered 1st year 23

24 Medicaid Pregnant Women Volume 8 Rules at 10 CCR G.5 MAGI Covered Groups (pregnant women) D. MAGI Methodology for Income Calculation D. Income Disregard E. Determining MAGI Household Composition E.2 Household size G.6 MAGI Covered Groups (legal immigrant pregnant women) Effective 10/1/2013, MAGI methodology for income calculation, disregard, and household composition: Counts as herself plus number of unborn children Up to 185% FPL o With additional 5% disregard Age 19 and over Eligibility up to end of month of 60 days postpartum Legal Immigrant Prenatal still applicable 24

25 CHP+ Pregnant Women Volume 8 Rules at 10 CCR E Eligible Persons Calculation of Household Income Disregards Household Enrollment Date Enrollment Date Effective 10/1/2013, MAGI methodology for income calculation, disregard, and household composition: Counts as herself plus number of unborn children Greater than 185% FPL but less than 250% FPL o With additional 5% disregard Age 19 and over Eligibility up to end of month of 60 days postpartum NEW! Eligible as of 1 st of month of application, not as of application date 25

26 Medicaid Parents and Caretaker Relatives Volume 8 Rules at 10 CCR G.4. MAGI Covered Groups (adults) D. MAGI Methodology for Income Calculation D. Income Disregard E. Determining MAGI Household Composition Definition of Adult MAGI Medical Assistance Effective 10/1/2013, MAGI methodology for income calculation, disregard, and household composition: Up to 100% FPL o Effective 1/1/2014, up to 133% FPL o With additional 5% disregard Must have a dependent child Transitional Medicaid and 4 Month Extended up to 100% FPL 26

27 Medicaid Adults Volume 8 Rules at 10 CCR G.4. MAGI Covered Groups (adults) D. MAGI Methodology for Income Calculation D. Income Disregard E. Determining MAGI Household Composition Definition of Adult MAGI Medical Assistance Effective 1/1/2014, MAGI methodology for income calculation, disregard, and household composition: Up to 133% FPL o With additional 5% disregard Age 19 through end of month turn 65 Does not have a dependent child Must not be eligible for Medicare 27

28 Prior Rules Still Applicable Citizenship Requirements for all programs Emergency Medicaid Retroactive Medicaid Definition of Caretaker Relative Express Lane Eligibility Direct Certification Other Health Insurance for CHP+ Enrollment Fees for CHP+ 28

29 Questions? 29

30 Household Composition 30

31 Objectives By the end of this session, participants will: Identify the difference between old & new Household Composition rules Interpret the new rules to solve scenarios and discuss how they relate to real world examples Correctly calculate household size using the new rules 31

32 New Household Composition Within these categories, Household/Monthly Budget Unit (MBU) is determined on an individual basis: Household composition for each individual in the case is determined based on the Tax Filer rules or the Non Filer rules Each individual in the case will have an MBU created with the household individual as the eligible person (adult or child) and others in the case showing as counted or excluded based on the new rules 32

33 Old Policy vs. New Policy In the past Medicaid was determined based upon the rules of AFDC and then TANF This meant that household composition was created around children; parents and spouses were typically included Medicaid law required that only the financial needs of an individual and anyone legally responsible for that person (and who was living with him/her) be considered in determining eligibility This often led to creation of groups (household composition) where siblings were excluded, along with step parents and others who did not have a legally responsible relative relationship 33

34 Old Policy vs. New Policy The new policies required by the ACA include everyone in the household around the individual, and then detail who is counted (along with their income) and who is not 34

35 Tax Filer vs. Non-Filer The first step in determining Household (HH) Composition is gathering information from each individual in the household on whether or not s/he plans to file taxes for the tax year in question, and whether or not s/he will be claimed as a tax dependent by anyone else 35

36 Tax Filer Rules The household consists of the taxpayer and spouse living with the taxpayer and all persons whom the taxpayer expects to claim as a tax dependent These individuals will count as household/mbu members. Any other individuals in the case who are not tax dependents of the taxpayer will be excluded in the MBU 36

37 Definition of Tax Dependent: A household member is counted as a Tax Dependent if he/she is claimed as such by the Tax Payer and does not meet the following exceptions, in which the household member: 1. Expects to be claimed as a tax dependent of somebody other than a spouse, biological, adopted or step parent 2. Is a child under 19 years old living with both parents, but the parents do not expect to file a joint tax return 3. Is a child under 19 years old who expects to be claimed by a noncustodial parent 37

38 Definition of Tax Dependent ACTIVITY If the household member does not meet any of the exceptions, then the Tax Filer (Tax Dependent) rules apply: The household consists of the Tax Dependent, the Tax Dependent s spouse if living with the Tax Dependent, the Tax Payer and all his/her other Tax Dependents Any other individuals in the case who are not tax dependent on the taxpayer will be excluded from the MBU If the household member meets any exception, then follow the Non Filer rules 38

39 Non-Filer Rules If the household member is not the Tax Payer or Tax Dependent, and did not/will not file taxes, then follow the Non Filer Rule. Non Filer Rule: Include individual s spouse; any natural, adoptive or step children under the age of 19; and if under 19 the individual s natural, adopted, or step parents and siblings under 19 as counted HH members in the MBU Anybody other than the abovementioned relationship will be excluded in the MBU 39

40 Household Size The household size for each MBU will include all the eligible and counted individuals in the MBU for the individual s household Each household individual s MBU might have a different household size, depending on the household composition A pregnant woman s household includes the number of children she is expecting 40

41 Household Composition Flowchart Use the Household Composition Flowchart to determine MBUs 41

42 Questions? 42

43 Verifications 43

44 ACA Goals for Verification Maximize automation through data sources Minimize need for documentation; reduce administrative burden Offer a simple and transparent process for consumers Ensure program integrity 44

45 Electronic Data Sources ACA states that we must rely primarily on electronic data sources May use current state electronic data sources if determined useful Individuals must not be required to provide additional information or documentation unless information cannot be obtained electronically or it is not reasonably compatible with attested information 45

46 Self-Attestation Can be accepted from: The applicant An adult in the applicant s household or family Authorized representative Someone acting responsibly for the individual (if minor or incapacitated) Is accepted for all factors of eligibility except as required by law, i.e., citizenship and immigration status 46

47 Colorado Verification Plan States are required to submit a verification plan to Centers for Medicare and Medicaid (CMS) Plan outlines eligibility factors and Colorado s options for verification of eligibility factors. This identifies the Department s: Verification policies and procedures Standards for determining the usefulness of data Circumstances under which it will consider information provided by an applicant to be reasonably compatible with information obtained through an electronic source 47

48 Eligibility Factor Self Attestation Accepted (Y/N) Verify with Electronic Data Source (Y/N); Name of Data Source Verification Table Goes Here! Need for documents Income Yes Yes Post eligibility with IEVS If outside reasonable threshold and no reasonable explanation Residency Yes No Only if questionable Age (Date of Birth) Social Security Number Yes No Only if questionable Yes Yes Verify through SSA Interface Only if questionable Citizenship No* Yes Verify through SSA SVES SCHIP Interface If no match, reasonable opportunity period provided while pending for documents Identity No* Yes DMV or SSA interface If no match, reasonable opportunity period provided while pending for documents Immigration Status No Yes SAVE through the Federal Hub If verification is not received from SAVE interface, documentation will be required Pregnancy Yes No Only if questionable 48

49 Definition of Reasonable Income Compatibility Reasonable Compatibility refers to an allowable difference or discrepancy between the income an applicant self attests and the amount of income reported by an electronic data source When discrepancies occur between self attested income and electronic data source results, the applicant will receive every reasonable opportunity to establish his/her financial eligibility 49

50 Definition of Reasonable Income Compatibility Process Through the test for reasonable compatibility OR By providing a reasonable explanation of the discrepancy OR By providing paper documentation in accordance with this section 50

51 Reasonably Compatible Income Income attestation and data sources are considered reasonably compatible when: Both attestation and data are below Medicaid MAGI levels Attestation is above Medicaid MAGI levels (regardless of whether data is obtained or if it is above or below Medicaid MAGI levels) Data is above Medicaid MAGI levels, attestation is below, but data is within 10% of attestation In these instances, eligibility will continue to be determined without the need for additional information or documentation 51

52 Non- Compatible Income If income information is not determined reasonably compatible, additional information is required A reasonable explanation of the discrepancy shall be requested. If the applicant is unable to provide a reasonable explanation, paper documentation shall be requested 52

53 Reasonable Compatibilit y 53

54 Reasonable Explanation If the client provides a reasonable explanation, no further documentation will be needed. These explanations include: Stopped working Hours changed Wage or salary changed Change in employment Marriage, legal separation, or divorce Death in family Required documentation for income will be the same as today (check stub, employer letter, etc.) 54

55 Questions? 55

56 Income 56

57 Objectives Identify the difference between old & new Income rules By the end of this session, participants will: Interpret the new tax filer rules to solve scenarios and discuss how they relate to real world examples Calculate income & eligibility using the new rules 57

58 A Note about Non-MAGI Programs There will be no changes to the way income is determined for Non MAGI programs For more information on income for Non MAGI programs, please see the resources available at including the Adult Medical and Long Term Care training modules presented at the Non MAGI training in June

59 The New World: What is Changing for MAGI Programs 59

60 Current MAGI & Expansion FPL FPL MAGI FPL Adults Parents Children Pregnant Women/CHP + Adults Parents/ Caretakers Children Pregnant Women/CHP + 60

61 Modified Adjusted Gross Income (MAGI) Financial eligibility for the consolidated Medicaid and CHP+ programs will be determined using methodologies based on Modified Adjusted Gross Income (MAGI), as defined at USC 26 36B(d)(2)(B) of the Internal Revenue Code MAGI for most taxpayers is equal to their Adjusted Gross Income as figured on their personal income tax return. It may also include: Any foreign earned income excluded from taxes Tax exempt interest Tax exempt Social Security income 61

62 MAGI MAGI is a methodology for how income is counted and how household composition and family size are determined MAGI is not a number on a tax return MAGI is based on federal tax rules for determining adjusted gross income (with some modification) No asset test or disregards (except acrossthe board 5% disregard, bringing income standard for adults to 138%) 62

63 Countable Income: Old World (Pre 10/1) Earned Unearned Employment Self employment Alimony Child Support In Kind Unemployment Veterans Benefits Social Security Benefits 63

64 Countable Income: New World (MAGI) Counts taxable income: Minus allowable tax deductions: Does not count nontaxable income: Salaries, Wages, Tips Capital Gains Unemployment Benefits Retirement Plan Contributions Child Care Mortgage Interest Social Security Title XVI Child Support 64

65 MAGI Countable/Exempt Income Income Type American Indians and Alaskan Native payments Education scholarships/grants Child Support Alimony Earned Income Tax Credit (EIC) Foster Care Payments Life Insurance Beneficiary Payment Shelter Countable/Exempt Exempt Exempt unless used for living expenses Exempt Countable Exempt Exempt Countable Countable 65

66 Income Disregards Pre 10/1 Medicaid: $90 each working adult $50 Child support Childcare ($200 for a child < 2 years, $175 years) CHP+ attested amount for: Daycare or Elder Care Child support Alimony Medical Expenses (including Health Insurance Premiums) 66

67 Income Disregards MAGI 5% across the board disregard for both Medicaid and CHP+ 67

68 $5,800 Exclusion If an individual makes $5,800 or less annually, CBMS will exclude that individual s income from the income calculation for MAGI households that include that individual This income should still be entered into CBMS 68

69 MAGI Household Composition Tax Filer Household consists of the taxpayer and spouse living with the taxpayer and all persons whom the taxpayer expects to claim as a tax dependent Tax Dependent The household consists of the individual, the individual s spouse if living together, the taxpayer claiming him/her as a tax dependent and all other tax dependents of the taxpayer Non Filer/meets exception The household consists of the individual and if living with the individual: Individual s spouse Individual s children under age 19 (natural, adopted or step) And if the individual is under age 19, the individual s parents (natural, adopted or step) and siblings (natural, adopted and step) 69

70 New Income Rules All household income of Eligible and Counted individuals will be counted towards the total countable income of the Medical Household Composition Lump sum income will be counted in the month it is received If the total annual countable income of an individual is less than $5,800, then that individual s income is considered exempt for MAGI Income calculation If an individual is a dependent of a tax filer, and that individual s income is less than the required amount for him/her to file a tax return, that individual s income will be exempt from MAGI income calculation 70

71 ACTIVITY Income/FPL Calculation Monthly Income 100% FPL (family size) 100 Household FPL % 71

72 Income/FPL $ Calculation ACTIVITY 100% FPL (family size) % FPL w/decimal point moved to the left twice Household FPL $ 72

73 Questions? 73

74 Single Medical High Level Program Group (HLPG) 74

75 Pre 10/1 World PEAK and CBMS contained multiple HLPG s Family Medicaid (FM) Child Health Plan Plus (CHP+) Long Term Care (LTC) Adult Medicaid (AM) Medicare Savings Program (MSP) Low Income Subsidy (LIS) 75

76 New World One Medical HLPG (does not include PE) 45 different subcategories/aid codes Client will be run through all applicable medical subcategories/aid codes prior to receiving a denial or termination 76

77 NF/Hospital 300% Institutionalized HCBS CCT Medical Hierarchy for CBMS Order of Sequence is as follows: HCBS EBD HCBS DD HCBS SLS HCBS CMHS HCBS BI HCBS PLWA PACE HCBS CHCBS HCBS CLLI 77

78 HCBS CHRP HCBS CES Medical Hierarchy for CBMS Order of Sequence is as follows: HCBS CWA HCBS SCI SSI Mandatory Pickle DAC QDW OAP Med A OAP Med B 78

79 OAP A Med > 65 Psych MAGI Pregnant Medical Hierarchy for CBMS Order of Sequence is as follows: CHP+ Prenatal Legal Immigrant Prenatal Psych <21 Eligible Needy Newborn CHP+ Newborn MAGI Children CHP+ MAGI Parents/ Caretakers 79

80 MAGI Adults Medical Hierarchy for CBMS Order of Sequence is as follows: Trans Med 4 month extended Buy In WAwD Buy In CBwD Refugee BCCP 80

81 QMB Medical Hierarchy for CBMS Order of Sequence is as follows: SLMB QI 1 QDWI OAP HCP A OAP HCP B LIS 81

82 Security CURRENT WORLD NEW WORLD Security access is based off the medical HLPG s the end user administers Security access granted to all eligibility end users who had security access to administer at least one medical HLPG (except PE) can now administer the ONE medical HLPG End users who only had read only access to medical programs continued to have read only access CBMS vendor did an automated security update for all end users who needed this profile 82

83 Questions? 83

84 Case Assignment 84

85 Objectives By the end of this session, participants will: Determine how CBMS will assign cases for MA sites, Peak, C4HCO, and Counties Pinpoint the location of a new case based on assignment guidelines 85

86 Medical Assistance Case Assignment MA cases will be assigned at Authorization Counties will maintain the ongoing case for any medical program approval that enters through their door 86

87 Medical Assistance Sites Denver Health will maintain the ongoing case for all MAGI cases that enter through their door. If the authorization results in a combo MAGI/Non MAGI or a Non MAGI only case then the system shall assign the ongoing case to the County of Residence (COR) Maximus will maintain the ongoing case for all MAGI cases that enter through their door. If the authorization results in a combo MAGI/Non MAGI or a Non MAGI only case then the system shall assign the case to the COR Medical Assistance Sites not equal to Denver Health or Maximus will not maintain a case load 87

88 PEAK/C4H CO All cases entered through PEAK/C4HCO that result in a real time determination (MAGI only) shall be assigned to the COR All cases entered through PEAK/C4HCO that result in a real time and non real time determination (MAGI/Non MAGI) shall be assigned to the COR All cases entered through PEAK/C4HCO that exception out in that a real time determination can t be made (i.e. interface down, etc.) shall be assigned to Maximus for eligibility determination Once eligibility is determined, or if the COR must determine for a Non MAGI program, case will be assigned to COR 88

89 PEAK/C4H CO/CBMS All cases entered through PEAK/C4HCO that exception out in that a real time determination can t be made (i.e. interface down, etc.) shall be assigned to the COR if a DHS HLPG is reflected on the case with the MA HLPG If a client reports a change of address via PEAK/CBMS that results in a change of county then the system shall automatically assign the ongoing case to the new COR only 89

90 PEAK/CBM S A client applies to PEAK and is: Determined to be active on an existing case o Referred to PEAK as active on o an existing case Referred to Report My Changes (RMC) But the client chooses to complete the New Application in PEAK as opposed to RMC o The client submits the application and does not receive Real Time Determination The Application is sent to the COR via PEAK Inbox NOT Maximus 90

91 PEAK/C4H CO/CBMS Continued If a client reports a change of address via PEAK/CBMS that results in a change of county and the current case is = to Denver Health or Maximus then the case shall remain with that MA site This case assignment process is for medical case assignment only and does not override the existing case assignment process for DHS programs that are assigned via PEAK or CBMS 91

92 Case Assignment Summary 92

93 Questions? 93

94 Case Conversion 94

95 Case Conversion Existing medical HLPGs were enddated effective 9/30/2013 and have been replaced by the MA HLPG effective 10/1/2013 Existing medical categories within existing medical HLPGs were enddated effective 9/30/2013 and new medical subcategories are effective 10/1/2013 Existing medical HLPGs are no longer visible to the end user to select when entering an application on or after 10/1/2013 All applications entered on or after 10/1/2013 will be entered for the MA HLPG and have eligibility determined under the MA HLPG regardless of the application date 95

96 Case Conversion Continued When the End User searches within the Case Inquiry or Individual Inquiry pages, only the MA HLPG and new MA subcategories will be visible The end dated HLPGs and categories for the client will only be visible to the End User within the Prior Aid page Client benefits remained the same when converted from the existing Medical HLPGs and subcategories to the ONE MA HLPG and subcategories Cases will have an equivalent aid code assignment 96

97 Case Conversion Continued Any CBMS page that displayed an existing medical HLPG will display the MA HLPG effective 10/1/2013. This includes alerts, case comments, redeterminations, etc. All case and individual information associated with the converted case will remain All cases with a closed FM, AM, LTC, MSP, CHP+ and LIS HLPGs at the time of conversion were restricted so that end users are unable to rescind the end dated HLPGs 97

98 Case Conversion Continued If a household member was active under the SSI Mandatory sub category/aid code at the time of conversion, an SSI med flag was set within the med span for the individual The CBMS environments were updated to include the new MA HLPG and the MA eligibility rules 98

99 Questions? 99

100 Adults without Dependent Children (AwDC) TRANSITION AND EXPANSION POPULATIONS 100

101 Objectives Describe the different scenarios that AwDC clients and applicants will encounter By the end of this session, participants will: Identify which category an AwDC client or applicant falls into Discuss how to help clients in each category manage ACA 101

102 AwDC Background In 2012 the Department of Health Care Policy and Financing (HCPF) began a new program to enroll a limited number of Adults without Dependent Children (AwDC) The limited enrollment was managed through a waitlist and a monthly randomized member selection process 102

103 AwDC and ACA In January 2014, funds provided by the federal government through the Affordable Care Act will allow Colorado to enroll all eligible adult clients with income up to 133% of the Federal Poverty Level (FPL) with no enrollment caps 103

104 AwDC Waitlist The waitlist ended October 1, 2013 The AwDC enrollment was increased in September to account for the attrition that would have occurred between October December 104

105 AwDC Transition Plan AwDC was transitioned to the new rules engine. There were three parts to the transition: Clients receiving AwDC benefits Clients on the AwDC waitlist New clients applying between October December

106 Clients Receiving AwDC Benefits These clients will continue to receive benefits October December Must continue to have income at 10% or less of FPL o Those that go above 10% will be denied between Oct Dec and fall into the category of new clients applying Must meet all other eligibility criteria Eligibility will be redetermined at their appropriate renewal period 106

107 Clients on the AwDC waitlist These clients will continue to wait for enrollment effective January 1, These clients: Will show as Approved and Waiting within CBMS Will be identified behind the scenes for a mass update Do not have to reapply for a January 1 enrollment 107

108 New Clients Applying Between October December 2013 These clients are adults without a dependent child between 0 133% FPL This also includes Parents/Caretaker Relatives between % FPL With the new rules engine, eligibility will be determined through all medical program categories If they are not eligible for any program they will be denied for enrollment between Oct Dec 108

109 New Clients Applying Between October December 2013 Continued Clients less than 133% FPL will receive an additional notice indicating they may be eligible for enrollment effective January 1, 2014 They will not be sent to C4HCO An identifier will be set for these individuals This may also include clients that were on Medicaid but were discontinued between Oct Dec (such as a 19 year old aging out) 109

110 Mass Update for AwDC At the end of November, a mass update will be run for clients. This includes: Clients on the AwDC waitlist New clients that applied between October December 2013 If the case is terminated or denied, the system will rescind and generate a mass update trigger to run EDBC As long as circumstance has not changed, clients will be eligible for benefits as of January 1,

111 Scenario 1: AwDC client already enrolled in benefits by September 30 September Client is already enrolled in benefits through the waiver October December Client maintains waiver eligibility; still enrolled in benefits January 1, 2014 Client is enrolled in Medicaid expansion; no need to reapply 111

112 Scenario 2: Client is on the AwDC Waitlist on September 30 September 30 Client is already on the AwDC waitlist; not enrolled in benefits October December Client information retained in CBMS; flagged for potential January enrollment; no need to re apply January 1, 2014 Eligible waitlist clients enrolled in Medicaid expansion 112

113 Scenario 3: Client applies between October December 113

114 Questions? 114

115 Call Center 115

116 Review the Single Streamlined Application and Phone Application Objectives By the end of this session, participants will: Know what to expect from ACA Direct clients appropriately Answer Frequently Asked Questions (FAQs) Refer to Frequently Used Phone Numbers 116

117 Single Streamlined Application (SSAp) What is a Single Streamlined Application (SSAp)? Single application for all programs o Medicaid o CHP+ o Federal tax credits through the Marketplace Used by all organizations 117

118 SSAp Continued The form will be: Used by the Marketplace, Medicaid and CHP+ Agencies Easy for applicants to complete Accepted online, in person, by mail or by phone 118

119 What does this mean for you? * Lake Research Partners, August 2011 Research has found that as many people want assistance by phone as in person* Twice as many want help over the phone compared to those who want help online* Phone applications will be especially important to supporting enrollment 119

120 Applications by Phone The ACA will require states to accept electronic and telephonic signatures Requirement extends to the Marketplaces Telephonic Signature Individual s recorded verbal assent Used in place of ink signature Legally enforceable 120

121 Telephonic Signature Applicant s signature must be securely stored by the agency for a defined period of time: As would be required by paper signature Three years past last date of open eligibility Should not be limited to those applying through the Marketplace call center 121

122 Telephonic Signature Continued Agencies must be able to securely transfer signature back and forth, along with the applicant s case file Centers for Medicare and Medicaid Services (CMS) is expected to issue detailed guidance around use in upcoming months 122

123 Day 1: Application by Phone We are aware that the technological requirements for Day 1 capture of telephonic signature may be prohibitive for many organizations If you receive a request to complete an application by phone: Direct applicant to HCPF Medicaid Call Center Provide caller with phone number: OR warm transfer by placing applicant on hold, calling above number, and transferring applicant 123

124 Obamacare Day 1: October 1, 2013 Callers may refer to ACA ( ah kah ) as: Health Care Reform The Exchange Health Insurance Marketplace Affordable Insurance 124

125 Day 1: October 1, 2013 Agents should be prepared to: Answer questions regarding ACA Encourage applicants to apply online at PEAK o Real time eligibility decision Direct those applying by phone to the HCPF Medicaid Call Center 125

126 HCPF Customer Contact Center Application Flow Call Customer Service Toll-free Line Step 1 Step 2 Select Application Prompt Route to Vendor Call Center Step 3 126

127 Future County Process Call Local County Office Step 1 Step 2 Select a Prompt County Agent takes SSAp by Phone Step 3 127

128 Types of Callers Families Married couples Persons with disabilities 128

129 Types of Callers Senior citizens Pregnant women Young adults 129

130 Key Words & Phrases Use when speaking with callers: easy, seamless transitions readily accessible consumer friendly streamlined, coordinated, & simplified 130

131 No Wrong Door to Health Insurance PEAK Connect for Health Colorado Medicaid Client Services County Human Services 131

132 Day 1: You Receive a Call I want to sign up for Obamacare. Can you help me with that? I sure can! Let s start with a few questions 132

133 Frequently Asked Questions Am I eligible? Will I lose my benefits? Will Obamacare cover my eyeglasses? 133

134 Frequently Asked Questions Question Why do I need health insurance? How much does insurance cost? When can I enroll? I have pre existing conditions can I still apply/enroll? How can I apply? Response Health insurance protects you from high costs when you need medical care. Depending on your insurance plan, you ll usually pay a monthly premium & possibly a deductible, plus copayments for services. Enrollment in the Marketplace begins October 1, Coverage begins January 1, Yes you can no longer be denied due to preexisting medical conditions. You can apply online through the PEAK website, in person at your county social services office, by mail or over the phone. 134

135 Frequently Asked Questions Question Do I have to submit an application for each program/plan? What can I do on PEAK? How will I be notified? When will I be notified? Response No a single medical application will be used to determine your eligibility for all medical programs. By the end of the year, you will be able to apply for Medicaid, verify your eligibility, add/remove people from your case, order medical cards, pay enrollment fees/premiums & much more. You will receive a Notice of Action (NOA) letter indicating your and, if applicable, your family s eligibility determination. If you applied online, you can also verify eligibility through PEAK. Note: if you applied for non medical assistance programs, like food assistance, you will receive multiple notices. 135

136 Frequently Asked Questions Question Who is eligible for ACA/Medicaid/Medicare? Response Anyone meeting the following criteria is eligible: Currently living in the U.S. Must be a U.S. citizen or national Must not be currently incarcerated Individuals who meet the income requirements (see below) should apply for Medicaid; individuals who do not qualify for Medicaid & who do NOT have affordable employer insurance can purchase insurance through the Exchange. Individuals over 64 are automatically eligible for Medicare. Can I get Medicaid? If you are a U.S. citizen, under 65 years of age, with income below 133% of the FPL (about $14,000 for an individual & $29,000 for a family of four), then you may now qualify for Medicaid. 136

137 Frequently Asked Questions Question Response What is MAGI? I thought health plans were required to keep children under 26 on their family s plan; why was my child removed from Medicaid? Modified Adjusted Gross Income (MAGI) is a new form of income calculation used to determine Medicaid eligibility across states. The calculation is based on Adjusted Gross Income (AGI) as defined in Internal Revenue Code 36B(d)(2). The new health law requires private insurances to keep individuals under 26 on their parent s plan; the law does not require public assistance programs (like Medicaid) to do so. On Medicaid, once a child reaches the age of 19, they are removed from their parents policy and must apply for Medicaid on their own OR can contact the Marketplace for additional options. 137

138 Frequently Asked Questions Question Response What are tax credits? Do tax credits apply toward Medicaid costs (like my copays?) The new tax credit available through the Marketplace helps reduce your monthly health plan premium costs. Credits are sent directly to your insurance company & applied to your premium. Tax credits only apply towards qualified health plans purchased through the Marketplace & cannot be applied towards Medicaid copayments or premiums. Does ACA cover breast pumps? No the ACA requires private insurances to provide breast feeding supplies but specifically excludes public assistance programs (like Medicaid) from this requirement. 138

139 Frequently Used Phone Numbers Entity Contact Connect for Health Colorado Website: connectforhealthco.com/ Phone: PLANS 4 YOU ( ) Medicaid Client Services Medicare State Health Insurance Assistance Program (SHIP) Website: colorado.gov/hcpf Phone: Website: medicare.gov Phone: MEDICARE ( ) Phone: Social Security Administration Website: ssa.gov Phone:

140 Conclusion Single Streamlined application will remedy current inefficiencies Individuals and families can obtain coverage online, in person, by mail, and by telephone Effective assistance over the phone will play a key role 140

141 Questions? 141

142 Simulation/Override Environment 142

143 Objectives By the end of this session, participants will: Summarize how eligibility will be determined using old rules List the steps that need to be followed when using the simulation environment Discuss override CBMS page 143

144 Simulation End Users will not be able to determine eligibility for ongoing MA prior to 10/1/2013 within the production environment This determination will need to be made within the new simulation environment that will house the rules prior to the October 1, 2013 implementation 144

145 Simulation Continued If an End User tries to determine eligibility prior to 10/1/2013 he/she will receive an error message The simulation environment will be limited to state personnel only (Limited HCPF Staff) Once eligibility has been determined for the months prior to 10/1/2013 in the new simulation environment, results will need to be entered into the production environment manually with the use of the override functionality To create or modify the client med span 145

146 Override New CBMS Screen: Medical Assistance Eligibility Determination Override The update override functionality will be limited to state personnel only (Limited HCPF Staff) The purpose of override is to have the ability to create/modify a med span based on the override record entered When a CBMS error message is received that eligibility cannot be run prior to 10/1 and pre 10/1 eligibility must be updated, submit a help desk ticket All End Users that have access to the MA HLPG will have read only access on this page 146

147 Questions? 147

148 Single Streamlined Application (SSAp) 148

149 Objectives Break down and discuss SSAp By the end of this session, participants will: Explore the application for similarities and differences to other applications Discuss your SSAp questions 149

150 Single Streamlined Application Online All applications must be receivable: By Telephone In Person By Mail Other Electronic Means as Commonly Available 150

151 Single Streamlined Application No interviews (in person or otherwise) for Medical Assistance (MAGI or Non MAGI) ever! Applications can be signed by: Applicant Non applicant in applicant s family or household Someone acting responsibly for a minor or person incapacitated An authorized representative, as designated 151

152 No Wrong Door Colorado SSAp States required to use the same application for Insurance Affordability Programs (IAPs) HCPF online SSAp is PEAK; C4HCO online follows federal model For the paper SSAp, Colorado has opted to take the federal model and modify according to Colorado needs This will replace our current Application for Medical Assistance 152

153 Components of the SSAp Standard Form Worksheet A Worksheet B Worksheet C Worksheet D Worksheet E Appendix A Captures the demographic information and information necessary to make a MAGI determination Health Coverage for Jobs American Indian or Alaska Native Family Member Assistance with Completing this Application Additional Information Required Additional Persons Glossary Provides terms and definitions from the application 153

154 Components of the SSAp: Worksheets Worksheet A (Health Coverage for Jobs) Used for health coverage for purposes of Marketplace only Worksheet B (American Indian or Alaska Native Family Member) Used for Marketplace purposes Worksheet C (Assistance with Completing this Application) Used to establish an Authorized Representative and capture Certified Application Counselors/Brokers/etc. (bottom hald for Marketplace) Worksheet D (Additional Information Required) This worksheet will be used to capture information for Non MAGI (Aged, Blind, Disabled/LTC, MSP, Buy Ins) Worksheet E (Additional Persons) Provides two additional worksheets for additional members 154

155 Application for Public Assistance The Application for Public Assistance has been updated by DHS This application will also capture the new data required for ACA Information will be captured within a section of the application o This is currently in progress CMS approval is also required for this application 155

156 Application Transition A transition plan is required to move from the current Application for Medical Assistance to the new Single Streamlined Application (SSAp) Goal to not have consumers have to fill out a new application if already filled out old application Supplemental page provided to capture additional required data 156

157 Questions? 157

158 PEAK 158

159 Objectives By the end of this session, participants will: Paraphrase to UX2014 elements : Summarize SSAp required data elements Understand changes with CHP+ and Buy In enrollment and Premiums 159

160 PEAK Modified to reflect the UX 2014 elements Public and Private Partnership o Center For Medicaid CHIP Services (CMCS), Center For Consumer Information and Insurance Oversight, Eleven States (Including Colorado) and Eight National and State Foundations IDEO: A global and Design Consultancy lead the design effort 160

161 PEAK SSAp required data elements Dynamic application Real Time Eligibility for MAGI CHP+ and Buy In enrollment and Premiums will be accepted via PEAK (Dec. Release) 161

162 PEAK Inbox MAGI eligibility exceptions NON MAGI Medical DHS Programs Data will already be within CBMS Applicable DHS program will need to be added 162

163 Questions? 163

164 Client Correspondence 164

165 Objectives By the end of this session, participants will: Identify additions to client correspondence notices Describe the update approval and denial sections Discuss how the move to one HLPG will modify notices 165

166 Background The client correspondence has been redesigned to align with a determination through multiple medical programs Individuals that meet eligibility criteria for several medical assistance categories will be determined for these categories and receive the category with the most benefits This redesign incorporates considerable feedback from various stakeholders that included eligibility sites, community partners, and advocates 166

167 Functionality The client correspondence is dynamic based on the household and each individual s eligibility determination Symbols were inserted to help distinguish between different actions taken 167

168 Benefit Categories Since the medical programs are moving to one HLPG, there is no need to display each program as before. Instead, consumers will see which type of benefit category they are eligible for There will not be separate notices for denial of different subcategories, only the type of benefit category The benefits associated with the approved category are as follows 168

169 Benefit Categories Continued Medicaid + Additional Long Term Care Services Medicaid No Premium required Medicaid Premium may be required Payment of Medicare Part A &/or B Premium + Co Pays/Deductibles Payment of Medicare Part A &/or B Premium Limited State Only Medical Assistance Payment of Medicare Part D Premium + Co Pays/Deductibles CHP+ Assistance 169

170 Correspondence: Header The header of the letter will provide the CBMS Case Number, the head of household name, address, and the date/time of eligibility determination The assigned eligibility worker will display on the righthand side along with his/her contact information 170

171 Correspondence: Approval The approval section will list all individuals in the household that are approved within the same benefit category and same effective date 171

172 Approval: Breakdown Benefit Category Individual Name and Medical Assistance ID Application Date Coverage Start Date Additional Information Supporting Rule The benefits associated with the approved category will display here Lists full name (first and last) of each approved individual and their associated State ID Lists the application date associated to the action taken Lists the date that the benefits are available to the individuals If there is additional information that needs to be provided, it will be listed within this area Provides the rule citation(s) for the action taken 172

173 Correspondence: Denial The denial section is for one individual that has been denied benefits. If more than one individual is denied, each individual will have his/her own section 173

174 Denial: Breakdown Benefit Category Individual Name and Medical Assistance ID Application Date Reason Supporting Rule The benefits associated to the denied category will display here Lists full name (first and last) of individual denied benefits Lists the application date associated to the action taken Provides the reason that the individual was denied. Multiple denial reasons may be listed if applicable Provides the rule citation(s) for the action taken 174

175 Correspondence: Termination The termination section is also for one individual whose benefits have terminated. If more than one individual within the household is terminated, each individual will have his/her own section 175

176 Termination: Breakdown Benefit Category Individual Name and Medical Assistance ID Coverage End Date Reason Supporting Rule The benefits associated to the terminated category will display here Lists full name (first and last) of individual Lists the date the coverage was terminated Provides the reason that the individual was terminated. Multiple termination reasons may be listed if applicable Provides the rule citation(s) for the action taken 176

177 Correspondence: Change(s) The change section provides information when changes occur Cases with changes of premiums for the Adult or Children s Buy In programs 177

178 Change(s): Breakdown Benefit Category Individual Name and Medical Assistance ID Effective Date/Month Reason Supporting Rule The benefits associated to the category with the change will display here Lists full name (first and last) of individual Lists the date the change will occur Provides the reason that there was a change for the individual. Multiple change reasons may be listed if applicable Provides the rule citation(s) for the action taken 178

179 Appeals and Additional Information 179

180 Appeals and Additional Information 180

181 Generating the Notice of Action When the client correspondence is triggered, only the reason code and action codes for the latest authorization (by benefit month) are printed Only one client correspondence will be generated for a medical case 181

182 Example 1 On case 1B12345, EDBC and Authorization occurs two times (for the same benefit months) EDBC Authorization time Eligibility Result time 8:45 am 8:55 am Denial 10:30 am 10:35 am Approval The letter sent out in batch overnight shall be the results from the 10:30 am Authorization. The Denial notices will not be sent. 182

183 Example 2 On February 20 th, EDBC and Authorization occurred on case 1B12345, three times in one day (for the same benefit months) EDBC time Authorization time Eligibility Result Benefit Months 8:45 am 8:55 am Denial February April 10:30 am 10:35 am Approval February April 1:50 pm 1:55 pm Termination April In this situation, both the Approval and Termination notices shall be sent. The termination begins in April instead of February because of 10 day noticing. 183

184 Example 3 On case 1B12345, EDBC and Authorization occur many times in one day. User ran EDBC 3 times in the day, but only authorized twice (did not authorize last EDBC run). Batch EDBC/Authorization will occur that evening EDBC time Authorization time Eligibility Result 8:45 am 8:55 am Denial 10:30 am 10:35 am Approval *Note: As online authorization didn t occur at 10:30 am, EDBC will rerun in batch. 8:45 pm (batch) 8:46 pm (batch) Approval The NOA sent out in batch overnight shall be the results from the 8:46 pm Authorization. 184

185 Example 4 On case 1B12345, EDBC and Authorization occurred twice in one day. Each of the EDBC runs covered different months EDBC Run Months EDBC time Authorization time January June 8:45 am 8:55 am April June 1:15 pm 1:18 pm The notice generated that evening will display the results for January, February and March using what was authorized in the 8:55 am authorization. If eligibility triggers a notice for April, May and June, those months will display what was listed in the 1:18 pm authorization. 185

186 Questions? 186

187 Interfaces 187

188 Interfaces Current functionality for the following interfaces will be modified to accommodate the conversion from multiple Medical HLPGs to one MA HLPG: IEVS BENDEX IEVS SDX 1634 SDX Medicaid Management Information System (MMIS) MAC (Medical ID Card) Medicare Part D State Enrollment Systematic Alien Verification for Entitlements (SAVE) IEVS CDLE IEVS IRS DMV PARIS PERM Audit 188

189 Verification and Communicati on CBMS/PEAK will be using data sources/interfaces to verify certain required verifications and to communicate between each other (CBMS/PEAK) 189

190 IEVS Colorado Dept. of Labor and Employment (CDLE) Will be modified to include the reasonable compatibility of 10% Will be modified only to post to Interactive Interview if equal to or greater than 10% (Comparison will be run between the sum of all the CDLE wage amounts against the sum of all the CBMS earned income amounts for the same quarter) Will not override or post if there is a current or previous months verified record/source Example: Check, Check stub, etc. IEVS letter language will be modified to reflect the new reasonable explanation and reasonable compatibility rules 190

191 Upcoming Changes Project 4340/Project 4792 Denial/termin ation data transfer from PEAK/CBMS Project 4378 CBMS MMIS Interface Updates Next Business Day Project 4376 Verify Lawful Presence (SAVE) interface via the Federal Hub Project 4438/Project 4477 PEAK call to the CBMS Rules Engine Real Time Eligibility CBMS Case/Individu al Clearance 191

192 Other Interfaces Social Security Administration (SSA) interface SVES SCHIP is the only interface that will be real time with PEAK Will be modified so that PEAK calls real time 192

193 Questions? 193

194 Connect for Health Colorado (C4HCO) 194

195 SB11-200: The Colorado Health Benefit Exchange Act of 2011 Passed in May 2011 Establishes framework for the State Marketplace Governed by a Board of Directors Legislative Implementation Review Committee Mission is to increase access, affordability and choice for individuals and small employers purchasing health insurance 195

196 What is the C4HCO? Compare information regarding cost and quality Receive support in the health insurance decision making process by call, text or inperson An open, competitive marketplace called Connect for Health Colorado for individuals and small employers to: Enroll in a plan Shop features of plans containing the same base benefits Determine eligibility for and access to federal financial assistance 196

197 Requirements under ACA Beginning Oct 2013 C4HCO and HCPF will have systems that interoperate (i.e. share data in a secure way) to determine eligibility for all insurance affordability programs (Medicaid, CHP+, Advance Premium Tax Credits and Cost Sharing Reductions) 197

198 Requirements under ACA No wrong door to enrollment A single streamlined application for insurance affordability programs (IAPs) Regulations require the following: Eligibility determinations to be based on MAGI for all IAPs Individuals must first be determined ineligible for Medicaid/CHP+ before eligibility is determined for Advance Premium Tax Credits (APTC)/Cost Sharing Reductions (CSR) 198

199 C4HCO Customer Support System C4HCO is creating a system of customer support that includes Self help online decision tools Customer Service Center (including cobrowsing and chat) Certified Health Coverage Guides Licensed and Certified Brokers 199

200 Type of Marketplaces Individual/family marketplace Tax credits and cost sharing subsidies Small employer marketplace (SHOP) for businesses and non profits with 2 50 employees (100 employees in 2016) 200

201 Upon entering the marketplace customers can: Individual Marketplace Move seamlessly into account creation and start an application Find information and assistance Browse health plan options and prices anonymously Determine interest in help paying for health insurance 201

202 Individual Marketplace Customers who choose to fill out an application to determine eligibility for assistance in paying for health coverage will: Answer questions regarding household and income Have identity, citizenship/lawful presence, incarceration and income verified View eligibility results 202

203 PEAK Application Process No Wrong Door PEAK Applicant starts an application Applicant submits the application Perform real time verifications Create a Case Medicaid Eligibility and Display results Automated Processes Worker or User Driven processes. Medical Only / No worker interaction needed CBMS Worker processes application & creates a case Worker conducts interview for DHS programs and manual verifications Worker runs Eligibility for all programs CBMS System generates Notices and Letters Send Approved case to MMIS for Medicaid Enrollment Cannot run Real time eligibility Dept. of Human Services Programs Applicant can use the Self Service portal to check the status of their applications. Send Application/ Results to C4HCO Applicant can use the Self Service portal to log into My Account and view their benefits and notices. Connect for Health CO Enroll Shop Plans APTC/CSR Determination Create Account Receive Application A Worker interaction might be required to process the case, in case of system errors or discrepancies. Medicaid Cards are mailed out by the MMIS System to the enrollees. 203

204 C4HCO and PEAK Results Each member s MA eligibility will be displayed If Medicaid and CHP+ eligible, they will stay in PEAK for follow up activities If eligible for the Marketplace, they will be routed to the C4HCO site to determine APTC/CSR o They will have the ability to shop for plans 204

205 C4HCO and PEAK Results If mixed families start on PEAK a similar process will happen as mentioned before Consumers will be enrolled into their eligible Medicaid or CHP+ program Those that are potentially eligible for the Marketplace will be offered a choice to link to C4HCO for follow up activities and learn more about the Marketplace 205

206 Questions? 206