. ACA & Marketplace updates for OE 6

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1 . ACA & Marketplace updates for OE 6 Presented By: Consumers for Affordable Health Care Date: October 1,

2 Our mission: To Advocate The Right To Quality, Affordable Health Care For Every Person In Maine. 2

3 Who is Consumers for Affordable Health Care? Consumer Assistance Program Services for Consumers HelpLine Potential eligibility screening Marketplace & MaineCare enrollment help Private insurance appeals assistance Services for Professionals HelpLine Workshops and trainings Assister ListServe Policy & Advocacy Public Policy research Legislative advocacy Administrative advocacy Coffee CAHC e-newsletter 3

4 Looking back: OE Looking ahead: OE Agenda Anticipating Challenges MaineCare Expansion & the Marketplace Section 1115 Waiver Q&A 4

5 Looking Back: Open Enrollment 75,809 Maine People Enrolled!

6 OE 5 by the numbers Number of people that selected a plan during Open Enrollment Maine Nation 75, Million Percent New Enrollees 22% 27% Percent Re-enrollees 79% 73% Percent Age 34 and Under 34% 29% Percent Selected Silver 57% 63% Percent Selected Bronze 39% 26% Percent with Financial Assistance 85% 83% Sources: 2018 Marketplace Open Enrollment Period Public Use Files, Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services (HHS), April 4,

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8 Looking Ahead: Open Enrollment 8

9 Open Enrollment Next Open Enrollment Period All Marketplace Plan Coverage Starts 2018 Nov Dec Jan. 1 9

10 Who s offering plans? BOI 2019 Rate Calculator:

11 Plan Networks Northern POS, Pathway X: Aroostook, Hancock, Penobscot, Piscataquis, Somerset, & Washington Southern HMO, Pathway X Enhanced: Androscoggin, Cumberland, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Waldo, & York PPO: Statewide HMO: Statewide HMO: Statewide Maine s Choice HMO (tiered network): Androscoggin, Cumberland, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Waldo, & York

12 Harvard Pilgrim Maine s Choice Plans The Maine s Choice plans use a tiered HMO network OOP:$ Preferred Tier: $ Highest level of cost sharing OOP costs for this tier reflected on Healthcare.gov plan display page PCP must be in Preferred Tier Services outside of this tier are never covered at preferred tier cost sharing- even in an emergency or specialists not available in this tier Standard Tier OOP costs aren t applied to preferred deductible or OOPM Standard Tier: $$ OOP: $$ Lower level of cost sharing OOP costs for this tier not shown on Healthcare.gov plan display page OON services can be coved at this tier for emergency & urgent care, and for specialists not available in network Preferred Tier OOP costs are applied to Standard Tier OOPM (but not deductible) o Combined OOP costs from both tiers never exceeds Standard Tier OOPM 12

13 Rates are going up, but so are APTCs APTCs are based on the Second Lowest Cost Silver Plan (SLCSP). The marketplace calculates the APTC amount needed to lower the premium cost for the SLCSP to the individual s expected premium contribution amount. So APTC amounts increase as plan rates increase.

14 Calculating APTC: Base price for SLCSP Expected premium contribution amount APTC amount Individual Family of 4 Chart adapted from: g/premium-tax-credits-answers-tofrequently-asked-questions/

15 Changes to tax rules Earned income requirement to file for single dependents increased from $6,350 to $12,000 o This means fewer dependents will need to include their income when calculating their household income. Alimony paid is no longer deductible and alimony received is no longer taxable income (starting with judgments after 1/1/19). Moving expenses are no longer deductible (except for members of Armed Forces). Tax filing thresholds are higher. For an individual it has increased from $10,400 in 2017 to $12,000. o This means fewer people will be required to file, and will thus be exempt from the individual mandate penalty for The Individual mandate penalty for tax year 2019 will be $0.

16 How to calculate MAGI using the new tax forms 16

17 Anticipating Challenges What s Coming Down The Pike?

18 Two warnings In past years, rate increase letters had misleading APTC information. People may end up canceling plans if they think they can no longer afford them based on incorrect information. If people truly cannot afford their premiums, it is better to proactively cancel the plan, rather than wait to be terminated for non-payment. This is because people must pay any owed premiums from the past 12 months BEFORE starting a new plan with the same insurance company. 18

19 Texas v. United States Department of Justice will not defend 3 key provisions in the Affordable Care Act (ACA) Individual Mandate Requires that people buy health insurance, unless they meet exemptions. Those that remain uninsured raise costs for others, which was offset by a tax penalty. Guaranteed Issue Insurers can t refuse to sell plans to people with pre-existing conditions Community Rating Insurers can only adjust plan rates based on family size, geographic area, age, and tobacco use. Prevents them from charging more for preexisting conditions. 19

20 Changes to Navigator Programs Navigator funding in Maine has been slashed by 82% since last year. Three Navigator Requirements eliminated: Each state must have at least two Navigator entities There must be at least one navigator entity in each state that is a community-based, consumer-focused non-profit Navigator entities must have a physical presence in their services area 20

21 MaineCare Expansion

22 Overview Mainers voted to approve Medicaid expansion on November 7, 2017 Mainers became eligible for expanded Medicaid on July 2, 2018, however the administration has delayed implementation of the law. Maine Equal Justice Partners (MEJP), CAHC, Maine Primary Care Association (MPCA), and other partners and Maine citizens have filed a lawsuit against DHHS to force the administration to start taking the necessary steps to implement expansion. Per court order, the state has filed a State Plan Amendment (SPA) for Medicaid expansion with CMS. However, the governor also sent a letter to CMS requesting that CMS not approve the SPA until funding has been appropriated. 22

23 Eligibility

24 Who does expansion cover? ~70,000 Mainers are newly eligible for MaineCare under expansion, including: Non-cats (adults under 65 years, without children in the home, who are not pregnant and don t have a disability) Parents with incomes between % FPL People with disabilities who are not eligible for Medicare with incomes between %, or with assets over the limit for MaineCare in the disability category 24

25 Eligibility Guidelines Individuals are eligible if they meet all of the following criteria: Are between years old Are not eligible for Medicare Household income does not exceed 138% FPL 2018 Monthly Income Limits $1,397 $1,893 $2,390 $2,887 25

26 What income counts? Income is calculated using MAGI method, or Modified Adjusted Gross Income. MAGI = Taxable income (AGI), plus: o o o Nontaxable Social Security, Excluded foreign income, and Tax-exempt interest Uses point-in-time income Assets do not count 2018 Monthly Income Limits $1,397 $1,893 $2,390 $2,887 26

27 Applications & Appeals How to preserve the right to retroactive coverage 27

28 How to Apply for MaineCare Online mymaineconnection Paper Application Print a paper application: Mail applications to: DHHS, 114 Corn Shop Lane Farmington, ME Or, fax to: In person Apply at any DHHS office. Find your local DHHS office at: hhs-apps/office_finder/ 28

29 Keep proof of application! No matter how you apply, keep proof of when the application was submitted. If you applied Online: Write down the application ID# and save a screen shot of the successful submission. By paper application: Send the application by certified mail so you get a confirmation receipt, or save a copy of the fax confirmation receipt. In person: Write down the application ID#. 29

30 My client was denied. Now what? DHHS is currently denying applications for MaineCare coverage under expansion. However, eligible individuals should still apply now so they can protect their right to retroactive coverage. In order to preserve this right they must take action. 30

31 Step 1: Appeal the denial You must appeal and request a fair hearing within 30 calendar days. Appeal letters should be ed to Farmington.dhhs@maine.gov AND mailed to: Commissioner, DHHS, 11 SHS, Augusta, ME Patients should specify in the letter if they want to attend the hearing by phone. If they don't ask for this ahead of time, they may not be given the option later on. You can request hearings on behalf of your patients if they appoint you as an authorized representative. 31

32 Step 2: Respond to the hearing notice DHHS was previously denying hearings to people denied MaineCare under expansion. They recently stopped this. People who appeal denials for coverage under expansion should now receive a letter from the Hearing Office notifying them of the option to go forward with their hearing now or to delay their hearing date pending the current lawsuit. We recommend people have their hearing delayed. If they have their hearing now, they will be denied. Consumers must opt-in to take advantage of this option. They should reply to the notice with a letter stating they would like to delay their hearing pending the outcome of the lawsuit. 32

33 Appeal Resources MEJP template appeal request for consumers: Online submission tool: Printable letter: 18.pdf Template appeal request letter for authorized reps: Authorized representative designation form: 33

34 MaineCare Expansion & the Marketplace What expansion means for people with income between % FPL

35 How does expansion impact Marketplace enrollees? People who are eligible for MaineCare are not eligible for the subsidies on the Marketplace. Most people with incomes between % FPL will likely have to cancel their Marketplace plans, once they have MaineCare. The Marketplace will not begin screening for Medicaid eligibility under expansion until after CMS has approved Maine s SPA application. As of right now, this means people under 138% will still be able to get APTCs for 2019 Marketplace coverage. 35

36 Step 1 Apply for MaineCare as soon as possible. What should % FPL Marketplace enrollees do? Step 2 Follow steps to preserve right to retroactive coverage. Step 3 After you get written confirmation from DHHS that MaineCare coverage is active, then cancel your Marketplace plan as soon as possible. 36

37 Overlapping Coverage Coordinating Transitions The Marketplace may cancel a person s APTC if they have MaineCare but that doesn t mean the Marketplace plan is canceled. People should still proactively cancel their Marketplace plan once MaineCare coverage is confirmed in writing. Overlapping Eligibility Due to the length of the application process for MaineCare and availability of retroactive coverage, many people may end up having overlapping coverage at some point during the year. If this happens, there is IRS guidance that protects people from having to pay back APTCs during the time they have overlapping coverage if they had APTCs and then became eligible for MaineCare. 37

38 Key takeaways Do NOT cancel the Marketplace plan until AFTER MaineCare provides written notice that coverage has been granted. It is possible many people will have retroactive MaineCare coverage for the months they still had a Marketplace plan this is okay! 38

39 Section 1115 Waiver

40 What is the 1115 Waiver? The administration submitted an 1115 waiver request to CMS that proposes several changes to Maine s Medicaid program. Maine s 1115 waiver request is currently still pending. If approved, these changes would impact people newly eligible under expansion and MaineCare enrollees in other coverable groups.

41 Proposed Changes in 1115 Waiver Work requirements for 19 & 20 year olds and many adults Monthly premiums for 19 & 20 year olds and many adults Copayments for some Emergency Department visits Asset limits Elimination of 90 day retroactive coverage

42 Where can I find more information? Visit and sign up for Coffee CAHC, our twice weekly health policy newsletter MEJP Medicaid Expansion Guide:

43 Questions & Answers Thank you! Let s stay connected!