Eligibility and Enrollment 2014: Underserved and Special Populations

Transcription

1 HEALTH REFORM IN WASHINGTON Eligibility and Enrollment 2014: Underserved and Special Populations A webinar for the Washington Association of Community & Migrant Health Centers June 10, 2013 Janet Varon and Daniel Gross Northwest Health Law Advocates

2 Goals Learn about new eligibility and enrollment policies as health coverage expansions are implemented Prepare for educating and assisting special populations to get affordable coverage

3 Presentation Agenda Overview and Timeline for ACA Implementation Existing and New Affordability Options for Low-Income Washington Residents Timelines for Implementation of New Options Changes to Existing Washington Programs and Timetable for Conversion Applying for Coverage Medicaid, CHIP, WAH and Insurance Affordability Options Medicaid Expansion Health Insurance Payment Subsidies Premium Credits and Cost- Sharing Subsidies Immigrant Eligibility Q&A Resources

4 Overview and Timeline for ACA Implementation In Washington State

5 Overview: Affordable Care Act Changes Many Aspects of Health Coverage Simplifies income eligibility rules for several Medicaid eligibility categories (MAGI) Medicaid expansion More affordable insurance for those ineligible for Medicaid Premium assistance Cost-sharing reductions Improvements in Medicare and commercial insurance

6 Affordable Coverage Programs Today If not eligible Private insurance plans High risk pool Hospital Charity Care Community clinics Source: Washington State Health Care Authority, with modifications

7 Affordable Coverage Programs After ACA Washington Apple Health Health Plan Finder Source: Washington State Health Care Authority, with modifications

8 Medicaid Expansion Will result in Medicaid coverage for about 350,000 Washington State residents, of whom about 261,000 will be new to Medicaid Will create a streamlined application and eligibility process

9 Medicaid Expansion - Eligibility General Eligibility Requirements Age Years Old Ineligible for Medicare Household Income up to138% of Federal Poverty Level using MAGI Rules (explained later). Citizenship/Immigration Status U.S. citizen or national or immigrant with lawfully present status for last 5 years (with exceptions) Social Security Number (with exceptions)

10 New Insurance Marketplace - HealthPlanFinder New marketplace for individual & small group insurance Qualified Health Plans (QHP s) that meet high standards, including Essential Health Benefit (EHB) package), organized by actuarial value: Bronze, Silver, Gold, Platinum (60 90% of actuarial value) Plus limited catastrophic (if under 30 or exempt from coverage mandate) Federal subsidies to help with costs of coverage Premium Assistance & Cost-sharing Reductions

11 HealthPlanfinder Individual Purchaser Eligibility Under 65 years old Ineligible for Medicare or other public coverage Lawfully Present in the United States

12 Timelines for New Affordability Programs New coverage begins 1/1/14, but you can apply starting 10/1/13 WA Apple Health: Rolling Enrollment Healthplanfinder: Open Enrollment First year: 10/1/13 3/31/14 Thereafter: 10/1 12/31 If miss open enrollment, must qualify for special enrollment

13 Changes to Existing Programs Families, Children and Pregnant Women Basic Health Medical Care Services/Aged Blind Disabled

14 Families, Children and Pregnant Women These programs will now use MAGI income rules. Immigrant status rules remain the same. Income levels for children and pregnant women remain about the same. Current enrollees will have to reapply. If they do not reapply, they may lose coverage as early as 1/1/14. HCA will contact people who don t reapply to facilitate their application.

15 Basic Health Individuals who are currently covered through Basic Health will have to reapply for coverage. If they do not apply, they will lose coverage as of 1/1/14 when Basic Health ends. Facilitated application process

16 Whose Coverage Will Change? Most families, children will remain Medicaideligible; others may move to subsidized Healthplanfinder coverage. Most Basic Health enrollees will qualify for Medicaid. Some Basic Health enrollees will move to subsidized Healthplanfinder coverage. Those with MAGI above 138% FPL Those with non-qualifying immigration status for Medicaid who are lawfully present

17 Medical Care Services & Aged Blind Disabled Most individuals currently in one of the following programs will be automatically converted to Medicaid: MCS (Medical Care Services) ADATSA (Alcoholism and Drug Addiction Treatment and Support Act) ABD (Aged Blind Disabled) For immigrants who are not eligible for Medicaid Expansion, the MCS program is likely to remain.

18 Applying for Coverage The New Application System

19 New Insurance Marketplace:

20 Educating patients on new options Provide information about income levels Remember, not all income is counted. If application doesn t ask, it isn t counted Offer information on immigration statuses If currently enrolled as a child, family member, pregnant woman or Basic Health, watch for information Use Healthplanfinder to renew your child soon and you can get coverage as early as January 1

21 How to Apply for Coverage One application, with no wrong door: apply online, by phone, or on paper (mail or drop off) State your income, household members, and other eligibility factors Electronic data-match Near-real-time result Plan selection Possible follow-up to verify information

22 How to Apply Persons with Disabilities HPF applicant is offered Medicaid or Qualified Health Plan coverage soon after applying May seek a disability review application is routed to DSHS Consider whether this will result in any better coverage for the individual

23 Scenario 1: Choosing a Program for Person with Disability Joan, a single person, receives Social Security Disability payments of $1440/month (150% FPL). She is not yet eligible for Medicare due to the 2-year waiting period. Medically Needy Program vs. Premium Credits/CSR Compare cost MN spenddown is $4,260 for 6 months; no cost-sharing Subsidized premium is $58/month or $346 over 6 months;* cost sharing maximum is $2,017/year Compare coverage Application strategy *Second-lowest cost silver plan.

24 Is There Extra Help for Those Who Speak Little English or Have a Disability? Limited English Proficiency Website in English and Spanish Key documents in 8 supported languages, other documents translated on demand Bilingual call center staff in Spanish and phone interpretation in ~ languages Disability Access Must provide auxiliary aids and other accommodations, but rules and policies still being developed In-Person Assisters key for these groups

25 Medicaid, CHIP, Other WAH Programs, and Insurance Affordability

26 Bottom Line Message for Clients If YOU - Have any kind of lawful status Are a Washington resident Will have a household income under 400% FPL in 2014 Are under 65 years old Do not have affordable employer-provided coverage You should qualify for free or low-cost health insurance

27 Medicaid Expansion Who is Covered Under the Expansion? Adults not in existing Medicaid categories, and those in existing categories with excess income or resources Within Income Limits - Family/household income 133% of FPL, plus automatic 5% disregard (effectively 138% FPL) Under Age 65, not receiving or eligible for Medicare Meeting existing immigrant eligibility requirements U.S. Citizens and Nationals Qualified Immigrants Immigrants who have had lawfully present status in the U.S. for 5 years Lawfully present immigrants falling within a statutory exception see below

28 Medicaid Expansion - MAGI MAGI Simplifies Many Programs Income Eligibility Rules Income eligibility will be based on household s Modified Adjusted Gross Income (MAGI) No asset tests Applies to Medicaid expansion population and some preexisting eligibility groups Non-MAGI income rules still apply to some classic Medicaid categories includes aged/blind/disabled SSIrelated, foster children, breast and cervical cancer, refugee program, MN/spenddown, etc.

29 Medicaid Expansion MAGI issues Income Point in Time Use current income or average to calculate MAGI (rules are pending). Exact amount may not be critical if below 138% FPL Rules for counting income and household composition are based on but not identical to tax-filing rules Significant exclusions includes child support, SSI, L&I, student aid, and others

30 Medicaid Expansion MAGI issues Household composition used to calculate MAGI may vary between members of the same household Some members of a HH who are all otherwise eligible for the same WAH program may qualify while other HH members do not, due to differing MAGI s.

31 Medicaid Expansion MAGI example Grandmother, mother and child living together where grandmother claims daughter and child (without income) as dependents on her taxes. For grandmother 3 person household For mother 3 persons household, as she is claimed as a dependent For child 2 persons, counting only mother s income -> Child s MAGI is lower

32 Healthplanfinder Subsidies: Eligibility MAGI Income Under 400% FPL: You can see where a family s income falls on a FPL chart here: resources/tools-foradvocates/guides/federalpoverty-guidelines.html FPLs are shown here; amounts may change in Not eligible for Medicaid, Medicare, CHIP, TriCare, etc. Not offered affordable coverage of minimum value through employer Not enrolled in coverage of minimum value through employer Not undocumented

33 Healthplanfinder Subsidies: Amount Premium Tax Credits Income Level Maximum Premium Up to 133% FPL 2% of income % FPL 3-4% of income % FPL 4-6.3% of income % FPL % of income % FPL % of income % FPL 9.5% of income Cost-Sharing Reductions Income Level Reduction in OOP Costs (compare to 70% silver) % 94% AV % 87% AV % 73% AV Select any AV tier except catastrophic Receive monthly in advance (paid directly to plan) or at close of tax year Possibility of reconciliation Select silver only! Only applies to in-network, in-ehb Plus: For those under 400% FPL, additional caps on maximum OOP spending

34 Scenario 2 Enrolling and Choosing a Plan Meet the Washington Family: Frank & Maria are uninsured U.S. citizens, married filing jointly Christina, their 4 year old child is an uninsured U.S. citizen, and a tax dependent Their household income is 250% of FPL. Based on these facts alone: Frank & Maria are NOT Medicaid eligible, but ARE eligible for Healthplanfinder QHP s, with premium assistance credits. Christina is eligible for Apple Health for Kids with a $20/month premium.

35 Scenario 2 - Enrolling & Choosing a Plan Comparing prices and plans: Maria & Frank are given a choice of 3 QHPs:* HealthTime (bronze): $45.64/month premium FeelGood (lowest cost silver): $307.64/month premium NewHealth (benchmark silver): $327.64/month premium Cost-sharing assistance is only available for silver Plans FeelGood and NewHealth AHK premium is $20 Maria & Frank want to be on same plan as Christina, with same family doctor Only HealthTime and NewHealth offer AHK plans. Both have their family doctor in network. *cost of plans after tax credit subsidy applied

36 Scenario 2 - Enrolling & Choosing a Plan Plan Choice Mechanics HPF QHPs - Maria & Frank can choose their plan online on HPF or with assister. AHK Plans - Christina will be auto-assigned a plan by HCA, UNLESS her parents request or seek assistance to have Christina assigned to AHK plan of their choice.

37 Immigrant Eligibility - Medicaid Medicaid Eligibility Citizenship and immigration status requirements remain the same and are extended to eligibility for Medicaid expansion coverage. Generally, for non-pregnant adults, this is: U.S. citizen or U.S. National Qualified alien Having lawfully present status for at least 5 years Exceptions to the 5 year bar

38 Immigrant Eligibility - Medicaid Medicaid Programs for Non-pregnant Adults Qualified Aliens Exceptions to the 5 year bar Entry prior to August 22, 1996; continuous residence until qualified Amerasian lawful permanent residents (LPR s) Asylees Cuban or Haitian entrants Persons granted withholding of deportation or removal Refugees Special immigrants from Iraq or Afghanistan Victims of trafficking Armed service members/veterans who are LPR, parolees or battered aliens and who meet other service-related or family relationship requirements.

39 Immigrant Eligibility - Other WAH programs Other WAH Programs Open to Immigrants Who Are WA Residents Apple Health for Kids (no status requirement) Note Currently children who are NOT lawfully present pay higher premiums, BUT this seems likely to be corrected in pending budget. WAH for Pregnant Women (no status requirement) Alien Medical Programs MCS Must be lawfully present in the U.S.

40 Immigrant Eligibility Lawfully Present Statuses for MCS Qualified alien for less than 5 years, without 5 year bar exemption Citizen of Marshall Islands, Micronesia, or Palau Immigrants paroled for one year or less Certain abused aliens not qualifying for battered immigrant exemption to the 5 year bar VAWA petitioners who have not yet received Notice of prima facie eligibility Applicants for adjustment of status, asylum, cancellation of removal, or suspension or withholding of deportation or removal Deferred enforced departure Granted Family Unity granted K, S, U or V statuses designated on a person s visa Lawful temporary residents under IRCA amnesty program Cancellation of removal, deferred action of suspension of deportation granted Order of suspension granted Residing in U.S. since before 1/1/72 Eligible to petition as special immigrant juvenile Stay of deportation granted Nonimmigrants allowed entry into the U.S. for a specific purpose for a limited time

41 Immigrant Eligibility Use HPF Even if You Are Not Eligible for Traditional Medicaid Use the HPF System for other WAH programs - Even if an applicant is clearly ineligible for traditional Medicaid programs, (s)he can still apply for other WAH programs like AEM, for which she may be eligible, through the HPF system. Don t forget Exchange-based coverage and assistance - Lawfully present nonqualified aliens who are ineligible for WAH can get coverage through the HPF, including premium and cost-sharing assistance with low to moderate income.

42 Immigrant Eligibility Sensitive Information Your sensitive information will not be shared with law enforcement - Immigration Status and SSN information submitted to HPF will not be shared with immigration or law enforcement agencies, including the U.S. Department of Homeland Security (seeking final confirmation from CMS on this). An SSN may not be required for some programs open to lawfully present immigrants Alternate forms of identifying information may be sufficient to qualify for some coverage open to lawfully present immigrants; the controlling rules/policies are still in development.

43 Immigrant Eligibility Non-applying household Members HPF will request immigration status and SSN for all family members, including those NOT seeking coverage BUT non-applying family members need not enter this information for the application to be processed Example An undocumented parent applies for coverage for her/his child for which the child is eligible. HPF requests a range of information regarding the child s household members, including name, income, SSN and immigration status. Some of this information (e.g., name and income) of all household members is generally required to determine the child s eligibility. BUT - The child s application will be processed, even if the undocumented parent does not input information into the fields for the parent s immigration status or SSN.

44 Scenario 3 - Immigrant Household Dmitri and Sasha are married with joint income <138% FPL Sasha is a Legal Permanent Resident, still within 5-year bar, and not pregnant Dmitri is undocumented, limited English proficient, fluent in Russian, and Spanish proficient Eligibility impact: Sasha is NOT eligible for Medicaid, but IS eligible for Healthplanfinder with subsidies. She can apply for coverage for herself without giving a SSN/lawful presence status for Dmitri. Dmitri is not eligible for Healthplanfinder insurance coverage. He may only use Healthplanfinder to apply for Alien Medical Programs (such as AEM for emergency care). He is now exempt from the individual mandate for himself, but his family is still subject to it.

45 Scenario 3 Immigrant Household Language Services Available Dmitri can use HPF Spanish-language site or request Russian phone interpretation. Key documents can be sent to him in Russian. Use Healthplanfinder to sort In-person Assisters by language spoken

46 Call Centers Where Can People Find Help in Understanding Their Options? In-Person Assisters Activities: outreach, application, info about plan choices and insurance affordability programs, facilitate enrollment Structure: lead agency contracts with smaller organizations Agents & Brokers Consumer Ombudsperson: grievances/appeals info

47 Resources

48 For More Information ACA in general: Washington Law Help publications: Federal Poverty Guidelines: WA Health Benefit Exchange (Healthplanfinder): Healthplanfinder applications: NoHLA:

49 Please note These materials and the accompanying oral presentation are provided for informational purposes only and do not constitute or substitute for legal advice. Some of the information in this presentation is subject to differing interpretations, may not yet be established policy, or may be subject to change. Anyone seeking advice concerning their legal rights to coverage, the coverage application process, or related issues should consider consulting with an attorney.

50 Thank You! Daniel Gross, Senior Staff Attorney Northwest Health Law Advocates Janet Varon, Executive Director Northwest Health Law Advocates