The Evolving Role of CHC s in Consumer Assistance

Transcription

1 The Evolving Role of CHC s in Consumer Assistance OACHC Spring Conference Tricia Brooks March 12, 2014

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3 2014 Federal Poverty Levels o On February 18, Ohio starting using the 2014 FPLs o The new levels are retroactive to January 1, 2014 o Caseworkers should be rerunning eligibility for individuals who were closed or denied based on 2013 levels but would be eligible under 2014 levels. 3

4 2014 Eligibility Levels for MAGI-based Coverage Monthly Children with Private Insurance Uninsured Children* (0 19) Pregnant Women* Adults* (19-64) Family Size 156% FPL 211% FPL 205% FPL 138% FPL 1 $1,517 $2,052 $1,994 $1,342 2 $2,045 $2,766 $2,687 $1,809 3 $2,573 $3,480 $3,381 $2,276 4 $3,101 $4,194 $4,074 $2,743 5 $3,628 $4,908 $4,768 $3,210 6 $4,156 $5,621 $5,462 $3,677 1 $18,205 $24,624 $23,924 $16,105 2 $24,539 $33,190 $32,247 $21,707 Annual 3 $30,872 $41,757 $40,570 $27,310 4 $37,206 $50,324 $48,893 $32,913 5 $43,540 $58,890 $57,216 $38,516 6 $49,873 $67,457 $65,539 $44,119 * Levels include 5 percentage point disregard 4

5 Ohio Medicaid is now processing account transfers from the Marketplace Electronic Account Transfer Benefits.Ohio.Gov How long will the 106,000+ backlog take to process? How many people will be bounced back to the marketplace? What about on the FFM side? Is it processing applications that Ohio has transferred to it? What happens to people who get stuck and run out of time? 5

6 Post-Enrollment Issues/Roles Medicaid enrollment never closes Changing plans Qualifying events/special enrollment periods Using benefits Appealing denials of benefits Exemptions from individual mandate Understanding tax reconciliation 6

7 MAGI and Medicaid 7

8 Generally, income and household rules are the same for Medicaid and PTC for tax filers; however there are some differences for non-filers and certain tax dependents 8

9 Medicaid Household Composition Tax Filers Household = all individuals in the tax filing unit Tax-filer Spouse filing jointly Tax dependents Children under age 19 Full-time students under 24 May include qualified relatives who earn less than $3,900 Non-Filers (more like current Medicaid; relationship based) Adults Adult Spouse Children under 19 Biological, adopted or step Would not include qualified relatives Children Child Parents (including step-parents) Children s siblings Biological, adopted or step Child s spouse, living together. The child s children, if living together. 9

10 Medicaid Exceptions for Tax Dependents 1 Individual is a tax dependent of someone other than a spouse or a parent (biological, adopted or stepparent) - i.e. Child living with grandparent 2 Child (under 19) claimed on noncustodial parent s tax return 3 Child (under 19) living with parents filing separately (married or not) If tax dependent meets any of these exceptions, use non-filer rules for determining Medicaid household for that individual only! 10

11 Two More Exceptions for Medicaid! 4 Married couples living together are included in each other s household regardless of whether they are tax-filers or non-filers 5 Pregnant woman counts as 2 people (or more if expecting multiple babies) for all members of the household in Ohio 11

12 What is MAGI? o Not a number but a formula o Adjusted gross income from line 37 of the Excluded foreign income + Tax exempt interest + Non-taxable Social Security benefits 12

13 Differences in how income and expenses are counted before and after MAGI Self-employment Pre-tax deductions or salary deferrals (flex spending accounts, childcare, 401(k)) PRE-MAGI MEDICAID Not all business expenses (i.e. depreciation) were deductible Included in gross income MAGI MEDICAID Counted with all tax deductible expenses and business losses (whatever carries over from schedule C/F, etc.) Not included in gross income Child support received Counted as income Not counted as income Alimony paid Not deducted from income Deducted from income Veterans benefits Counted as income Not counted as income Workers compensation Counted as income Not counted as income Step-parent income State option but not always counted toward child s eligibility Counted as income TANF and SSI Counted as income Not counted as income 13

14 Deduct pre-tax contributions/salary deferrals when reporting income. Certain employee contribution to benefits that are deducted from wages before federal taxes are calculated. Taxes are calculated on the reduced wage and are therefore lower. Common pre-tax contributions Dependent Care Medical Flex Spending Accounts 401(k) or 403(b) Retirement Accounts 14

15 How will Ohio verify eligibility? Criteria to be verified through electronic data sources* Income Citizenship Immigration status Criteria to be accepted based on applicant self-attestation Residency Age/date of birth Household composition Pregnancy Data Sources: federal sources (SSA and DHS) state sources (State Wage Data, Unemployment Compensation, Vital Statistics, Work Number) 15

16 Federal Reasonable Compatibility Standards for Income Verification NEW RULES: What the applicant reports for income and what the electronic data source reports DOES NOT have to be an exact match, IF it does not affect the eligibility outcome! If the income attested to by applicant and the data source are both below the Medicaid cutoff, individuals are enrolled in Medicaid. If the income attested to by applicant and the data source are both above the Medicaid cutoff, individuals are referred to the FFM for screening for APTCs and CSRs. 16

17 What if the applicant reports Medicaid-eligible income but the data source disagrees? If difference is < 5% If difference is > 5% Ohio will accept the Ohio will contact applicant attestation and enroll in for information or Medicaid. verification. Example: Medicaid cutoff is $2,276 for household of three: Applicant reports $2,200 Data source indicates $2,300 Difference is $100, less than 5% (4.4%) Family is enrolled in Medicaid Example: Medicaid cutoff is $2,276 for household of three: Applicant reports $2,100 Data source indicates $2,300 Difference is $200, more than 5% (8.8%) Additional information or verification is requested. 17

18 What if the applicant reports income over Medicaid but the data source disagrees? If applicant reports income above the Medicaid cutoff regardless of what the data source indicates, they will be denied Medicaid and referred to FFM for screening for APTCs and CSRs. This is why it is important for applicants to report income accurately and deduct any pre-tax contributions. (see Slide 14) 18

19 Changing Plans and Special Enrollment Periods Once enrolled, can change plans before effective date Once coverage is effective, cannot change plans until next open enrollment period (November 15, 2014 January 15, 2015) Exception between now and end of open enrollment if all of these conditions exist: Change to plan with same insurer Change to plan in same tier and with same cost sharing reduction Change is required to move to more inclusive network or other limited circumstances identified by CMS Exception throughout the year for qualifying events which trigger a special enrollment period: Marriage or divorce Birth or adoption of child Loss of other coverage including Medicaid 19

20 Preventive Care Services with A or B rating from US Preventive Services Task Force must be provided at no cost entiveservicestaskf orce.org/uspstf/usp sabrecs.htm Using Health Insurance Cost-Sharing Caps 2014: $6,350 for individual, $12,700 for family plan (CSRs lower caps) May not include out-of-network care or care not included in EHB/covered benefits Separate OOP caps for Rx and medical benefits in 2014 In 2015, total of separate caps cannot exceed total dollar limit Benefit Limits Lifetime dollar limits banned in all plans Annual dollar limits banned in all plans except in grandfathered individual plans Limits can still apply to services that are not considered EHB Number of visits (i.e. physical therapy) can be limited

21 What if the plan denies my care? Internal Review External Review 21

22 Internal Appeals Process Plans must give notice of denial: Prior Authorization 15 days Service Received 30 days Urgent Care 72 hours Consumer has 6 months to appeal Plan must give decision on appeal: Prior Authorization 15 days Service Received 30 days Urgent Care As quickly as medical condition requires; no more than 4 business days 22

23 External Appeals Process Consumer must request an external review within 60 days of plan s notice of appeal decision. External appeal decision by independent third party within 60 days of request for external review. Plan must accept the independent party s decision. 23

24 Exemptions from Individual Mandate Exemptions Uninsured less than 3 months Lowest cost plan > 8% of household income Not required to file tax return Member of federally recognized tribe Recognized member of health care sharing ministry Member of recognized religious sect Incarceration Not lawfully present Hardship Exemptions* Homeless Faced eviction/foreclosure in past 6 mos Shut-off utility notice Domestic violence Death of close family member Fire, flood or other disaster Filed bankruptcy in past 6 mos Outstanding medical expenses (24 mos) Individual coverage cancelled and QHPs are not affordable For a complete list of hardship exemptions, see 24

25 Exemption Process Claim exemptions on your 2014 tax return by April 2015 OR Apply using proper paper form (by mail only currently) If exempted based on affordability, consumer may also qualify to buy a catastrophic plan through the Marketplace Exemption is NOT required if you have a gap of less than 3 months. 25

26 Tax Reconciliation There are many unknowns and we have a lot to learn.but we will need to be prepared to explain why someone may owe taxes. And then use that information to assist with future income projections. 26

27 Network Adequacy and Inclusion of Essential Community Providers 27

28 Recommendations to Strengthen Proposed Standards for ECP 30% ECP participation - Should be higher (50%?) - Should be clear it s a minimum requirement not a standard - Require plans to contract with at least one ECP in each category in each county, not just offer contract in good faith If retained, define good faith offer - Rates competitive with commercial reimbursement - Not limited to select services or more expensive plans Require issuers to submit a narrative explaining how they will provide adequate services to medically underserved children and children with special health care needs 28

29 Looking Ahead to the Evolving Role of Consumer Assistance 29

30 Ideas for Improving Consumer Assistance Next Navigator FOA Allow coordination of assistance activities More flexibility - Cross-allocation of resources for other assistance programs - Sub-contracting with entities to do only outreach - Balance between statewide and niche focus Strengthening Infrastructure Navigator/CAC Portal Provide secure mechanism for phone assistance Improvements to application, identity verification process, help text and notices Dedicated support units within call center and case management sites Access to policy experts Training Live training options Live system training Enhanced training - Medicaid - Children s issues - Immigrant issues - Tax rules - MEC Local QHP specifics Training and tools for income projection 30

31 Georgetown Health Policy Institute Center for Children and Families Tricia Brooks Our Website: Our child health policy blog: Say Ahhh! 31