Modified Adjusted Gross Income (MAGI): Exchange and Medicaid Eligibility Flow Charts Updated per March 2012 Final Rules and June 2012 Supreme Court Decision October 3, 2012 These charts illustrate MAGI eligibility processes for premium tax credits, cost-sharing reductions, and Medicaid eligibility. They also detail the new Medicaid eligibility groups, based on our interpretation of the regulations. The document highlights the areas where states have policy flexibility and where decisions need to be made by the State. 1
Table of Contents Topic Area Legend Page (s) 4 Coverage Option Overview 6 MAGI Calculation 8 MAGI Calculated Public Assistance Categories 10 n-magi Medicaid Other Categories 11 n-magi Medicaid Referral 12 MAGI Tax Subsidy Determination Detailed Processes 14 Check Citizenship/Verify SSN 15 Check Incarceration 16 Check State Residency 17 Determine Household Size 18 Calculate MAGI Household Size 19 Determine Household Income 20 Calculate FPL 8-12 13-20 State Decisions Needed 22-25 2
Legend 3
Flow Chart LEG Prior Enrollment State Specific Comment Determine Household Size P# Detailed Process Indicator 1 Continued from Another Page P# Detailed Process Page # Household Size Info Found Electronically? Process Description *# State Decision Needed Process Decision Connector 1 Continued on to New Page Process End Indicator The Exchange must enter into agreements with Medicaid Agency to enable individual and dependents to be screened for Medicaid based on non-magi eligibility example disability. Regulation/Rule Brief Start Process Connector Process Start Indicator 138%* FPL 5% disregard included (For optional expansion, applies to Medicaid determinations only) Brief Coverage Area ** Under PTC eligibility % of income indicates the % of income an individual is required to pay after which the PTC will cover remaining premium. For Cost-sharing this indicates the increased plan Actuarial Value (AV) an individual is eligible for based on a 70% AV silver plan. AV indicates the % of costs the plan covers vs. the individual. At 100% AV an individual has no cost sharing. 4
Coverage Option Overview 5
Coverage Option Overview Individuals enrolled in affordable employer sponsored coverage or eligible for minimal essential coverage through an employer are not eligible to receive advanced payments for premium tax credits or cost sharing reductions. Coverage Options Employer Sponsored Coverage /Other Acceptable Insured with Minimal Essential Coverage Individuals applying for coverage on the Exchange have the ability to decline to be screened for eligibility for Medicaid, PTC and cost-sharing reductions. In States that elect Medicaid expansion, Medicaid eligibility extends to all non-medicare eligible individuals under 138%* FPL and tax credit eligibility extends from 138%*FPL to 400% FPL based on MAGI. Exchange Individual Coverage Insured by non-exchange Commercial Plan Off Exchange Public Assistance n MAGI Medicaid n-subsidized Individual Coverage Public Assistance Individual Mandate Exemption The Medicaid Agency must adopt the Modified Adjusted Gross Income (MAGI) calculation methodology for all individuals applying for the new and consolidated Medicaid categories. t Eligible for Assistance Insured through Individual Exchange Commercial Plan Tax Subsidy/Cost-Sharing Reduction Insured through Exchange Commercial Plan w/ Subsidy MAGI Calculation Medicaid Categories Children s Group Pregnant Women Parent/Caretaker Adult (State Option) SCHIP Former Foster Children Insured through Medicaid t Insured The regulation consolidates eligibility categories for parents and other caretaker relatives, pregnant women, and infants and children under age 19. n-magi Medicaid Determination Medicaid n-magi Medicaid Income Determination Required 65 & older ABD & Medically Needy Long-Term Services & Supports Medicare Cost Sharing By Request Individuals can still be eligible for Medicaid based on disability or other current Medicaid categories; their income would not be calculated based on MAGI. Insured through Medicaid 6
MAGI Calculation 7
MAGI Calculation Eligibility must be redetermined every 12 months. *2, 3, 4, 5 Start Request for Public Assistance/Insurance *1 When possible the agency must complete the redetermination without requiring information from the individual. *2 For Eligibility determinations the Exchange will rely on the federal hub for income and citizenship information, when available. n MAGI application or trigger or request for non- MAGI review? 2 The Exchange must verify whether an applicant is eligible for or enrolled in an employer-sponsored plan. Access Federal HUB Eligible for Employer Sponsored Plan? Includes verification of Indian status. Indians are eligible for reduced and special costsharing reductions and may not have to complete subsidy eligibility process. An applicant can have employer coverage and be MAGI Medicaid eligible or have ESI and Medicaid as payor of last resort (with exception to SCHIP). In Medicaid, all unborn children counted in determining family size of pregnant women. If household tax filer does not verify applicants attestation, applicant will not be eligible for advanced payments of the PTC or cost-sharing reductions. The Medicaid Agency must adopt MAGI calculation methodology for all individuals applying for the new and consolidated Medicaid categories. Individuals that are determined not eligible for Medicaid must be screened for advanced payments of PTC and costsharing reductions. Public Assistance Enrollment 1 Denied Exchange Coverage Does t Request Medicaid Eligibility Review? Determine Household Size Determine Household Income Calculate FPL Below 400% FPL? *6 P17 P19 P20 Independent Enrollment through Exchange Check Citizenship/SSN Check Incarceration Check State Residency Citizen, t Incarcerated, and State Resident? P14 P15 P16 Individual Case Approved? Individuals who are in the process of being determined eligible for Medicaid on a basis other than MAGI must be screened for eligibility in insurance affordability programs (MAGI Medicaid, Premium Tax Credits, and Cost Sharing Reductions) for interim coverage. If an applicant s attestation cannot be verified, the Exchange must review on a case by case basis and provide exceptions, as appropriate, and an explanation of circumstances. The Exchange must accept attestation if the discrepancy or difference does not impact the eligibility of the applicant. Denied Exchange Coverage All individuals have the right to appeal any eligibility determination for Medicaid, PTC, cost sharing subsidies, or QHP eligibility. At any FPL an Indian enrolled in a QHP is eligible for services without cost sharing from Indian Health Services, Indian Tribes, Tribal Organizations, or Urban Indian Organizations. This special costsharing must be provided without the individual having to go through the determination for insurance eligibility programs. 8
MAGI Calculated Public Assistance Categories 1 0-250% FPL? Under 19 years old? Under State s Income Threshold? Children s Group *19 *19 Minimum: 133% FPL - or - for infants under age 1 such higher income standard as of 12/19/89 or 7/1/89 had authorizing legislation Maximum: Higher of 133% FPL; MAGI equivalent of 3/23/10 or 3/23/13 income level if higher; or for infants under age 1 185% FPL 3 Info on App suggests non-magi eligible or requests non-magi determination or Medicaid income determination required? Pregnant? Under State s Income Threshold? Minimum: Higher of 133% FPL or such higher income standard up to 185% FPL as of 12/19/89 or 7/1/89 had authorizing legislation Maximum: Higher of MAGI equivalent as of 3/23/10 or 3/23/13 income level if higher; or 185% FPL Pregnant Women Group 3 Below State s SCHIP income threshold -or- Medicaid enrolled child on 12/31/13 determined ineligible for Medicaid due to elimination of income disregards? 2 Parent/Caretaker? Under State s Income Threshold? Minimum: AFDC income standard as of 5/1/88 Maximum: MAGI equivalent for 1931 families as of 3/23/10 or 12/31/13 or 7/16/96 AFDC income standard increased by CPI Parent/Caretaker Relative Group 3 The regulation consolidates eligibility categories for parents and other caretaker relatives, pregnant women, infants and children under age 19. n-consolidated mandatory and optional eligibility groups are maintained. *7, 8, 19 Between Parent/Caretaker FPL & 138%* FPL? Have Child under 19 enrolled in Medicaid or minimum essentially covered? Option: Adult Group 3 Between 0%-138%* FPL? Option: Adult Group 3 t eligible for Medicaid Under 26, in foster care on 18 th birthday, Medicaid enrolled while in foster care? Former Foster Child Group 3 Exchange Commercial Plan A new optional category is created for adults between 19 and 65 who are at or below 138%* FPL regardless of caretaker status. 250-400% FPL SCHIP 3 Determine Tax Subsidy 4 9
n-magi Medicaid Other Categories The regulation exempts from MAGI methodology individuals for whom Medicaid does not make an income determination, Medicare Savings Program individuals, and individuals being determined eligible on basis of blindness, disability or need for long-term services & supports. 2 income determination required by Medicaid (e.g., Title IV-E, SSI, Express Lane) Electronic Case Transferred to Medicaid & enrolled in applicable category Application for Medicare Savings Program? Electronic case transferred to Medicaid &enrolled in Medicare Savings Program n MAGI application, request for non-magi review or application identifies potential non-magi eligibility Exchange notified of Medicaid determination Exchange notified of Medicaid determination Can enroll in Adult Group or PTC and/or cost sharing reductions while non-magi review is pending. Electronic Case transferred to Medicaid Review for eligibility on basis of blindness, disability, medically needy coverage or need for long-term services & supports Determined Eligible based on disability/need for long term services & supports? Enrolled in applicable category Eligibility maintained in Adult Group or Tax Subsidy Exchange notified of Medicaid determination 10
n-magi Medicaid Referral 3 Individual Request n- MAGI Medicaid Determination? OR Exchange have reason to believe eligible for n- MAGI Medicaid? Referral to n-magi Medicaid 11
MAGI Tax Subsidy Determination 4 At any FPL an Indian enrolled in a QHP is eligible for services without cost-sharing from Indian Health Services, Indian Tribes, Tribal Organizations, or Urban Indian Organizations. This special costsharing must be provided without the individual having to go through the determination for insurance eligibility programs. Between 100-133% FPL? Between 133-150% FPL? If individual is an Indian below 300% FPL then individual is eligible for Cost Sharing Reduction to 100% of Plan AV. PTC** Cost Sharing ** 2% of Income 94% Plan AV Between 150-200% FPL? PTC** Cost Sharing ** Between 200-250% FPL? 3% of Income 94% Plan AV PTC** Cost Sharing ** Between 250-300% FPL? 4% of Income 87% Plan AV PTC** Cost Sharing ** Between 300-400% FPL 6.3% of Income 73% Plan AV PTC** Cost Sharing ** 8.05% of Income 70% Plan AV PTC** Cost Sharing** 9.5% of Income 70% Plan AV DRAFT - Eligibility Process Flows -Based on our Interpretation of IRS NPRM 26 CFR PART 1 and February 2012 CCIIO Actuarial Value and Cost Sharing Bulletin 12
Detailed Processes 13
Check Citizenship/Verify SSN Check Citizenship Start Citizenship found in federal hub to match attestation? Citizen National Lawfully Present Native American Continued Medicaid requirement to provide emergency services to individuals not eligible for full Medicaid due to their immigration status. Self-Attestation Agency must verify Indian status and cannot accept self-attestation. Eligibility process continues SSN verified by info in federal hub? Exchange finds an inconsistency Information verified against information from electronic sources (DHS) for lawful presence in US, individual with no SSN and where SSN doesn t match Reasonably Compatible? *9 Eligibility process continues Exchange makes reasonable effort to identify the inconsistency and notifies individual and gives 90 days for application filer to provide satisfactory documentation. Eligibility process continues and if meets other eligibility criteria, HIX provide non-medicaid coverage during this time. *10 The 90 day reasonable opportunity period does not apply to Medicaid. Individual is not enrolled in Medicaid until the discrepancy is resolved. Inconsistency resolved after 90 days? Individual remains enrolled Period can be extended if applicant is making good faith effort to obtain additional documentation. If enrolled, Individual is disenrolled *11 14
Check Incarceration Check Incarceration Start Incarceration is not a factor of eligibility which needs to be verified for purposes of determining Medicaid eligibility. It is generally prohibited for Medicaid to cover services while individuals are incarcerated. Approved Electronic Data source available for verification of incarceration? *12 Reasonably compatible? *9 Eligibility process continues Exchange makes reasonable effort to identify the inconsistency Inconsistency resolved? Eligibility process continues The 90 day reasonable opportunity period does not apply to Medicaid. Resolution period can be extended if applicant is making good faith effort to obtain additional documentation. *11 Self Attestation Exchange makes reasonable effort to identify the inconsistency and notifies individual and gives 90 days for application filer to provide satisfactory documentation. Eligibility process continues and if meets other eligibility criteria, HIX provide non-medicaid coverage during this time. Inconsistency resolved after 90 days? Individual remains enrolled *10 Individual is disenrolled, if enrolled 15
Check State Residency Check State Residency Start State Residency found in federal hub? Residency verified? Adult: Where living & intends to reside or is seeking employment or employed Document that provides evidence of immigration status may not be used alone to determine that individual is not state resident. Eligibility process continues Self Attestation Child <21: living in, or state of residency of parent/caretaker with whom child resides Exchange finds an inconsistency If attestation of residency is not reasonably compatible with other information provided, the Exchange must examine information in data sources that are available to the Exchange and approved by HHS. Eligibility process continues. State can accept selfattestation without further review Data in another Electronic Source & Compatible? *9, 12 The 90 day reasonable opportunity period does not apply to Medicaid. An individual is not enrolled in Medicaid until the discrepancy is resolved. Exchange makes reasonable effort to identify the inconsistency and notifies individual and gives 90 days for application filer to provide satisfactory documentation. Eligibility process continues and if meets other eligibility criteria, HIX provide non-medicaid coverage during this time. *10 Resolution period can be extended if applicant is making good faith effort to obtain additional documentation. *11 Inconsistency resolved after 90 days? Eligibility Process Continues Eligibility process stops 16
Determine Household Size Determine Household Size Start Household Size Info via Fed Data Hub - Filer? Verified by Requestor? The Exchange must compute annual household income for the family based on the number of dependents on the tax return. Calculate MAGI Household Size P18 Data Found via Other Sources? *12 Use data from Hub as household size Basic rule for tax filers is that the household size consists of the taxpayer and all tax dependents. Attestation must be verified with the tax filer. Self-Attestation from Requestor Reasonably Compatible? *9 Agency must accept self-attestation of pregnancy unless the State has information that is not reasonably compatible with the attestation. States can require verification of pregnancy with multiples for purposes of determining household size for Medicaid. *13 Use Self-Attested Household Size In Medicaid, a pregnant woman is considered a household of two (or more if carrying multiples). States have the option to count the unborn children in determining the family size of other members of a pregnant woman s household for Medicaid eligibility purposes. *14 Use Manually Calculated Size as Household Size Calculate MAGI Household Size Requestor Provide Paperwork Received and Approved w/in 90 Days? P18 *10 Sufficient Electronic Secured Data Available? Use Other Electronically Found Household Size The 90 day reasonable opportunity period does not apply to Medicaid. Individual is not enrolled in Medicaid until the discrepancy is resolved. t eligible for Continued Determination Due to Insufficient Data 17
Calculate MAGI Household Size Calculate MAGI Household Size Start Is the individual a tax filer? Is the individual claimed as a dependent? If individual cannot substantiate that another individual is a tax dependent for the year in which Medicaid coverage is sought, non-filer rules apply. Is the individual: Other than a spouse, biological, adopted or step child Under 19 or under 21 & full time student & claimed by non-custodial parent Living with both parents who will not file joint tax return *15 The individual is a non filer The individual s Household size is the tax filing household size Married couples living together are included in the household of the spouse regardless tax filing status. In Medicaid, unborn children are included in household size for pregnant women. State has option to count unborn children in household size for other household members. *14 Household size consists of if living with the individual: (1) the individual s spouse; (2) the individual s qualifying children ; (3) if the individual is under 19 or 21 and a full time student the individual s qualifying parents and siblings. 18
Determine Household Income Determine Household Income Verified by Requestor? Start Household Income Info via Fed Data Hub - Filer? Tax subsidy requires filing for continued receipt of benefits. Must search to see if applicant has filed for unemployment benefits. Attestation must be verified with the tax filer. Data Found via Other Sources? Self-Attestation from Requestor *12 Reasonably Compatible? *9 If applicant s income attestation is higher than reported and does not impact eligibility OR is no more than 10% below, Exchange must accept attestation without further verification. Higher Self-Attestation and eligibility impact? < 10% Lower and PTC? If Medicaid and eligibility impact? Use Fed Hub Electronically Found Household Income Medicaid eligibility is based on current monthly income. Annual income must be converted to monthly number. State option to use projected annual income for ongoing eligibility. Medicaid MAGI exceptions must be applied including : Deduct sources counted as income by IRS but not Medicaid (taxable *18 scholarships, grants; AI/AN exceptions; Lump Sum Payments counted only in month received) Exclude income of child or other tax dependent who files taxes but isn t required to *16 Count Social Security Income that is tax exempt Accept Self-Attested Household Income without further verification Gather sum of income for household: Pay Stubs, Letters of employment *17 Medicaid count Lump Sum in month received. Grants/ Scholarships not counted (<138%* Only), AI/AN Income not counted Attest that to an accurate projection of next benefit year income for non-medicaid. Use Manually Calculated Income as Household Income *18 Requestor Provide Paperwork Received and Approved w/in 90 Days? Sufficient Electronic Secured Data Available? Use Other Electronically Found Household Income *10 The 90 day reasonable opportunity period does not apply to Medicaid. Individual is not enrolled in Medicaid until the discrepancy is resolved. t eligible for Continued Determination Due to Insufficient Data or no longer filer 19
Calculate FPL Calculate FPL States have the option of performing an Assessment via an Exchange and then a Determination through Medicaid (option A) or a Determination through the Exchange (option B) *6 Start Option A Calculate FPL The State-Operated Federal PTC Partnership model may allow contracting with the Federal Exchange to perform the Determination Assessment as shown in Option A. Start Option B Calculate FPL If a state selects the option that the Exchange will perform the eligibility determination, no additional information can be collected at this time from the applicant. Assessed Above 100% FPL or 138%* FPL at State Option Assessment = Determination for Exchange Gather Additional State Medicaid Specific Information from Applicant In the event that the State has another entity perform an eligibility assessment, the State can then collect additional, non-duplicative, information to determine Medicaid eligibility. Perform Medicaid Determination and Re- Calculate FPL Assessed Above 138%* Assessed Above 100% FPL or 138%* FPL at State Option PL Replace Assessed FPL with Medicaid Process Calculated FPL Medicaid Process FPL Determined 20
State Decisions Needed 21
State Decisions Needed (1 of 4) 1. Will the State use the CMS application or develop a state specific application? For the n-magi application, will the State use the single streamlined application & supplemental forms or an alternative application? 2. A redetermination of eligibility must be made without requiring additional information from the individual when reliable information is available to the State to complete the renewal. What will be considered reliable information? 3. For Medicaid renewals, the State can extend the reconsideration period during which a new application is not required. Will the State offer a longer reconsideration period? The State may also implement a 90 day reconsideration period for reasons other than non-timely submission of renewal materials. 4. The State may replicate the MAGI redetermination process for non-magi Medicaid populations. Will the State implement these renewal procedures for non-magi? 5. The Exchange may automatically enroll qualified individuals at open enrollment in QHPs. Will this option be implemented? 6. The State may delegate Medicaid determinations to the Exchange or Medicaid may make an eligibility determination in addition to the Exchange s initial assessment. 22
State Decisions Needed (2 of 4) 7. The State can expand the definition of caretaker relative to include another relative based on blood, adoption or marriage, domestic partner or adult with whom the child is living and assumes primary responsibility. 8. In defining who is considered a dependent child for purposes of eligibility for the Medicaid Parent/Caretaker Relative Group, the State may eliminate the deprivation requirement. Dependent children can also be defined as either under 18 or 18 and full time student in secondary school or training if before age 19 child is expected to complete training. 9. Within the rules guidelines for upper and lower limits, State to define rules for what is considered reasonably compatible when self-attestation does not match electronic data. State to determine when self-attestation will be allowed without further verification through electronic data sources. 10. State to determine the reasonable time period for allowing individuals to provide verification documents for Medicaid eligibility determinations. 11. The 90 day grace period for providing documentation to resolve discrepancies may be extended when the applicant demonstrates a good faith effort has been made to obtain the required documentation. Will this option be utilized and under what circumstances? 23
State Decisions Needed (3 of 4) 12. State to define other electronic data sources (approved by HHS) that will be utilized in addition to those accessed through the Federal Data Hub. 13. For Medicaid eligibility, State may require verification of pregnancy with multiples for purposes of determining household size. 14. States have the option to count the unborn child(ren) in determining the family size of other members of a pregnant woman s household for Medicaid eligibility purposes. 15. For purposes of determining household composition for Medicaid, State has option to count children as either under Age 19 or under Age 19 or in the case of full-time students, under 21. 16. If individual is found Medicaid ineligible due to lump sum payment, State may opt to reconsider eligibility in a subsequent month without requiring a new application. 17. For a tax dependent claimed by an individual other than a spouse or parent, the State has the option to count as income available cash support provided by the tax filer. 24
State Decisions Needed (4 of 4) 18. For individuals determined Medicaid eligible under MAGI, states may elect to base ongoing financial eligibility on current monthly household income or projected annual income for the remainder of the calendar year. Thus, State needs to decide whether to use a point in time income or projected annual income in the Exchange. State can also opt to continue to account for reasonably predictable fluctuations in income for Medicaid determinations. 19. States to determine income standard for Medicaid consolidated groups within minimum and maximum parameters defined in federal regulation. 25