Health Coverage Programs 2018 Neil Cronin Basic Benefits Training February 13, 2018 1 Affordable Care Act (ACA) changes in MassHealth & Connector in 2014 2
2014 ACA Improvements in MA MassHealth eligibility up to 133% -(138% MAGI) Help paying for health insurance up to 400% FPL Fewer gaps in coverage One-stop-shopping for health and dental insurance (online application) 3 Post-ACA Subsidized Coverage
What is MassHealth? 1.8 million members $15 billion budget Mostly federal-state Medicaid Also federal-state non- Medicaid Children s Health Ins. Progr. (CHIP) Small number in stateonly program 5 42 USC 1396 et seq. Medicaid 42 CFR Part 430 et seq. Federal agency: Centers for Medicare and Medicaid Services (CMS) Federal website: Medicaid.gov 2dry sources: National Health Law Program, healthlaw.org 6
How Medicaid works States operate within framework of federal law: Eligibility: mandatory & optional groups Benefits: mandatory & optional services Flexibility for states in many areas: delivery systems, rates, amount, duration & scope of covered benefits, premiums & cost sharing State plan approved by CMS Federal reimbursement in Mass. 50% or more of total costs 7 1115 Demonstrations 42 USC 1315 ( 1115 of Soc. Sec. Act) Secretary of HHS can authorize federal reimbursement beyond Medicaid options & can waive many provisions of Medicaid statute MassHealth has operated under an 1115 demonstration for most of its under 65 population since 1997 8
MassHealth MassHealth Single state agency: Executive Office of Health and Human Services (EOHHS) Day to day administration: Office of Medicaid Long term services & supports -Dept. of Elder Affairs & Office of Medicaid G.L. c. 118E 130 Code of Mass. Regs (CMR) Website: mass.gov/masshealth 9 Coverage Types in MA Connector Programs ConnectorCare QHP with APTC Health Connector Plans- (QHP with no subsidy) Covered in afternoon Programs o Standard o CommonHealth o CarePlus o Family Assistance o Limited MassHealth Administered Programs Children s Medical Security Program (CMSP) Health Safety Net (HSN)
MassHealth Programs MassHealth Program Standard CommonHealth CarePlus Low-income adults 21-64 Population Lower-income kids & young adults age 19-20, parents, pregnant women, disabled individuals, breast and cervical cancer patients, lower income HIV positive individuals, certain low income adults classified as medically frail, and elder adults (65+) Higher-income people with disabilities, (children, onetime deductible adults 19-64, working disabled individuals 19 or older) Family Assistance MassHealth Limited Higher-income kids, higher income individuals with HIV Immigrants ineligible for MassHealth Standard or CarePlus because of their immigration status 11 Counting income post-aca Modified Adjusted Gross Income (MAGI) Applies to almost everyone except Seniors eligible for MassHealth based on age People eligible for MassHealth based on need for long term care People for whom MassHealth does not make an income decision e.g. SSI, TAFDC & EAEDC recipients 12
More about MAGI Basically using tax rules for who to include in household & what income counts but with exceptions and modifications Income deduction in MassHealth MAGI: deduct 5% of 100% FPL for Family Size Lots more MAGI information in on-line materials 13 Immigrants No ACA change in federal Medicaid (MassHealth Standard or CarePlus) Qualified (not 5-year barred) adults eligible for MassHealth Standard & other benefits like US citizens Lawfully present children under 19 up to 300% FPL & 19 & 20 year olds up to 150% FPL are eligible for MassHealth like US citizens Lawfully present individuals are eligible for benefits through Connector like US citizens 14
More about Immigrants Immigrants & Public Benefits Basic Benefit Training on March 8, 2018 Link to materials from Immigrants & Public Benefits BBT on line (currently 2017; will be updated March 8, 2018) 15 Standard Low income kids and young adults age 19 20 150% FPL Parents 133% FPL Pregnant women and infants 200% FPL Persons with breast & cervical cancer 250% FPL HIV+ adults 133% FPL Elder adults (65 plus) 100% FPL + asset test 16
Newly eligible for MH Standard starting in 2014 Pregnant women (regardless of immigration status) up to 200% in Standard Young adults 19-20 with income up to 150% FPL HIV+ under 65 with income up to 133% FPL (133-200% still in Family Assistance) Former foster children up to age 26 regardless of income Adults up to 133% FPL eligible for DMH services or determined medically frail & choose Standard over CarePlus 17 Family Assistance HIV+ Adults 133% - 200% FPL Premiums above 150% FPL Children 150% - 300% FPL Direct Coverage if uninsured Premium Assistance with dental wrap if employerbased insurance is available Premiums Start at $12 per child, $36 maximum for 3 or more children, waived if parents pay premium in ConnectorCare 18
ACA Improvements for Children in Family Assistance Children 200%-300% FPL no longer have to be uninsured for prior 6 mo. (no waiting period) Premium Assistance now available for children 200%-300% FPL enrolled in a parent s employerbased insurance at time of application Children who lose coverage for nonpayment of premiums can re-enroll after 90 days even if back premiums are not paid 19 CommonHealth Higher Income people with disabilities Children under 19 Working disabled adults (including 65 & over) One-time deductible adults under 65 No Upper Income Limit Premiums above 150% FPL 20
CommonHealth for adults The post-aca eligibility system cannot yet make a determination based on disability for adults in CommonHealth Initial decision will not be based on disability, but will say to expect another decision 2d decision is manually generated by MassHealth workers using legacy eligibility system 21 MassHealth CarePlus (Medicaid Expansion Adults) Adults 21-64 with income up to 133% FPL & not eligible for Standard & not on Medicare Starting March 1, 2018, managed care enrollment can be any time of month (no longer only on 1 st of month) MassHealth CarePlus unless Medically Frail & choose MH Standard 22
Medically Frail/Special Health Needs Medically Frail adult eligible for CarePlus must be given the option to enroll in Standard Remain in CarePlus until they affirmatively seek MassHealth Standard Helps people who have special health needs but not (or not yet) found disabled Don t confuse with frail elder waiver MassHealth Limited Ineligible for MassHealth Standard or CarePlus due to immigrant status Infants up to 200% FPL Adults under age 65 with incomes up to 133% FPL Children under age 21 up to 150% FPL, and Individuals 65 or older with income up to 100% FPL with limited assets. Lawfully present but not Qualified adults may have Limited AND ConnectorCare
Coverage under MassHealth Limited Only emergency services are covered. This includes some ongoing conditions where there is an immediate need for treatment, such as kidney dialysis. It includes labor and delivery Emergency ambulance services Not limited to Emergency Room services Children s Medical Security Plan (CMSP) Uninsured children who are not eligible for any MassHealth benefit, other than Limited No upper income limit No citizenship requirement Premiums begin at 200% FPL, full premium cost at 400% FPL Limited benefits, such as $200 limit on drugs, limited hospitalization, etc. Doesn t count as insurance on federal taxes for 2018
Health Safety Net (HSN) Not insurance Pays for uncompensated care in acute care hospitals or community health centers Full or partial coverage depending on income Medical Hardship regardless of income (formula) No citizenship requirement 27 2016 Cuts TO HSN Limiting retroactive coverage to 10 days down from 6 months Beginning deductible for partial free care at 150% FPL down from 200% FPL Capping eligibility at 300% FPL down from 400% FPL Also, implementing existing policy limiting HSN to 90 days for eligible, but unenrolled, Connector Care members
Changes Gov. proposed for Fiscal Year 2019 Change state law to reduce MassHealth upper income limit for non-disabled adults from 133% to 100% FPL (except for adults who are pregnant, breast/cervical cancer or HIV+) 100,000 parents & 40,000 childless adults Ask (but don t require) Connector Board to raise income limit for Plan Type 1 from 100% to 138% FPL & add a dental benefit 29