Affordable Care Act Application, Verification & Renewal

Affordable Care ActApplication, Verification & Renewal

Session 5

Presented by Tokie Moriel & John Tvedt

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Session Objectives

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• Explain MAGI processes for:• Eligibility and Enrollment• Verification• Renewal

• Look at other Key Points including:• Reasonable Compatibly Standard• Residency• Notices – Consumer Rights• Appeals

Seamless, Streamlined System of Eligibility and Enrollment

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Single, Streamlined Application

• All applications must be receivable via: – Online, telephone, in-person, mail, and other electronic means

as commonly available

• No in-person interviews for MAGI eligibility

• Applications can be signed by: – Applicant – Non-applicant in applicant’s family or household – Someone acting responsibly for a minor or an incapacitated

person– A designated authorized representative


Minimizing Consumer Burden

• May only require an individual to provide information that is necessary to make an eligibility determination.

• May request information for other insurance affordability programs or benefit programs

• Requesting SSNs of non-applicants is permitted if:

– It is voluntary

– It is used only to determine eligibility

– Clear notice is provided to individual


Principles of An Effective Online Application

• Dynamic

• Real-time verification

• Pre-populate when available


Providing Assistance

• Assistance must be provided through all modes of application submission

• Individuals must be allowed to utilize other assistance of his/her choice

• Assistance must also be provided at renewal


Application Processing Standards

• Eligibility determination for applicants may not exceed:

– 90 days – disability basis

– 45 days – medically needy

– 30 days – regular applications


Scenario: Applicants and Non-Applicants

• Non-applicant parent wants coverage for applicant child

– What should we ask for of a non-applicant:• Contact information • Tax filing status• Family relationship • Parent’s income verification


Verification

• Goals:

– Maximize automation through data sources

– Minimize need for documentation; reduce administrative burden

– Simple and transparent process for consumers

– Ensure program integrity

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Primary Reliance on Electronic Sources

• Federal Data Services

• Medicaid/CHIP agency must obtain the information through the Hub.

• Other Electronic Data Sources

• Reducing the need of paper verification

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Efforts To Decrease Reliance on Paper Documentation

• No further documentation will be required unless information cannot be obtained electronically or it is not reasonably compatible with attested information.

• Documentation from the individual is permitted only to the extent that establishing a data match would not be effective.

• Impact on program integrity

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Self-AttestationValidation of Data

• Self-attestation can be accepted for:

– For many factors of eligibility except as required by Federal law, i.e., citizenship and immigration status or by the State of Iowa such as income

– Pregnancy

• Self-attestation can be accepted from:

– The applicant, an adult in the applicant’s household or family, authorized representative, someone acting responsibly for the individual (if minor or incapacitated)

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Reasonable Compatibility

• Apply the “Reasonable Compatibility” standard:

– Information is relatively consistent and does not vary significantly or in a way that is meaningful for eligibility

– Income information obtained through an electronic data match is reasonably compatible with income information provided by the individual, if both are either above or both are at or below the applicable income standard or other relevant income threshold

– If income information is not compatible, apply 10% threshold– If income if still not compatible, obtain verification prior to

making an eligibility determination

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Reasonable Compatibility Scenario 1

• Eligibility level = 100% FPL – Attested Income = 85% FPL

– Only reports earnings from work

• Data Sources:– IRS (previous year) = 95% FPL

– Quarterly Wage (past 3 months) = 92 % FPL. Only used if income is not reasonably compatible with IRS data match

• No affect on eligibility = reasonably compatible – Determine eligible for Medicaid

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• Eligibility level = 100% FPL

– Attested Income = 160% FPL

• Data Sources:

– None needed

• Above Medicaid limit so determine ineligible and screen for CHIP and if applicable CSR/APTC through the Marketplace.

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• Eligibility level = 100% FPL – Attested Income = 90% FPL

• Data Source – IRS (previous year) = 160% FPL

– Quarterly Wage (past 3 months) = 140% FPL

• Options when there is a discrepancy with income:– Apply reasonable compatibility standards 10% threshold

– Request explanation from individual of discrepancy

– Request documentation from the individual

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If Found Ineligible at Application Due to

• Income that could not be validated

• The FFM will notify the household of what options are available to them and what the cost is for each option

• Alien/Citizenship Status

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Periodic Renewal

• For beneficiaries whose eligibility is based on MAGI: Eligibility must be renewed once every 12 months, unless there is a change that affects eligibility

• For beneficiaries eligible based on MAGI or non-MAGI: DHS renews eligibility, without requiring information from the individual, if it is able to do so based on the case information or other more current information available to the Department

• If eligibility can be renewed based on available data, no renewal form is needed

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Renewing Eligibility

• If the individual is renewed based on available information:

– DHS must notify the beneficiary, but cannot require that the notice be signed and returned

• For MAGI eligibility, if the beneficiary can’t be renewed based on the available information:

– DHS must provide a renewal form pre-populated with the information available and request the additional information needed to determine eligibility and to sign the form within 30 days

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Pre-Populated Forms for Renewals

• Allow for response online, over the telephone, by mail and in person

• Provide at least 30 days for response

• Verify information provided by the beneficiary

• 3 Month/90 Day Reconsideration Period for individual terminated for failure to submit a renewal form

• Notify the beneficiary of the decision

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If Found Ineligible at Renewal

• Prior to making a determination of ineligibility, DHS must consider all bases of eligibility

• If a beneficiary does not respond to the renewal form, and coverage is terminated on that basis, eligibility can be reconsidered if the individual responds within three months without being required to submit a new application.

• If a beneficiary is ineligible due to an increase in income, the agency should determine potential eligibility for CHIP, APTC, and QHP, and transmit the electronic account as appropriate

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Changes in Circumstances

• Conduct redetermination when there are changes that may affect eligibility

– As reported by beneficiary

– As received via data matching

– Limit requests only for needed/required information that has not been electronically verified.

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Renewal Scenario 1

• Initial application shows beneficiary is a citizen and has two jobs, with income verified by quarterly wage data

– At annual renewal, quarterly wage database finds the income from those two jobs is similar, still within Medicaid range, and no new jobs appear. No need to re-check citizenship because it is not subject to change

– Renew eligibility for the beneficiary and a notice showing the information used to make the decision and a requirement to report if any information used to determine eligibility is incorrect or has changed

– No response from the individual is not necessary

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Renewal Scenario 2

• Initial application shows beneficiary is self-employed with income which has been validated by federal and state data sources

– At annual renewal, income data sources are checked but no information is found about the individual

– A pre-populated form with the available information is sent to the beneficiary for review and response

– The beneficiary is given up to 30 days for a response before renewing or terminating coverage

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State Residency Policy

• Alignment with ACA, CCIIO/Marketplace definition and CHIP

• No gaps in coverage between, Medicaid , CHIP, and Marketplace based on different residency policies

• Limited policy change in Medicaid Residency rules

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Definition of Residency for Medicaid

• Adults - Where an individual is living or intends to reside

– Including without a fixed address or

– Entered the State with job commitment or seeking job

• Children – Where an individual resides

– Including without a fixed address or

– State or residency of individuals parent

• Students

– Retain flexibility for states

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Residency Verification

• Self–attestation permitted

• Electronic data sources and requesting additional information from the individual follow general verification rules

• Evidence of immigration status cannot be used to determine that an individual is not a State resident

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Who Is Not Affected?

People who are exempt from the MAGI residency requirements includes:

• Individuals living in institutions or foster care placements

• Individuals receiving IV-E assistance (foster care or adoption assistance)

• Persons without capacity to express intent

• Portions of the CHIP definition

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Coordinating Eligibility Notices

• Combined Eligibility Notice features

– Single combined notice for MAGI-based eligibility across all insurance affordability programs and enrollment in a QHP

– Single combined notice generated by the agency that completed the last step in making the eligibility determination (“last touch”)

– Required by January 1, 2015

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• Individual applies through the State portal and is determined eligible for Medicaid

– DHS issues a combined notice of eligibility informing individual of Medicaid approval and APTC/CSR denial

• Individual applies to the FFM. FFM is not authorized to make Medicaid/CHIP determinations. Individual is eligible for Medicaid (MAGI)

– The FFM assesses individual as Medicaid eligible (MAGI) and transfers to the Department. DHS issues a combined notice of Medicaid approval and APTC/CSR denial

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• When issuing a combined notice is not feasible, a coordinated content notice is required.

• A family applies to the CHIP agency. Children are eligible for CHIP and parents are eligible for APTC/CSR

– CHIP issues a notice informing the family that the children are eligible for CHIP, with coordinated content informing the parents that they appear eligible for APTC/CSR and their account has been transferred to the Marketplace for further review

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Notices Content Standards

• Notices must be in plain language and accessible

• Content must be included on how to request a determination on a basis other than MAGI (Medicaid eligibility notices)

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Notices Content Standards

• Approval notice must include:

– Basis and effective date of eligibility

– Change reporting requirement affecting eligibility

– Information on benefits and services and required premiums/cost sharing, if applicable

– Medically needy, as appropriate

– Adverse action notice must include the effective date of the action.

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Electronic Notices

• Current regulations require paper-based, mailed notices

• ACA requires Medicaid & CHIP agencies to offer beneficiaries and applicants the option to receive electronic notices

– Consumer protections must be in place

– Opt-in and opt-out

– Post notice to secure electronic account

– If electronic alert/communication undeliverable, send notice by regular mail

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Working to Protect Consumers

• Consumers have the right to:

– Information about why a claim or coverage has been denied

– Appeal

– An independent review

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Conclusion

• Additional ACA webinars

• Session Review – Income Maintenance Workers ONLY

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Affordable Care Act Application, Verification & Renewal

Documents

Transcript of Affordable Care Act Application, Verification & Renewal