Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit

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Health Care Reform and Medicaid/NCHC Eligibility

WSS Leadership Summit

Carolyn McClanahanChief, Medicaid Eligibility

Division of Medical AssistanceApril 22, 2014


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Health Care Reform Legislation

• Federal

– The federal Patient Protection and Affordable Care Act, P.L. 111-148, (ACA) as amended

– March 23, 2010 – signed by President Obama


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Summary Provisions

• Expanded coverage optional for states

• Implementation of Health Benefit Marketplace for uninsured (formerly called “exchange”)

• Medicaid/NCHC Eligibility Changes

• Enrollment streamline and simplification


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Expanded Coverage Optional for States

• Original federal legislation required Medicaid expansion to most individuals up to 133% (138%) fpl in new eligibility group

• Included childless adults, caretakers above current coverage limit

• Did not include age 65+, pregnant women, individuals with Medicare

• Supreme Court decision – Congress could not require states to expand – must be optional for states


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Expanded Coverage Optional for States

• NC Session Law 2013-5

• NC will not expand Medicaid as provided in ACA

• NC will maintain the current coverage groups


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Summary Provisions


• Implementation of Health Benefit Marketplace for uninsured (formerly called “exchange”)




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Implementation of Health Benefit Marketplace

• Federal Health Benefit Marketplace created:– States can build State Marketplace – States can build Partnership with Federally Facilitated

Marketplace (FFM)– States can use the FFM

• NC Session Law 2013-5

• NC will utilize the Federally Facilitated Marketplace


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Implementation of Health Benefit Marketplace

• Individuals/families can purchase insurance

• Income < 400% fpl – may qualify for Advance Payment Tax Credits (APTC)/cost-sharing assistance– Must have income above 100% fpl

• Eligibility determination for APTC and cost-sharing similar to Medicaid/NCHC

• Household/income based on IRS rules– Income eligibility based on MAGI (Modified Adjusted Gross Income)


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Summary Provisions


• Implementation of Health Care Marketplace for uninsured (formerly called “exchange”)




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Medicaid/NCHC Eligibility Changes

• No changes to ABD/MQB eligibility– Excluded from MAGI methodology

• All Family & Children’s Medicaid programs affected– Use tax definition of household and income– MAGI income methodology

• New coverage group– Former foster care children up to age 26


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Eligibility Change: IRS – based methodology

• MAGI – a methodology for how income is counted and how household composition and family size are determined

• Household composition – tax household– includes stepparent, if in tax household– Includes siblings (biological, adopted, step)

• Income – based on federal tax rules for determining adjusted gross income (with some modifications)

• No asset test or disregards (except 5% disregard across the board)


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Eligibility Change: New questions

To help determine household composition:

• Is the individual a tax filer?

• Does the individual expect to be claimed as a tax dependent?


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Eligibility Changes:

• If not tax filer or tax dependent, build household similar to tax household

• Household - adult:– Individual– Spouse– Natural, adopted or step children

• Household – child:– Individual– Natural, adopted, step parent– Natural, adopted, step siblings

• Child: individual under age 19 or, at state option, 19 or 20 and a full-time student


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Eligibility Change: Income

• May disregard income of child/tax dependent if do not plan to file taxes

• Child support is non-countable income

• Social security – countable based on amendment to ACA


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Eligibility Change: MAGI

• Taxable Adjusted Gross Income (AGI) with a few modifications

• Disregards/exclusions– States cannot give current disregards

• Earned income disregards ($90, 27-1/2 %, child care)

– Only disregard is 5% from the MAGI calculation


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MAGI-Equivalent Income Limits

• Income limits adjusted due to difference in deductions• Purpose: to “hold harmless” eligibility standards so,

as a group, individuals do not lose eligibility• CMS – contracted with vendor to provide calculations

for states• Revised income limits:

– Example: current 185% may be converted to 192% (not actual converted amount)

– Should receive the converted income limits sometime later this month


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Summary Provisions


• Implementation of Health Care Marketplace for uninsured (formerly called “exchange”)




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Streamline/Simplification

• ACA mandates individuals may apply for all insurance affordability programs:– In person– Mail– Electronic– Phone

• Insurance affordability programs:– Medicaid– CHIP (NCHC)– APTC (Advance Payment of Tax Credits)/Cost-sharing


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• States and Marketplace: must have web portal for applications

• “No Wrong Door” - Individuals may apply at any agency/site for all insurance affordability programs


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• One application for all insurance affordability programs

• CMS is developing the model paper and on-line application

• Individuals who only want medical coverage must have streamlined model application available

• States can get alternate application approved – must submit State Plan Amendment (SPA)


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• Must rely on electronic data for verification• Request info from applicant only if not available

electronically or discrepancy• Move to “real-time” eligibility determinations as much as

possible• Experience should be as seamless as possible for

applicant – no duplicate requests for information• Renew coverage based on information available


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Final: Time Frames

• October 1, 2013– Open enrollment for insurance affordability programs– Must accept single streamlined applications and apply

new rules– Must be able to transmit information to Marketplace– Evaluate under current rules for eligibility prior to

1/1/14• January 1, 2014

– Coverage under insurance affordability programs can begin

Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit

Documents

Transcript of Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit