Medicaid, Medicare, and ACA Insurance Plans

Medical Insurance

Jacob M. Eden, [email protected]

AIDS Law Project of Pennsylvania1211 Chestnut Street, Suite 600

Philadelphia, PA 19107(215) 587-9377

mailto:[email protected]

138% No resource

testMAG

I

100%$2k

resource limit

up to 200%with disregardsH

H

250%$10,000 resource limit

up to 500%with disregardsM

AWD

$2,199(3xSSI)W

aive

r

500% - No resource test

SPB

P

Premium Assistance 138% - 400%Cost Sharing Help

138 - 250%Mar

ketp

laceAC

A

100%

200%

300% 400%

500%

Medicare has no limits

Patient Protection and Affordable Care Act

• Often called Affordable Care Act, ACA, or Obamacare.• Signed into law in 2010. Fully phasing in by 2020.• Survived several constitutional challenges

Some Key Provisionso Dependents covered until age 26o No lifetime limits on hospital stays or other essential health benefitso Insurers cannot deny coverage for pre-existing conditions. o Insurers must offer same premiums within the same age and

geographical groups – gender or health conditions cannot be considered (except tobacco use)

o Put requirements on businesses to provide health insurance to employees

1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Three-legged StoolThe ACA has often been described as a three-legged stool – all legs are necessary for affordable, comprehensive health care for all.

1. No pre-existing conditions exclusion2. Everyone must be covered3. Coverage must be affordable:

1. Medicaid2. Marketplace


Medical Assistance


Benefits - MCOs• For people on Medicaid only (i.e., no Medicare):

o Physical Health administered through a Managed Care Organization (MCO)• In Philadelphia and surrounding counties:

o Aetna Better Health; UnitedHealthcare Community Plan; Health Partners Plans; Keystone First.

o (Changing sometime in 2017; RFP going on now . . . Again)• Covers: Almost everything, including doctors, hospitals,

prescriptions, non-emergency medical transportation, limited dental.

• Copays are either non-existent or $1-3 (cannot charge copay for medicines whose only approved indication is for treating AIDS.

o Mental Health through Community Behavioral Health (CBH)1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902

Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Benefits – Dual Eligibles• Medicaid comes in two types for people with Medicare

o Buy-in: Pays the Medicare Part B premium

o Medical Assistance: Pays deductible, copays, and coinsurance.• Paid through “fee-for-service” (i.e., ACCESS card)• Does not cover prescription drugs . . .

o But eligibility for MA, automatically makes a person eligible for Medicare Part D Extra Help (which limits copay to $3.80 max per prescription).

o Up to 120% FPIG possible to have both Buy-in and MA; above 120% must choose between Buy-in or MA.


MAGI Medical Assistance

a.k.a., Expansion MA(Affordable Care Act)


Medicaid Expansion• As of January 1, 2015, Pennsylvania has an expanded

Medicaid program

A Brief History• Before the expansion:

o To be eligible, must be low income AND fit into a category• Categories included: over 65; disability; pregnant; child; or parent

o “Traditional” Medicaid still exists: including Healthy Horizons and MAWD

• After the expansion:o All adults between 18-64 are eligible, if low income (and meet other

restrictions). No additional “category” required.• Low income = income less than 138% of the Federal Poverty Line (FPL)

MAGI MA Eligibility for Adults

• Income less than 138% FPL• Age 19-64• Pennsylvania Resident• Not eligible for Medicare (Part A or B)• U.S. Citizen

o Some immigrants may qualify but rules are complicated

• Note: No asset test! (Big change from traditional MA)1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902


Income• What is 138% FPL?

o Look at 2016 Benefit Amount and Income Levels (handout)o For an individual: $1,366 per month / $16,394 per year

(full time minimum wage worker earns $15,080 per year)o For a family of four: $2,795 per month / $33,534 per year

• What income is counted?o MAGI: Modified Adjusted Gross Income

• Basically:if the income is taxable, it counts; if it is not taxable, it does not count.

o More Complex:• Adjusted Gross Income + tax exempt interest + foreign income +

Social Security Benefits (with exception of SSI)

Income Eligibility for MAGI

Adults: 138%Children 6-18: 138%Children 1-5: 162%Children 0-1: 220%

Pregnant women: 220%


1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

What Income CountsCounted Excluded

• Wages & tips

• Unemployment Compensation• Social Security benefits(Retirement, Survivors, and Disability)

• Pensions

• Dividends and interest

• Alimony received

• Rents & royalties

• Veterans benefits

• Workers’ compensation

• TANF (Temporary Aid for Needy Families)

• SSI (Supplemental Security Income)

• Child support

• Scholarship income

• Student loan interest

• Gifts and inheritances


Deductions(These are standard tax deductions – i.e, the “adjusted” part of adjusted gross income)

• Student loan interest ($2,500 maximum)• Self-employed health insurance.• Deductible part of self-employment tax.• Health savings account deduction.• Educator expenses (maximum $250).• Certain business expenses of reservist, performing artist and fee-basis government

officials.• Job related moving expenses.• Self-employed SEP, SIMPLE and qualified plans.• Penalty on early withdrawal of savings.• Alimony paid.• IRA deduction (under 50, maximum of $5,500; over 50, $6,500).• Tuition and fees (maximum of $2,000).• Domestic production activities.

Only available for Tax-filer applicants (see later slides for non-tax filers)

Household Size• Determining the Household size for MAGI purposes:

o Person by person determination• It’s possible for each person living in the same

house to have different household sizes

o Three sets of rules in determining size:• 1. Tax Filer• 2. Tax dependent• 3. Non-filers and non-dependents



Courtesy of CLS

138% No resource

testMAG

I

100%$2k

resource limit


H



AWD

$2,199(3xSSI)W

aive

r


SPB

P


138 - 250%Mar

ketp

laceAC

A

100%

200%

300% 400%

500%


Traditional Medical Assistance


Not eligible for MAGI Medical Assistance?

• Both Healthy Horizon and Medical Assistance for Workers with Disabilities (MAWD) still exist! Remember when calculating income for these programs, use the SSI counting rules. That includes the 50% disregard for earned income!o Income is not the only requirement. There are resource limits and other

requirements (like a job for MAWD).


Supplemental Security Income (SSI) Counting Rules

• To determine Countable Income:o CI = UI + EI

• Unearned income (UI)o $$$ - $20 general disregard

• Earned income (EI)o $$$ - $65 (earned income disregard) divided by HALF


Example: Bob receives $500/month from his aunt and $465/month from his job. What is his COUNTABLE income?

UI = $480 ($500-$20)EI = $200 (($465-$65)/2)CI =$680

Healthy HorizonsPeople over 65 or with Disabilities

•Disabled 12 months or moreoEmployability Assessment Form

(EAF) (PA 1663)Must check Box 1 or Box 2

ORoReceipt of Social Security Disability benefits

OR

•Over 651211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902


Healthy Horizon Income Limits

• Income Limit is 100% poverty for family size – $990 for a family of 1 in 2016

• Use SSI income counting rules

o EARNED INCOME DISREGARDS• $20 (general exclusion for everyone)• $65• One half of remaining earned income


Healthy Horizons Resource Limit

• $2,000 individual

• $3,000 couple

• NOTE: No Resource test for HH if there is a minor child in the house!


MAWD• Underused program• For clients under 65 with income too high for

Healthy Horizonso People working despite serious medical conditions

o People with disabilities whose spouses earn too much for them to get Healthy Horizons

• Working and receiving compensationo Job can be small–one hour per week.

• Receiving SSD, completed EAF or health sustaining meds form


Who should get MAWD?• Too “rich” for Healthy Horizons

• Full time workers with significant health problems -- NEED TO SHOW DISABILITY

• DISABLED individuals with incomes over 100% of poverty -- NEED TO GET A JOB


What is a Job for MAWD?• No specific number of hours required

• No requirement that taxes be withheld

• No specific hourly rate required (minimum wage is typical)

• Self-employment forms/business plan rarely needed, but often improperly asked for


MAWD Income Limits - 2016

YOU WILL RARELY ENCOUNTER ANY CLIENT WHO IS OVER INCOME FOR MAWD

• 250% FPL

• Family of 1 $2,475

• Family of 2 $3,338

• Don’t forget the EARNED INCOME DISREGARDS ($20; $65; one half the rest!)

• The effective income limit for a single person who works despite his or her disability is OVER $54,000 per year!


MAWD Resource Limit• $10,000


MAWD Costs• Unlike other categories o Medical Assistance,

people on MAWD must pay a monthly premium for their coverage.

• The premium is 5% of Countable Income

• Typical cost is between $50-100o Some plans on the Marketplace, with subsidies, could cost lest.

However, those plans will usually have higher out of pocket costs in deductibles, co-pays, and co-insurance.


Proving Disability for MAWD

• On Social Security Disability, or

• EAF, or

• Health Sustaining Medication Form (PA 1671)


Special Pharmaceutical Benefits Program

(SPBP)


SPBP• SPBP is Pennsylvania’s version of the AIDS Drug

Assistance Program

• Run out of the Department of Health, not DHS

• Covers:o Prescription drugs – not just HIV prescriptions but a wide varietyo Some lab work

• SPBP HIV/AIDS is the payer of last resort and third party resources must be used before payment is made by the program.


SPBP Eligibility• Applicants must be:

o a resident of Pennsylvania,

o have a gross annual income of less than or equal to 500% of the Federal Poverty Level (FPL), and

o have a diagnosis of HIV/AIDS to qualify for the program.

• No resource test1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902


SPBP & other Insurance• SPBP works well with other insurance.

• It’s possible for a person to have:o Private insurance and SPBPo Medicare and SPBPo Medicare, Medicaid, and SPBP

• Medicaid does not cover prescription drugs when paired with Medicare, which is where SPBP can help.


Medicare


The Basics• Administered by Social Security Administration

(SSA)

• Traditional Medicare “Red, White and Blue” card

• Three Parts (Parts A, B, D – Part C is not really a part)


Eligibility• Age 65, or:

• Disabled and worked long enough to be insured (generally 40 quarters)

NOTE – Coverage starts 24 months after eligibility for Social Security checks (don’t forget 5 month waiting period for checks)

Exceptions ESRD; Lou Gehrig’s disease


Medicare Part A

• Hospital Insurance

Covers inpatient hospital, SNF, home health, and hospice care

No premiums for almost all beneficiaries

Has copays and deductibles


Medicare Part B• Physician services, some outpatient services,

some preventive services, ambulance services, and durable medical equipment (DME)

• Has premiums, copays, and deductibles.


Medicare Part B Premiums• Varying Monthly Premiums (2016)

$121.80 -- individuals with incomes less than $85,000 (single)(Most people who were eligible pre-2016 still pay $104.90)

Higher income folks – higher premiums


Medicare Part B Co-payments

• Medicare generally pays 80% of allowable charge

• The remaining 20% falls to beneficiary, unless has a secondary insurance (for example, Medicaid).o Charity Care is also an option


Medicare Part D• Prescription Drug Benefits

Began January 1, 2006

• Must pick a plan from a private insurance company during yearly open enrollment period

• Has premiums, copays, and deductibles -- important to pick the right plan!

• Assistance for low-income individuals1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902


Medicare Part DTwo types of Part D plans:

• Stand Alone Prescription Drug Plan (PDP)

• Medicare Advantage Plan with Prescription Coverage . . . Which brings us to Part C.


Medicare Part C

• Not really a part, but a compilation of A, B, & D

• Managed Care for Medicare Beneficiaries

• Combined Medicare coverage and prescription drug coverage

• “Special” Plans for full DUAL ELIGIBLES (Medicare and Medicaid) a/k/a

“SPECIAL NEEDS PLANS”


Affordable Care ActMarketplace


Marketplace• On the marketplace, people buy private insurance

plans for coverage.• There are set enrollment periods

o Open Enrollment: November 7 – January 31• For coverage starting January 1, must apply by December 15 and

pay first premium by December 31.

o Special Enrollment: You can enroll in plans for 60 days following certain “life events”. These events are usually related to losing insurance, whether because someone died or married/divorced or got/lost a job.


Insurance Terms & Concepts

• Premiums: The monthly cost a person pays for a health plan. Paid directly to the health insurer.

• Cost-sharing: Charges a person pays as he or she uses benefits covered by a plan. Usually paid directly to various service providers.o Deductible: Amount a person must pay before the plan begins paying.

• Beware of plans that include prescription drug coverage in the deductible.o Copayments: Set dollar amount for an item or service that an enrollee must

pay. • For example, $10/copay to see Primary Care Physician, which is paid

directly to the PCP.o Coinsurance: Set percentage of an item or service that an enrollee must pay.

• For an example, if a person has 10% coinsurance for X-rays and an X-ray costs $500, the person pays $50 for the X-ray.


Terms continued• Maximum Out-of-Pocket limit (OOP): The highest

amount that an enrollee can pay in cost-sharing. Once this number is reached, the plan covers all costs (even for services that previously required copays or coinsurance). o Usually only applies to in-network care. Out of network care may have

no or higher OOP limit.


Metal Level Tiers of Qualified Health Plans (QHPs)

METAL LEVEL PLAN TIERSQHPs must provide plan designs consistent with actuarial values

Platinum 90% actuarial value

Gold 80% actuarial value

Silver 70% actuarial value

Bronze 60% actuarial value

Catastrophic coverageHigh deductible health plan available for individuals up to age 30 or some individuals exempted from the individual responsibility requirement

Actuarial value is a measure of the percentage of expected health care costs a health plan will cover and is considered a general summary measure of health plan generosity. It represents an average for a population and does not necessarily reflect the actual cost-sharing experience of an individual.

Cost

s cov

ered

by

a pl

anPrem

iums paid by consum

er

The AFFORDABLE part of the Affordable Care Act

The affordable care act has provisions to reduce the cost of both PREMIUMS and Cost-Sharing:• Premium :

o Advanced Premium Tax Credits : Available to people with income between 100% and 400% FPL, in theory. • Available for any QHP, regardless of Tier

• Cost-Sharing:o Cost Sharing Reduction Plans: Silver plans that reduce cost-sharing for

people with income between 100% - 250% FPL.• Only available for Silver Tier plans.


Income Counting• MAGI – Modified Adjusted Gross Income is used to

calculate eligibility for premium subsidies and cost sharing reductions. That is Adjusted Gross Income, plus some other income, most importantly, Social Security Benefits (but not SSI).

• Household size is the determined by tax paying unit. Thus, tax-filer counts own income plus any dependents. Any dependents count own income plus the tax-filer’s and any other dependents.


Advanced Premium Tax Credit

• Uses projected annual income• Must file taxes

o “reconciliation” occurs at tax time, where if you earned more than you predicted, you must repay. But if you made less, you might get more tax credits.

o If married, must file a joint return (unless Head of Household, survivor of domestic abuse, or an abandoned spouse).

• Must enroll in a Qualified Health Plan (all plans on the Marketplace are QHPs)

• How is it calculated?o It’s complicated. The subsidy is equal to the region’s benchmark plan minus a

person’s expected premium contribution.


Cost Sharing Reduction Plans

• People with incomes between 100% - 250% FPL qualify for additional Cost Sharing Reductions.

• To be eligible for these savings a person must be eligible for the tax credit and be enrolled in a silver plan.

• The reductions are provided through enrollment into special Cost Sharing Reduction silver plans, where the insurer automatically alters the cost-sharing burden.


Cost Sharing Reduction Plans

• Standard Silver: 70% CSR Plans• Up to 150% FPL: 94% (CSR 94) / OOP Max: $2,250• 151% - 200% FPL: 87% (CSR 87) / OOP Max: $2,250• 201% - 250% FPL: 73% (CSR 73) / OOP Max: $5,200

• It is up to insurer how to make a Silver plan cover more of the medical costs. Most use a combination of lowering the deductible, copays/coinsurance, and Out-of-Pocket maximums.


Real Time Determinations• The Marketplace makes real time determinations on

whether a person qualifies for a premium or a CSR plan.

• An eligibility notice will then be sent.

• The person then must send in any needed verification. Uploading this information is best, but if mailing include the bar code on the eligibility notice.


Resources for Applying• Choosing and applying for Marketplace plans is daunting.

Many variables must be considered.

• There are many resources out there to help people apply: Navigators, Assistors, and Brokers.

• Healthcare.gov has a “find local help” button. Within 5 miles of Philadelphia, there are 81 organizations with assisters: including the Health Federation, Philadelphia FIGHT, Mazzoni, PHMC (at various places). Assissters are federally trained and should be able to assist in applications.



CSR 87 CSR 94CSR 73

138% No resource

testMAG

I

100%$2k

resource limit


H



AWD

$2,199(3xSSI)W

aive

r


SPB

P


138 - 250%Mar

ketp

laceAC

A

100%

200%

300% 400%

500%


Medicaid, Medicare, and ACA Insurance Plans

Healthcare

Transcript of Medicaid, Medicare, and ACA Insurance Plans