What is CalHEERS?

CALHEERS OVERVIEW

• CalHEERS is an acronym. It stands for ‘California Health Eligibility, Enrollment, and Retention System’.

• CalHEERS is the business rules engine we will use to determine eligibility for the new government subsidized insurance programs. It is a web-based application, similar to the C-IV system we currently use to determine eligibility.

COMMON TERMS OF THE NEW WORLD

• CalHEERS – California Healthcare Eligibility and Enrollment Retention System• MAGI – Modified Adjusted Gross Income. MAGI

recipients can include the new adult group (19-64), children, pregnant women and parent/caretaker relatives • APTC – Advanced Premium Tax Credit• CSR – Cost Savings Reduction• BRE – Business Rules Engine• Non-Filers - Individuals who neither file a tax

return nor are claimed as a tax dependent on someone else's tax return

COMMON TERMS OF THE NEW WORLD

• Tax Dependent - An individual for whom another individual properly claims a deduction for a personal exemption in a tax year.• MEC – Minimum Essential Coverage• QHP – Qualified Health Plan• SHOP – Small Business Health Options Program• Non-MAGI – Non MAGI persons consist of those

who requested a full MC determination, Former Foster Care age 18-25, Medicare only recipients, LTC and ABD persons (including those claiming disability).

FPL LEVELS AT A GLANCE

MODIFIED ADJUSTED GROSS INCOME (MAGI) OVERVIEW

• 1931(b) population predominantly transitions to MAGI (435.218)

• The family size is the number of persons in the individual’s tax household (435.603)

• MAGI recipients can include the new adult group (19-64), children, pregnant women and parent/caretaker relatives (435.119)

• The income amount used will be determined by the person’s MAGI (435.603(d)(2))

• An Asset test is not required for MAGI determinations (435.603(g))

• There will be administrative renewals, which are automatic and based on the customer’s current information (435.949 & 435.956)

MODIFIED ADJUSTED GROSS INCOME (MAGI) OVERVIEW

• There will be a grandfather period – during Jan – Mar 2014. Negative changes to existing beneficiaries will be ignored (the details are still being worked on)

• There will be a request for information letter developed by DHCS that counties (or Consortia – TBD) will have to send toward the end of the year, to determine the tax household.

• The last MC MSR will be sent in November 2013 (these are being replaced by the administrative renewal)

• There will be a pre-enrollment period from Oct-Dec 2013

OCTOBER TO DECEMBER PRE-ENROLLMENT

CalHEERS will be accepting applications as of October 1, 2013; however, the interface between SAWS and CalHEERS will not go live until January 1, 2014.

Access Channel Responsibility falls to

SAWS (in person/phone) The county will assist

with the application through the CalHEERS portal (may include plan selection) and if necessary an Non MAGI application through C-IV.

SAWS Portal (C4Y)

CalHEERS PortalCalHEERS will complete the application/plan selection process.

CalHEERS Call Center

QUESTION TO DETERMINE TAX HOUSEHOLDS (DRAFT)

HOUSEHOLD EXAMPLE (EASY MAGI)

• Jen is a single adult who lives alone and is applying for a health subsidy program. She expects to file a tax return and does not expect to be claimed by anyone else as a dependent. Income = $1250/month and $15,000/year• The tax Household consists of Jen only (HH size =

1) • Jens MAGI income of $1,250/mo is 134% FPL• Since the new income standard for the Adult

group is 138% FPL, Jen is eligible to MAGI

HOUSEHOLD EXAMPLE (EASY NON-MAGI)

• Jen is a single adult living alone. She expect to file a tax return and does not expect to be claimed by anyone as a tax dependent. She applies for a health subsidy program and claims she is disabled, but had not been found disabled per Federal rules. Income = $4500/mo and $54,000/year

• The tax Household consists of Jen only (HH size = 1) • Since Jen’s income is 483% FPL (the new adult group

is 138% FPL) she is ineligible for MAGI or APTC/CSR• Because Jen indicated she is disabled, she is referred

to the county via the CalHEERS/SAWS interface for a non MAGI determination

ADVANCED PREMIUM TAX CREDIT (APTC) CRITERIA

• Household income must be between 100% and 400% of the Federal Poverty Level.• Covered individuals must be enrolled in a

"qualified health plan" through an Affordable Insurance Exchange.• Covered individuals must be legally present in the

United States and not incarcerated.• Covered individuals must not be eligible for other

qualifying coverage, such as Medicare, Medicaid, or affordable employer‐sponsored coverage.

HOUSEHOLD EXAMPLE (APTC)

• Jen is a single adult living alone. She expects to file a tax return and does not expect to be claimed by anyone as a tax dependent. She applies for a health subsidy. Income = $2,873/mo and $34,476/year• The tax Household consists of Jen only (HH size =

1) • Since Jen’s income is over 300% FPL (the new

adult group is 138% FPL) she is ineligible for MAGI and granted APTC.

WHAT THIS MEANS TO C-IV

A new page will be added to display Referrals Received from CalHEERS. When the current status is received they referral can be linked to a C-IV case. Once the EDBC has been run with this MAGI Determination, the status will update to “Complete”. (DRAFT Mock up)

WHAT THIS MEANS TO C-IV CONT.

A new page will be added to display changes reported from CalHEERS. This page will be a list of all the change reporting updates from CalHEERS.The user will receive an auto-generated task when change reporting information is received. (DRAFT Mock up)

WHAT THIS MEANS TO C-IV CONT.

A new link will be added to C-IV entitled “MAGI Eligibility”. This page is where workers can run MAGI eligibility for a case, by selecting the month and clicking Run MAGI. (DRAFT Mock up)

WHAT THIS MEANS TO C-IV CONT.

After clicking Run MAGI, the MAGI Determination list page refreshed to indicate the request has been submitted to CalHEERS and the results will be provided by the message center. (DRAFT Mock up)

WHAT THIS MEANS TO C-IV CONT.

When the determination from CalHEERS has been received, the MAGI Determination Summary page will display the results. (DRAFT Mock up)

WHAT THIS MEANS TO C-IV CONT.

Since MAGI uses the tax household to determine family size, new pages will be added to C-IV to collect this information.

WHAT THIS MEANS TO C4YOURSELF

• C4Yourself will be updated with the questions from the Single Streamlined Application (CA version) once it has been finalized. This will allow the necessary data to be gathered for MAGI/APTC/CSR determinations.• To accommodate these changes, several new

pages will be added to C4Y. For example, the collection of the tax household information will be on a new page.

WHAT THIS MEANS TO A WORKER

POLICY AREAS PENDING FUTURE FEDERAL GUIDANCE

• Final data elements of the single streamlined application• Case management/handling of mixed households (Medi-

Cal/APTC)• Final verification plan and impact to SAWS/county business

processes • Whether medically needy with a SOC is minimum essential

coverage• Business processes associated with continuing the Medi-

Cal/CalWORKS linkage • Transitional Medi-Cal (TMC)• Impact of open enrollment period to SAWS/counties• Notice of Action content and triggers• Senate Bill 87/Ex parte requirements

POLICY AREAS PENDING FUTURE FEDERAL GUIDANCE

• Outreach to potential Exchange/MC eligible, CalFresh, CCS, etc.

• Case management of mixed cases and mass updates• Renewal processing for MAGI and non-MAGI eligibility• Periodic verification processing for MAGI and non-

MAGI eligibility• Handling of Appeals after adjudication• Handling of CalWORKs timed-out adults• Policy for where potential applicants are directed to

mail applications (county vs. CalHEERS service center)• Final ACA aid codes

QUESTIONS?