THE ACA, ELIGIBILITY & ENROLLMENT Shanna Hanson, FHFMA
100 Years Ago (1906) Life expectancy 47 Bathtub 14% Telephone 8% Cars 8,000 Paved roads 144 miles Speed limit 10 mph CA 21 st most populated state Births at home 95% Avg worker $200-$400 per year Drs 90% no college Women washed hair once a month Las Vegas pop. 30 High school grads 6% Marijuana, heroin, morphine all legal
Health Coverage Memory Lane 19 th Century: Little or no money 1930s: Insurance 1962: Medicare 1965: Medicaid Low-Income Families; ABD 1986: Pregnant Women and Infants (State Option) 1989: Pregnant Women and Children (Mandated) 1990: Children 6-18 (Phased In) 1997: SCHIP 2010: PPACA 2014: TOMORROW!!!
Objectives Review areas of eligibility and enrollment process impacted by the ACA, regardless of expansion Examine what changes and how Help you prepare your staff and facilities for changes Todays Agenda
Language is Important States May vs. States Must State Option vs. Required by States Proposed vs. Final (Rules) MAGI Modified Adjusted Gross Income Medicaid, Marketplace or both? Marketplace (a.k.a., Exchange) FFM Federally Facilitated Marketplace FSP Federal State Partnership Marketplace State-Based Marketplace
Language is Important QHP Qualified Health Plan. Insurance coverage sold through the Marketplace, subsidized or not. APTC Advanced Payment of Tax Credits. Subsidies received for QHP coverage in the Marketplace. IAP Insurance Affordability Programs. Medicaid, CHIP, APTC Subsidized QHP. IPA In-Person Assister. State program, separate from the Navigator program. CAC Certified Application Counselor Unfunded assister.
Expansion vs. Non-Expansion Overview Supreme Court Decision Cant penalize a state that does not expand Medicaid to 133% of Federal Poverty Level. No other provisions of the law affected. Example: coordination with the Marketplace, including use of standard income eligibility methods, apply.
Expansion vs. Non-Expansion So What? Impact on Medicaid Program Administration State policies and procedures will change Materials published Training provided Culture shifts State Medicaid systems must communicate electronically with the Marketplace Coverage gap in states that choose not to expand Other expansion models being considered
Impact of ACA on Eligibility and Enrollment Application Assistance Presumptive Eligibility Eligibility Verifications Technology
Process designed to be more consumer friendly Forms: single streamlined, multi-benefit or supplemental Interview: no face-to-face for MAGI Reconsideration: 90 days without new application Signatures: electronic, phone, fax, other Submission: online, phone, in person, mail or IAP agency (no wrong door) Application No Wrong Door!
Application So What? Path to eligibility will be easier, less burdensome, and take less processing time. Federal government published three applications Additional supplemental forms may be needed Other application options exist Application assistance is a necessity Massachusetts: less than 1 in 18 finish online Approved !
How Many Assisters Do We Need? 2.25 hours estimated per consumer 211,000 consumers 475,445 total hours of assistance Assuming assisters are using 85% of their time over six months of open enrollment to help consumers 884 hours per assister 475,445 / 884 = 538 assisters needed Arkansas New Hampshire $73,000 per assister estimated, plus overhead costs $600,000 grant 8 or less navigators Georgetown University Health Policy Institute Center for Children and Families
Assister by Marketplace Type Federally FacilitatedState-federal PartnershipState-based Navigator: program development Federal government State Navigator: program management Federal government Federal government with state participation State Navigator: funding Federal government awards grants to a minimum of two entities in the state, one of which must be a community- based organization State can use federal exchange establishment grants for planning, but cannot use that funding for operations In-person assister: program development Will not have themRequiredOptional In-person assister: program funding Not applicable State can use federal exchange establishment grants to establish and operate the program Certified Application Counselor: program development Required for marketplace, optional for Medicaid Certified Application Counselor: funding None
Navigator and IPA Duties 1.Maintain expertise 2.Maintain a fair, accurate and impartial manner 3.Facilitate selection of a QHP 4.Provide referrals for enrollees 5.Provide information in a culturally and linguistically appropriate manner 6.Perform outreach and education
CAC Duties Marketplace (All) Provide information. Assist individuals to apply for coverage. Help to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs. Medicaid/CHIP (Some or All) Provide information. Help individuals complete an application or renewal. Work with the individual to: Provide documentation Submit to the agency Interact with the agency Respond to agency requests Manage their case
Marketplace CAC Certification Requirements 1.Registers 2.Is trained prior to providing application assistance 3.Complies with applicable authentication and data security standards, and with the privacy and security standards 4.Provides application assistance in the best interest of applicants 5.Complies with any applicable state law(s) 6.Provides information with reasonable accommodations 7.Enters into an agreement
Authorized Representatives Designated by the applicant/beneficiary Has the legal authority to interact on behalf of the applicant/beneficiary Can sign the application Receives notices Individual or organization Must be allowed by the state
Hospital Enrollment So What? 1.Possibility of larger staff focused on assistance 2.Staff space allocations 3.Centralized or decentralized 4.Privacy for applicants 5.Performing tasks outside of your core business 6.Initial and ongoing training 7.Staff certification 8.Staying current with program and policy changes 9.Employing the most efficient and effective processes
Presumptive Eligibility Presumptive Eligibility (PE) Enrollment by Qualified Hospitals Participate as a Medicaid provider; Notify state Medicaid agency of its decision to make PE determinations; Agree to make determinations consistent with state policies and procedures; At state option, assist individuals in completing and submitting the full application and in understanding any documentation requirements; and Not be disqualified by the state Medicaid agency. PE Expansion Groups
Presumptive Eligibility So What? Provider payment during temporary eligibility period Payment stands even if person found ineligible State rules will vary, which may make PE more or less attractive to hospitals Risk of becoming uninsured after PE period Staffing, logistics, privacy, training and certification
Eligibility MAGI-Based Medicaid: Collapse into 4 groups MAGI-Excepted Medicaid: Aged, disabled, etc. Optional Groups: BCCT, working disabled (exempt from MAGI) Emergency Medicaid: No changes Retroactive Coverage: Up to three months Spend down in 209(b) States not Medically Needy: Aged, blind, disabled
Eligibility Maintenance of Effort: 9/30/19 for children Children Highest level for age group 185% Federal Poverty Level for infants Enrollment While Pending (e.g., disability): MAGI-based or QHP enrollment while pending for MAGI-excepted coverage Medicaid is retroactive, QHP coverage is not MAGI-excepted Medicaid would be a secondary payer for overlapping eligibility
Eligibility CriteriaMAGI-Based Medicaid/CHIPQualified Health Plan HouseholdTax household with exceptionsTax household IncomeTax rules with exceptionsTax rules Disregard5%Not applicable Budget PeriodPoint in time (current month) Annual based on last tax return Start DateUp to 3 months retroactiveProspective
Eligibility So What? States may drop and/or change Medicaid programs when the Maintenance of Effort expires 12/31/13, except for children Program options will impact: Process the applicant goes through Cycle time Payment to the provider
Verifications What Age, DOB, Household Size: States may verify Income: Process and sequence could vary Pregnancy: Self-attestation How Data-driven Process: Electronic sources Documentation Submission: Online, phone, in person, or via mail Electronic Data Matches: States decide usefulness, frequency and time-frame (could be after enrollment)
Verifications How Contd Self-Attestation: Permitted, except as required by law, or not permitted by law When Documentation is Permitted: Not reasonably compatible When State Law Does Not Permit Self Attestation: State option to accept self-attestation unless ACA does not permit Reasona