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 state most populated 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 1930’s: 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

Today’s 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.

 

IAP – Insurance Affordability Programs.

Medicaid, CHIP, APTC Subsidized QHP.



IPA – In-Person Assister.

State program, separate from the Navigator program.



APTC – Advanced Payment of

Tax Credits. Subsidies received for QHP coverage in the Marketplace.

CAC – Certified Application Counselor

Unfunded assister.

Expansion vs. Non-Expansion

Overview

 Supreme Court Decision – Can’t 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

Application

Process designed to be more consumer friendly



Forms:

single streamlined, multi-benefit or supplemental 

Interview:

no face-to-face for MAGI 

Reconsideration:

application 90 days without new 

Signatures:

electronic, phone, fax, other 

Submission:

online, phone, in person, mail or IAP agency (no “wrong door”)

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?

New Hampshire

  

$73,000 per assister estimated, plus overhead costs $600,000 grant 8 or less navigators Arkansas

     

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

Georgetown University Health Policy Institute Center for Children and Families

Navigator: program development Navigator: program management Navigator: funding In-person assister: program development In-person assister: program funding Certified Application Counselor: program development Certified Application Counselor: funding Assister by Marketplace Type Federally Facilitated State-federal Partnership State-based

Federal government Federal government Federal government awards grants to a minimum of two entities in the state, one of which must be a community based organization Federal government Federal government with state participation Federal government awards grants to a minimum of two entities in the state, one of which must be a community based organization State State State can use federal exchange establishment grants for planning, but cannot use that funding for operations Will not have them Not applicable Required for marketplace, optional for Medicaid Required Optional State can use federal exchange establishment grants to establish and operate the program State can use federal exchange establishment grants to establish and operate the program Required for marketplace, optional for Medicaid Required for marketplace, optional for Medicaid None None None

Navigator and IPA Duties

3.

4.

5.

1.

2.

6.

Maintain expertise Maintain a fair, accurate and impartial manner Facilitate selection of a QHP Provide referrals for enrollees Provide information in a culturally and linguistically appropriate manner

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

Criteria

Household Income Disregard Budget Period Start Date

MAGI-Based Medicaid/CHIP

Tax household with exceptions Tax rules with exceptions 5% Point in time (current month) Up to 3 months retroactive

Qualified Health Plan

Tax household Tax rules Not applicable Annual based on last tax return Prospective

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 Cont’d

– 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 Reasonably Compatible: Both attestation and electronic information are either above or below the eligibility level Reasonable Opportunity Period: 90 days for Marketplace; differs for Medicaid

Verification “So What?”

   Verifications plans will be state specific State policy decisions will be based on their verification plan Transparency

Technology

Open enrollment: 10/1/2013 - 3/31/2014

 Online application system must support single streamlined application  Electronically Pass Accounts: Medicaid and the Marketplace  FFM Medicaid “Determination” or “Assessment” – – Medicaid eligibility determination or Medicaid eligibility assessment (at the state’s option)  Implement state access to “The Hub”  Systems must support new renewal process

Technology “So What?”

   Open enrollment without the technology to support it will create backlogs and frustration.

State rules dictate the type of Medicaid decisions that can be made by the FFM.

A lot to do. Will states be ready?

Wrap-Up

 Reviewed six areas of the eligibility process impacted by ACA, regardless of expansion. Application Assistance Presumptive Eligibility Eligibility Verifications Technology   Examined what changes and how.

Gave you points to ponder as you begin to prepare your staff and facilities for the changes ahead.

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