Social Worker’s Guide to the Marketplace:

Getting clients enrolled in the Health Insurance Marketplace, Medicaid, and CHIP • • [Presenter Name] [date] 1

Today’s Presentation Covers

       Background information on the Marketplace, Medicaid, and CHIP Eligibility requirements Enrollment checklist Enrollment period, exceptions and penalties Opportunities to assist with enrollment Tips on how to encourage your clients to enroll Resources 2

Why Help Clients Get Covered?

Coverage helps prevent illness

Marketplace plans cover 100% of the costs of:

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15 preventive services for adults

, such as screening and counseling for tobacco use, substance misuse, and obesity. 

22 preventive services for women

, such as screening for breast cancer and osteoporosis.

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26 preventive services for children

, such as hearing screening, and immunizations.

Source: https://www.healthcare.gov/what-are-my preventive-care-benefits/adults/

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Why Help Clients Get Covered?

Coverage protects against high health care costs

 The average cost of a 3 ‐ day hospital stay is $30,000.  Fixing a broken leg can cost up to $7,500.

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Why Help Clients Get Covered?

  

Coverage brings peace of mind 80.1 million

people in the U.S. have unintentional injuries every year.

10.3 million

U.S. children experience asthma.

117 million

adults (about 50% of adults) have one or more chronic conditions. Sources: http://www.cdc.gov/nchs/fastats/injury.htm

http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf

http://www.cdc.gov/pcd/issues/2014/13_0389.htm

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Why Help Clients Get Covered?

Getting coverage is simpler with one single application through the Marketplace

Submit single, streamlined application Online, Phone, Mail or In Person Verify and determine eligibility Eligible for Marketplace or Medicaid/CHIP Enroll (Medicaid/CHIP) Enroll (Marketplace) 6

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What is the Marketplace?

  A website where individuals and families can directly compare private health insurance plans and enroll in a plan. Some states operate their own Marketplace. Everyone can get to the right Marketplace by going to https://www.HealthCare.gov

and entering the state they live in. 8

How Does the Marketplace Work?

   

Step 1:

Create a user account

Step 2:

Complete the application

Step 3:

Shop for a plan

Step 4:

Enroll To find in-person local assistance, go to https://Localhelp.HealthCare.gov

or contact the Call Center 1-800-318 2596 9

Who is Eligible for Marketplace Coverage?

 

A person is eligible for coverage if he or she:

 is not eligible for job-based coverage.

 has job-based coverage that does not meet minimum coverage.

is a U.S. citizen or is a lawful resident. is under 26 years of age and is not claimed as a tax dependent by parents.  is not incarcerated at the time of enrollment. 10

Saving Money on Coverage

• •

Advanced Premium Tax Credit.

Households earning between 100% and 400% of the federal poverty level (from about $23,850 to $95,400 for a family of four in 2014) can get financial assistance in the form of a tax credit.

Cost Sharing.

Households that earn up to 250% of the federal poverty level (about $29,175 for an individual and $59,625 for a family of four) are eligible for cost-sharing assistance. Cost sharing limits the amount a household has to pay for out-of-pocket costs.

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Marketplace Enrollment Checklist

Social Security numbers (or document numbers for lawfully residing residents) Date of birth Health insurance policy numbers Income An “Employer Coverage Tool” completed by the employer(s) 12

Marketplace Enrollment Period

OPEN ENROLLMENT PERIOD FOR 2015

BEGINS

2014 HEALTH INSURANCE COVERAGE

ENDS

FIRST DAY OF COVERAGE FOR 2015

BEGINS

OPEN ENROLLMENT PERIOD FOR 2015

ENDS

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Individual Shared Responsibility Payment

In 2014, you pay the greater amount of: In 2015, you pay the greater amount of: In 2016* you pay the greater amount of: 1% of your yearly household income — OR — $95 per adult, and $47.50 per child under 18 2% of your annual household income — OR — $325 per adult, and $162.50 per child under 18 2.5% of your annual household income — OR — $695 per person, and $347.50 per child under 18 *After 2016, increase is based on cost of living.

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Fee Exemptions

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A person is exempt from the penalty if he or she:

 was uninsured for less than 3 months of the year.

 would have to pay more than 8% of household income.

is not required to file a tax return.

would have been eligible but was denied Medicaid because they live in a state that has not expanded its Medicaid program.

opposes insurance for religious reasons.

was incarcerated. a member of a federally recognized tribe or eligible for services through an Indian Health Services provider.

 experienced extreme hardship, such as homelessness.

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Special Enrollment Period

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Qualifying life event

Getting married or divorced Having or adopting a baby Moving Gaining citizenship Rejoining the community after incarceration Involuntarily losing other health coverage, such as by losing a job or aging off of a parent’s plan 16

How to Motivate Clients to Enroll

I can’t afford it It’s too complicated I don’t need healthcare, so I don’t need insurance I would rather pay the fee than enroll in healthcare I struggle reading English I don’t know where to go for help 17

Questions about the Marketplace?

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What is Medicaid?

   A partnership between the federal and state governments to provide free or low-cost health coverage. There are minimum core Medicaid coverage and eligibility requirements that apply across all states.

No two states are alike. Each state may elect to expand coverage to include different groups or income levels, or to increase covered services.

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Who is Eligible for Medicaid?

       Low-income pregnant women Low-income children Low-income parents Adopted children, those in foster care, or those who aged out of foster care and are under 26 years old People who receive Supplemental Security Income People on Medicare who have low incomes (dual-eligible) Childless Adults (in certain states) 21

How the Medicaid Expansion Affects Your Clients

    If you live in a state that's expanding Medicaid, your clients probably qualify if they make up to $16,105 a year for 1 person ($32,913 for a family of 4).

If they live in a state that hasn't expanded Medicaid, qualifying will depend on income.

Even if your state hasn’t expanded Medicaid coverage, they should still apply. They may qualify under your state’s existing rules. States are continuing to make coverage decisions. They could expand Medicaid in the future.

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Medicaid Enrollment Checklist

Citizenship or eligible immigration status Foster care status Identity Income Pregnancy status State residency Tribal memberships 23

Medicaid Enrollment Period

 Clients can sign up for Medicaid through the Marketplace or through their state agencies at

any time of the year

.  If they qualify for coverage, Medicaid may retroactively cover their medical expenses for up to three months, as long as they qualified for Medicaid at the time the expenses were incurred. 24

How to Motivate Clients to Enroll

I have to wait until open enrollment to enroll in Medicaid? Medicaid is only for people on welfare I’m an immigrant so I can’t get Medicaid Too much paperwork I already have Medicare so I don’t need Medicaid I struggle reading English Where can I get more information on Medicaid?

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Questions about Medicaid?

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What is CHIP?

 CHIP provides health coverage for children whose families earn too much to qualify for Medicaid yet do not have access to affordable insurance through their employers.

 At minimum, CHIP covers check ups and preventive care, immunizations, hospitalization, lab and x-ray services, and dental care at no cost to families. Other health care may require copayments. 28

Who is Eligible for CHIP?

 Children and teens 18 years of age and younger.

 Children in families earning about $47,700 a year for a family of 4 are generally eligible. 29

Streamlining Eligibility

Express lane eligibility Presumptive eligibility Continuous eligibility

Allows states to use findings from “express lane agencies” to enroll children in CHIP. Allows health care providers to make a rapid assessment of a child’s eligibility and provide temporary eligibility until an official determination is made by the state. Means that children who are already enrolled in CHIP can be covered up to a full year, regardless of changes in family status.

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CHIP Enrollment Checklist

Age Child’s citizenship or eligible immigration status Identity Income Other health insurance a child might qualify for Pregnancy status State residency 31

CHIP Enrollment Period

 Your clients can apply for CHIP through the Marketplace at www.HealthCare.gov

or calling 1-800-318-2596.  They can also go through their state agencies or by calling 1-877-KIDS-NOW (1-877-543 7669).

 Enrollment is available year round 32

How to Motivate Clients to Enroll

I’m not poor, so my children won’t qualify I don’t want to sign up now because soon I’ll have a better job with good benefits I’m too busy to enroll; I have too many things to deal with already I don’t want to get deported if I try to enroll my child I don’t read English very well I don’t have a computer at home I can’t verify my income; I get paid in cash My kids are teenagers; they really don’t need health care I applied once before, but I didn’t qualify 33

Questions about CHIP?

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Resources to Help Enroll Special Populations

There is a document called

Resources for Special Populations

with additional information. Populations include but are not limited to:  African American   Agricultural/Migrant workers Formerly incarcerated individuals   Hispanics/Latinos Homeless people   Immigrants Students/Young adults 36

Resources for Newly Insured Clients

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From Coverage to Care

http://marketplace.cms.gov/technical-assistance resources/c2c.html

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What If I Have New Medicaid or CHIP Coverage?

https://www.healthcare.gov/what-if-i-have-new medicaid-or-chip-coverage/ 

Using Your New Insurance Coverage

https://www.healthcare.gov/using-your-new marketplace-coverage/ 37

How You Can Help

 Use social media to share links with partners and clients  Display HealthCare.gov and Marketplace.cms.gov materials in your office or website  Share resources with client during in-person meetings and through professional networks  Become a Champion for Coverage organization  Become a Certified Application Counselor (CAC) organization 38

Become a Certified Application Counselor Organization

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What is it?

An organization whose staff and volunteers help people understand, apply, and enroll for health coverage through the Marketplace.

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What are the qualifications?

Your organization needs to be a community health center or other health care provider, hospital, a non-federal governmental or non-profit social service agency in a state with a Federally-facilitated Marketplace or a State Partnership Marketplace 39