Putting the Pieces Together: Medicaid, CHIP, and
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Transcript Putting the Pieces Together: Medicaid, CHIP, and
Putting the Pieces Together:
Medicaid, CHIP, and Subsidized Coverage
through the Marketplace
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Kyle Fisher
Staff Attorney
[email protected]
October 2013
What is the PA Health Law Project?
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We are a statewide nonprofit that offers free legal
advice to low-income people with insurance
problems.
We:
Operate a toll-free helpline
Provide community education
Engage in policy advocacy
Session Topics
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Health Insurance Marketplace
Basics
& how to apply
Marketplace Subsidies
Premium
Tax Credits
Cost-Sharing Reductions
Medicaid & CHIP
Eligibility
Basics
How to apply
What does the ACA do?
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Good News!
More people will be able to get insurance
Provides real coverage – 10 essential health benefits
Provides subsidies to make coverage affordable
Choice of plans – simple language, no fine print
Patients can get help signing up
The Work Ahead
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Not such Good News
People don’t know this is coming
78% of uninsured adults don’t know about these changes
72% of people eligible for the affordability programs don’t
know
*According to a survey by Enroll America
Post-ACA Insurance Landscape
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Employer Sponsored Insurance
53% of the population in PA (2010-11)
Medicare
Medicaid
CHIP
Federal Health Insurance Marketplace
For Individuals
For Small Businesses (50 or fewer FTE)
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Marketplace Basics
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Requirements to purchase insurance through the
Health Insurance Marketplace (aka Exchange):
Reside in Pennsylvania
Be a US Citizen or lawfully present
Not be incarcerated
How to Apply
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Online:
Healthcare.gov
By phone:
1-800-318-2596 (available 24/7)
paper application
Navigators & Certified Application
Counselors (“CACs”)
By mail:
In person:
When:
(open enrollment)
2013: Oct. 1 – March 31, 2014
2014: Oct. 15 – Dec. 7
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How to Afford
Marketplace Coverage
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PREMIUM TAX CREDITS &
COST SHARING REDUCTIONS
Marketplace Basics - Subsidies
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Two types of subsidies:
Premium Tax Credits
Advanceable, refundable tax credits to help consumers afford the
monthly cost of insurance
Cost-Sharing
Reductions
Discounts that lower the amount consumers have to pay out-ofpocket for deductibles, coinsurance, and copayments
Marketplace Basics - Subsidies
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Who qualifies?
Premium Tax Credits
Income between 100-400% FPL
Cannot be eligible for other “minimum essential coverage”
• Medicaid, Medicare, CHIP, VA care = minimum essential coverage
Cannot be offered “affordable” (<9.5%) employer-based coverage
Cost-Sharing
Reductions
Income between 100-250% FPL
Eligible for premium tax credits
Enroll in Silver-level plan
What income counts?
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Modified Adjusted Gross Income (MAGI)
New, tax-based measure
AGI + tax exempt interest + foreign income
+ Social Security benefits
Includes alimony and unemployment compensation
RULE: income counts unless exempted by tax rules
MAGI does not count:
child support, workers compensation, veterans’ benefits
Whose Income Counts?
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Household = Tax Unit
Filer
Spouse
Qualifying
Children &
Relatives
Premium Tax Credits
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How is the Premium Tax Credit Determined?
Cost of benchmark plan
Minus expected premium contribution
Second lowest priced silver plan in Marketplace
Based on expected household income for 2014
Equals credit amount
Advance credits are paid directly to the insurance plan
Premium Tax Credits
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Expected ≠ Actual Premium Contribution
Used to determine premium tax credit
PTC can be use to purchase any metal type, not just silver
Cost Sharing Reductions
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Types of Marketplace Plans – "Metal Levels"
Children
Pregnant Women
Highest Premiums &
Lowest Cost Sharing*
Parents & Caretakers
Lowest Premiums &
Highest Cost-Sharing
*before CSR
Cost Sharing Reductions
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How do Cost Sharing Reductions work?
Three levels of CSR based on income
Paid directly to the Silver plan
Seamlessly reduces enrollee’s out-of-pocket charges
Actuarial
Value
Standard
Silver – no
CSR
100-150%
FPL
151-200%
FPL
201-250%
FPL
70% AV
94% AV
87% AV
73% AV
Types of Plans – “Metal Levels”
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Medicaid & CHIP
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ELIGIBILITY BASICS &
HOW TO APPLY
Medicaid Eligibility Basics
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Residency
Category
Income & Resources
Immigration Status
Medicaid
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Categorical Eligibility
Children
Pregnant Women
Parents & Caretakers
Persons with Disabilities
Temporary
Permanent or 12 months+
Workers with Disabilities
Has 5% premium
Seniors
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Medicaid
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Income Counting Rules:
Modified Adjusted Gross Income (MAGI)
Non-MAGI
MAGI
Children
Medicaid & CHIP
Pregnant Women
Parents & Caretakers
*no resource test
Persons with Disabilities
Temporary
Permanent or 12 months+
Workers with Disabilities
Seniors
*resource test(s)
Medicaid
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Income Eligibility
MAGI
Children
(age 6-18)
Pregnant
Women
Parents &
Caretakers
FPL
133%
Non-MAGI FPL
Persons w/
Disabilities
100%
(12 mnth+)
215%
Workers w/
Disabilities
250%
33%
Seniors
100%
CHIP Eligibility Basics
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Child is under age 19
Resides in PA
Citizen or lawfully present
Uninsured & ineligible for Medicaid
FPL Income Limit
(before 5%
disregard)
Free
CHIP
Low Cost
CHIP
Full Cost
CHIP
208%
314%
No limit
Medicaid & CHIP
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How to Apply – Use:
COMPASS
Healthcare.gov
or COMPASS
Children
Pregnant Women
Parents & Caretakers
www.compass.state.pa.us
Persons with Disabilities
Temporary
Permanent or 12 months+
Workers with Disabilities
Seniors
Marketplace & DPW Interface
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“No wrong door”
Marketplace screens Medicaid/CHIP eligibility
DPW forwards inelig. applicants to the Marketplace
electronic accounts forwarded, in both instances
“Determinations” vs “assessments”
Marketplace will determine Medicaid eligibility until Jan. 1
For a Jan. 1, 2014 start
Thereafter, it will assess Medicaid/CHIP eligibility
Live Resources
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Healthcare.gov
Help 24/7
Online chat
800-381-2596
Navigators and Certified Application Counselors
https://localhelp.healthcare.gov/
Resources
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Medical Assistance Eligibility Handbook
http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm
CHIP’s Eligibility and Benefits
http://www.chipcoverspakids.com
IRS Q&A on Premium Tax Credits:
http://www.irs.gov/uac/Newsroom/Questions-and-Answers-on-the-Premium-Tax-Credit
IRS website for ACA Tax Provisions
http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Home
KFF Subsidy Calculator
http://kff.org/interactive/subsidy-calculator/
Center on Budget and Policy Priorities – ‘Beyond the Basics’
http://www.healthreformbeyondthebasics.org/
PHLP Helpline: 1-800-274-3258