Transcript Training for the FC’s Affordable Care Act

March 2014

The Affordable Care Act establishes a new
Health Insurance Marketplace. People who
need health insurance can go to the
Marketplace, find out what they’re eligible for
and apply for the plan that’s right for them.
They can apply through a web-site, by phone,
by mail, or with personal assistance. There
are four kinds of coverage.
03/21/2014
2

Medicaid

Children’s Health Insurance Program (CHIP)

Private Health Insurance Plans (The Exchange)

Small Business Health Options Program
(SHOP) Marketplace
03/21/2014
3



The timeline to begin enrolling in the Marketplace will be Oct. 1, 2013 with eligibility start
date Jan. 1, 2014. After January 1, 2014.
Medicaid will be effective same month of
enrollment.
CHIPS policy is being looked at to begin the same
month of enrollment also.
Private Insurance will be Jan 1, 2014 to March 31,
2014. The Insurance will begin the next month
after enrollment. There are special
circumstances to be enrolled in private insurance
such as birth, death of spouse, etc.
03/21/2014
4


Medicaid will cover everyone who lives in
West Virginia, is a US citizen, is under the age
of 65, and earns less than 138 percent of the
federal poverty level (FPL).
Medicaid coverage for pregnant women is
155% FPL.
03/21/2014
5

Children’s Health Insurance Program (CHIP)
will continue to be available for income
eligible children, but current enrollees who
are in families with income below 138% of FPL
will be transferred to Medicaid.
03/21/2014
6

Private Insurance is for individuals/families
whose income is above 138% FPL level.
03/21/2014
7

Federal poverty level is the amount of money
that an individual or family earns and is used
to determined eligibility for Medicaid, CHIP
and subsidized private insurance plans. The
federal poverty level varies by income and
family size.
03/21/2014
8


Eligibility is determined based on access to
the “federal hub” which includes information
from databases from IRS, the Social Security
Administration, etc.
All three of the insurance options will be
determine using the modified adjusted gross
income (MAGI).
◦ Medicaid and CHIP will use a family’s current
earnings in the month they apply.
◦ The Marketplace will use what a family is expected
to earn.
03/21/2014
9

Modified Adjusted Gross Income (MAGI).
◦ This method adopts the income tax definition of
what counts as income. In general, income that is
taxable will be counted for the purpose of
determining Medicaid eligibility.
◦ Examples of non-taxable income:
Child support, VA benefits
03/21/2014
10

All taxable income for adults, parents,
spouses, and for a child that filed income
taxes. The only exception is grants or
scholarships.
03/21/2014
11

No
03/21/2014
12

The ACA expanded Medicaid eligibility for
MAGI populations to include all children and
adults who meet income and other
guidelines. ACA leaves current eligibility
intact for traditional Medicaid programs such
as people who are blind or disabled, or in
need of long-term care services.
03/21/2014
13

No, The Marketplace will make the eligibility
decisions based on access to the “federal
hub” which includes information from
databases for the IRS, the Social Security
Administration, Homeland Security, and other
state and federal agencies.
03/21/2014
14

The Smith family consists of Roger, who is a mechanic; Sally, who
works at a local restaurant; and Amy, their three-year old
daughter. Neither Roger’s nor Sally’s employer offers health
insurance coverage. Sally goes to the Marketplace, enters her
social security number, and other personal information. The
marketplace pulls up the recent tax return. Then the Social
Security Administration will verify that all members of the Smith
family are US citizens. The family’s income is $27,500. Sally
reports she is pregnant. Given these circumstances, the
Marketplace determines that Sally is eligible for Medicaid
(pregnant and in a family earning less than 155% of FPL), and her
information is forwarded to WV for enrollment. Amy, their three
year old is, eligible for CHIP, and her information is forwarded to
CHIP. Roger qualifies for a private insurance policy. He will be
given a list of private insurances to select from.
03/21/2014
15

Sally will not be asked about family resources,
nor can the Marketplace require a face to face
interview. Sally will need to “attest” that her
family’s current month income is $2,292. Since
this amount is “reasonably compatible” with the
IRS’s data base, the Marketplace accepts this.
The Marketplace must also accept Sally’s
attestation that she is pregnant. Sally cannot
solely attest regarding whether she, Roger and
Amy are US citizens. This must be checked
electronically with the Social Security
Administration or other data bases.
03/21/2014
16

Self attestation is what a person states is his
or her income, family size, where he or she
lives, and other eligibility criteria.
03/21/2014
17

To be eligible for a QHP (Qualified Health
Plan), an applicant must be a US citizen or an
immigrant who is lawfully present in the US,
be a resident or intend to be a resident of
West Virginia and not be incarcerated.
03/21/2014
18



Bronze: 60% paid by insurance company, 40%
co-pay
Silver: 70% paid by insurance company, 30%
co-pay
Gold: 80% paid by insurance company, 20%
co-pay
03/21/2014
19










Ambulatory patient services
Inpatient and outpatient hospital services
Maternity and newborn care
Mental health and substance use disorder
services
Prescription drugs
Laboratory Services
Clinically effective preventative services without
payment of deductibles, co-payments or
coinsurance
Chronic disease management
Pediatric services, including vision health benefits
Rehabilitative and habilitative services
03/21/2014
20



Yes
Premium tax credit: Assist in the form of
advanceable tax credit. “Advanceable” means
that the federal government will pay the credits
directly to the applicant’s insurance company on
a monthly basis. Also, if you are married, you
must file a joint tax return
Cost Sharing: Is only available with the silver
plan. Individual or families with incomes 250% or
below the FPL who select a silver plan will have
reductions in their deductibles, copayments and
co-insurance. The reduction depends on what
level the applicants fall in the FPL.
03/21/2014
21



CAMC became a Certified Application
Organization with CMS.
This allowed us to train our eligibility
specialists, that included ten Financial
Counselors, two Medicaid Eligibility workers,
four state workers and four CEA workers to
become Certified Application Counselors
(CAC).
Presumptive Eligibility Certified.
03/21/2014
22




Consents
Conflict of interest
Certificates displayed
Policy and procedures written
03/21/2014
23
Before ACA

Only screened
Inpatients and high
dollar outpatients
After ACA

Screening all self pay
03/21/2014
24


Tablets
Each Financial Counselor received a tablet
having all systems loaded on the tablet to
have a mobile office. This allows us to reach
the clinics, ER, etc..
03/21/2014
25


Created a 1-800 number to have a
centralized phone number to have patients
call with questions and appointments.
Created a brochure to hand out at all Points
of service that has our 1-800 number on it
with information about the program.
03/21/2014



Working with CAMC Physicians group that
have 27 locations to ensure compliance.
Handed out brochures.
Developed scripts for an uninsured patient to
be referred for a financial screening.
03/21/2014
27




Worked with Human Resources to help
employees that needed assistance with the
Marketplace or Medicaid application.
Financial Counselor attended CAMC Benefit
Fair to answers employee questions.
Attended several internal staff meeting.
Financial Counselor will be attending our
annual community Healthfest Event.
03/21/2014
28
03/21/2014
29