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
Kfisher@phlp.org
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