About These Materials Families USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for

About These MaterialsFamilies USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for a training program for DC eligibility workers. These workers determine eligibility for Medicaid and other benefit programs (including SNAP and TANF). They will help consumers apply for coverage and financial assistance, report changes, renew coverage, and verify the information that is needed to determine eligibility. These workers will not be responsible for helping consumers select health plans.

These training materials are posted here as an example that can be adapted for other training programs. They contain information that is specific to the District of Columbia, which would have to be changed if used in another state. Contact Families USA at [email protected] for assistance with adapting these materials.

mailto:[email protected]

ESA Policy Training Day 1

Prepared by Families USA for use in the District of Columbia

Overview• Why is the Affordable Care Act changing

Medicaid and private insurance?

• How is Medicaid changing in DC?

• What is DC Health Link?

• How do premium tax credits and cost-sharing reductions work?

• What happens if income changes?


Background on the Affordable Care Act


Why is the Affordable Care Act changing Medicaid and private insurance?

• Many people are currently uninsured

• Antiquated eligibility systems are hard for workers and consumers to use

• Private insurance is expensive

• Consumer protections are limited • Pre-existing conditions lead to denials of

coverage

Families USA2013


The District of Columbia

DC is a leader in coverage, but nearly 7% are still uninsured.• DC covers adults up to 200% of poverty and kids

up to 300%• Unlike most states, DC already covers childless adults

But there is still work to do . . .• Total Uninsured Population:

U.S. - 15.1% DC - 6.9%• Number of Uninsured

People in DC, 2011: 42,007

Source: CBPP analysis of Census Bureau data from the American Community Survey 2011


New Affordable Care Act Protections: 2014

• Those who do not qualify for Medicaid (due to income or five-year bar) can get new premium tax credits

• Low-income adults will newly qualify for Medicaid in many states (but they are already covered in DC)

• People can apply online and verify information electronically

• Private insurers cannot deny people coverage or charge them more because they are sick


DC Medicaid and the Affordable Care Act


Medicaid Will Stay the Same for Most People

• DC is preserving its good coverage levels

• DC is modernizing applications, eligibility determinations, and renewals


Modernizing Eligibility Determinations

• Most applications can be done online

• Numerous eligibility categories not necessary

• Electronic verification will be used when possible

• New application will determine eligibility for Medicaid and premium tax credits


MAGI and Non-MAGI Eligibility

Eligibility for most Medicaid recipients will be determined using new system

• New MAGI (Modified Adjusted Gross Income) rules

• Used for parents/caretaker relatives, children, pregnant women, and childless adults aged 21-64


Eligibility for some will still be done by ESA for now• Used for those who are aged, blind,

disabled, or need long-term care services

• We call this the “Non-MAGI” population

MAGI and Non-MAGI Eligibility (cont’d)


MAGI Income

• Based on how IRS calculates tax income• Example: Instead of subtracting income

disregards and deductions from income like we do today, take away adjustments to income

• New system will calculate all of this for you


MAGI Household Composition

• New way of defining household based on who is on the same tax return (if family files taxes)• Some exceptions in Medicaid• Different rules for families that do not file

taxes

• New system will determine household composition for you


Introduction to DC Health Link


How DC Health Link WorksNew marketplace for private insurance for individuals, families, and small businesses• Provides clear, comparative information about

plans from different insurance companies

• Some will get help paying premiums for these plans

• Includes only plans that meet quality standards


What is your role in DC Health Link?

• ESA workers will help DC residents apply for coverage

• New system uses one application for:• Medicaid• Premium tax credits for DC Health Link

plans


Overview1. What are DC Health Link plans like, and

how will DC residents be able to compare plans?

2. What type of assistance is available to people buying DC Health Link plans?


What will DC Health Link plans cover?• Coverage similar to that offered by most employers• All plans must cover a minimum benefits package,

called Essential Health Benefits (EHB)

Essential Health Benefits (EHB)1. Outpatient services 6. Prescription drugs

2. Emergency services 7. Rehabilitative and habilitative services

3. Hospitalizations 8. Laboratory services

4. Maternity and newborn care 9. Preventive services

5. Mental health and substance use disorder services (no day or visit limits in DC)

10. Pediatric services (includes oral and vision care)


Medicaid Benefits Differ from DC Health Link Benefits

Medicaid covers the 10 Essential Health Benefits, PLUS:EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) services to children under 21

Family planning services

Access to federally qualified health centers

Emergency and non-emergency transportation to medical care

Medicaid covers more than the Essential Health Benefits and does not charge enrollees premiums, so it is important to help people who qualify get Medicaid instead. All applicants to DC Health Link will be assessed for Medicaid eligibility.


Plans offered in four metal levels:

Different Levels of DC Health Link Plans

Metal Level GenerosityPlatinum (highest monthly premiums)

Covers about 90% of medical care costs

Gold Covers about 80% of medical care costs

Silver Covers about 70% of medical care costs

Bronze (lowest monthly premiums)

Covers about 60% of medical care costs

Note: Measured based on total cost of covered benefits for a typical population


Platinum plan: Premiums cost the most, but plan pays more (and patient pays less) for health care servicesBronze plan: Premiums cost the least, but plan pays less (and patient pays more) for health care servicesSilver and gold plans: Somewhere in between

Understanding Metal Levels


Hypothetical Plans

Metal Level Full Premium Price at Age 40

Deductible Patient Co-Pay for Sick Care Doctor Visit

Platinum $460 $0 $20/primary$40/specialty

Gold $370 $0 $30/primary$50/specialty

Silver $295 $2000 $45/primary$65/specialty

Bronze $230 $5000 $60/primary$70/specialty


Why are we talking about these costs?

We’ll come back to these plan levels when we talk about premium tax credits and cost-sharing reductions. People who get premium tax credits will also have to choose a metal level plan.


Premium Tax Credits


Premium Tax Credits: The Basics• Premium tax credits help people pay for health

insurance if they do not have job-based coverage, Medicaid, or Medicare

• Premium tax credits pay a certain amount of monthly premiums, based on income

• Through DC Health Link, people can get tax credits monthly based on expected annual income

• At tax time, premium tax credits are adjusted based on actual annual income


Example: Lower Monthly Premiums

Latisha, age 55, has a small catering business. A health plan charges her $420/month in premiums, which is a huge portion of her income of $34,000/year. She applies to DC Health Link and is found eligible to enroll in a plan with premium tax credits. With the tax credits, she pays $265/month for a silver plan.


Lower Incomes, More HelpThe less income someone has, the less he or she has to pay.

Example: With income at 100% of the poverty level ($11,490 for an individual), a person pays 2% of income for a silver plan’s premiums. With income at three times the poverty level ($34,470), a person pays 9.5% of income for the same silver plan’s premiums.


The Amount People Pay Depends on the Plan They Choose

• Premium tax credit amounts are based on the cost of a silver plan. If a person or family wants more comprehensive coverage, they can buy a gold or platinum plan and pay the difference.

• Those who want lower premiums can buy a bronze plan, but they would face higher costs for medical care.


Example• A silver plan costs $400. Keisha’s tax credit is:

$400 (full cost) - $120 (expected contribution) = $280 credit.

• A bronze plan costs $300. Keisha can use her tax credit for this, and her monthly premium would be only $20 ($300 - $280 = $20), but she’ll have higher copayments or a higher deductible in this plan.


•People can report their income changes to get premium tax credits and cost-sharing reductions adjusted

•If someone’s annual income is higher than projected, he or she may have to pay back excess premium tax credits up to a cap (this is called “reconciliation”)

•If someone’s income is lower than projected, he or she will get more in premium tax credits at the end of the year

•Cost-sharing reductions do not need to be paid back

Income Changes


Review: Question #1

TRUE or FALSE:If a person receiving premium tax credits has an increase in income and does not report it, she may end up owing some of her premium tax credit back at the end of the year.


Answer: Question #1

TRUENot reporting an increase in income could mean that a person needs to pay back some of her premium tax credit.



Review: Question #2

QUESTION:A person has found out she is eligible for a $100 premium tax credit. Will she pay more in premiums for a gold plan or a silver plan offered by the same company?


Answer: Question #2

ANSWER:The gold planThe gold plan will cost the person more in premiums because it is a more expensive plan. The government pays the same premium tax credit no matter which plan the person picks.


DC Coverage Assistance Options in 2014

Approximate Income Levels as a Percent of Poverty


Cost-Sharing Reductions


People with incomes below 250% of poverty will get extra help paying for medical services in certain plans

• This will reduce the maximum amount that a sick person would pay out of pocket

• It could reduce the deductible, co-insurance, or copayments in a silver plan, making it more like a gold or platinum plan

Cost-Sharing Reductions: The Basics


What is cost-sharing?


Income as % of Poverty Level

(Shown for a Family of One)

Out-of-Pocket Maximum Cost-Sharing

for an Individual (Double for a Family)

Co-Pays/Co-Insurance/

Deductibles Are Similar to This Metal Level Plan

100-150% $2,250 Platinum

150-200% $2,250 Gold

200-250% $5,200 Silver

In DC, most people in these income brackets will be getting Medicaid. A small population may be in private DC Health Link plans with cost-sharing reductions.

Cost-Sharing Reductions (Individual)


Maria is very sick, and she is not eligible for Medicaid because she is under a five-year bar. Maria’s income is about 180% of poverty. She pays all of her medical expenses until she reaches her plan’s deductible, and then she pays copayments for drugs and doctors. QUESTION:At what point will her plan stop charging her copayments?

Cost-Sharing Reductions: Question #1


ANSWER:When her medical out-of-pocket medical expenses for the year reach $2,250, excluding premiums

Cost-Sharing Reductions: Answer #1


QUESTION:Richard does not qualify for Medicaid because his income is 220% of poverty. At what point will his plan stop charging copayments?

Cost-Sharing Reductions: Question #2


ANSWER: When his out-of-pocket medical expenses for the year reach $5,200

Cost-Sharing Reductions: Answer #2


You will play an important role in helping people apply for help with their coverage

The new system will do much of the work for you

This training is designed to help you understand why the new system works the way it does

You will be able to refer applicants to additional sources of help

Things to Remember

Applications



What’s changing?

• New application for MAGI-based Medicaid and premium tax credits

• Many ways to apply

• Easier eligibility determination


New Applications• Two online applications:

• Full application for financial assistance• MAGI Medicaid• Premium tax credits and cost-sharing

reductions

• Shortened application to buy a full-cost DC Health Link plan

• You can help encourage people to fill out the full application, since new help is available


Which groups use other applications?• Medicare assistance programs (SLMB, QMB,

Low-Income Subsidy)

• “Non-MAGI” Medicaid for elderly, blind, disabled, people who need long-term care, medically needy

• DC Alliance

• Other benefits, such as SNAP and TANF


Ways to Apply

• Online• By phone• In person• By mail

In-person interviews are not required!


The Advantages of Using the Online Application

• Application is easy to read

• Help by phone available 24/7

• Some information will be pre-populated

• Allows for real-time verification

• Application is dynamic

• Applicant gets information on whether or not eligibility has been determined at the end


People Will Still Want In-Person Help

• Trusted government agencies

• In-Person Assisters (IPAs)/Navigators (new)

• Other groups, like community clinics and hospitals


In-Person Assisters • Funded by DC Health Benefit Authority

• Conduct outreach and education in the community

• Trained to help with application and plan selection

• Provide help in other languages and assistance for people with disabilities

• Give impartial information


Certified Application Counselors• Another type of assister trained to help with

application and plan selection

• May be staff in community health clinics, hospitals, schools, or other community organizations

• Registered with DC Health Link, but not funded

• Focused on helping people who come through their doors, rather than conducting active outreach


Accessibility

• Applications and forms must be accessible for people with limited English proficiency and people with disabilities

• Application will be available in English, Spanish, and, later in 2014, Amharic


What does the application ask about?

• Household

• Income

• Citizenship and immigration status

• Residency

• Pregnancy

• Other coverage


Applicants and Non-Applicants

• Some household members may be non-applicants

• Important to list all household members to get full benefits• For instance, a large household with income of

$45,000 may be entitled to more benefits than a smaller household with the same income

• People DO NOT have to list Social Security numbers or immigration status for non-applicants


Example: Tania

Tania is applying for health coverage. She and her husband have children. Her husband does not want health coverage, but he agrees that the rest of the family should apply.

What can you tell Tania?


Answer: What to Tell Tania

ANSWER:Tania can list her husband as a non-applicant and does not need to provide his Social Security number. The computer may not be able to electronically verify household income without the Social Security number, but she can provide paper documentation of her husband’s income.


Getting an Authorized Representative

• Consumer can designate authorized representative (power of attorney, authorized representative form, etc.)

• May also be assigned through a court order

• Can be designated at any time:• Online through “My Account”• By mailing a request to a service center • In person at a service center

• Can be changed at any time


What Authorized Representatives Will Do

• Authorized representatives will receive:• Copies of notices sent to the consumer • Other communications on behalf of consumer

• Authorized representatives will be able to:• File an application and renew coverage • Provide information and documentation• Explain rights and responsibilities • Provide representation in an interview or

hearing


Verification

• New system uses electronic data sources first

• Will accept attestation for some things (for example, pregnancy and household composition)

• Will need documentation of income, citizenship, and immigration status if no electronic data is available

• Some differences between attestation and electronic data sources will need to be resolved and some will not

• System will check electronic data sources for you and tell you when documentation is needed


Processing Applications

• Outside time limits for processing Medicaid applications remain the same

• 45 days• 90 days for people applying on basis of disability

• Some eligibility determinations will happen right away

• System will automatically send notices to:

• Applicant• Applicant’s employer, if necessary


Open Enrollment• Time to enroll in DC Health Link plans that can be

purchased with premium tax credits

• First open enrollment season: October 1, 2013 to March 31, 2014

• Future years’ open enrollment seasons: October 15 to December 7 (enroll in 2014 for coverage to be effective Jan 1, 2015, for example)

• People can still apply for and enroll in Medicaid at any time


What will happen to peoplein non-MAGI Medicaid?

• Screening questions in application will identify people who might qualify

• Because determinations (for example, disability) take longer, applicants can enroll in what their income qualifies them for while they wait


Review: Question #1QUESTION:Which of the following groups will have their Medicaid eligibility determined through the new online application?

• Pregnant women• Parents• Adults under age 65 without children• Adults over age 65• People with disabilities


Answer: Question #1ANSWER:• Pregnant women• Parents• Adults under age 65 without children


Review: Question #2

QUESTION:Starting in October, people will be able to apply in which of the following ways:

a. By phoneb. By mailc. In persond. Onlinee. All of the above


Answer: Question #2

ANSWER:E – All of the abovePeople will be able to apply by phone, by mail, in person, and online.

Individual Responsibility



Why is this requirement part of the law?

• To encourage people to get coverage now, rather than wait until they are sick

• To keep insurance affordable


Starting in 2014, each individual, including children and seniors, must:

1. Have minimum essential coverage (which we’ll explain in a minute); OR

2. Qualify for an exemption; OR

3. Make a payment when filing his or her federal tax return. This payment is the “individual shared responsibility” payment.

Individual Responsibility


What is “minimum essential coverage”?

• A basic set of benefits and financial protections that a plan must have to be considered adequate health coverage

• Most people in the U.S. already have minimum essential coverage through:• An employer (their own employer or employer of spouse

or parent)• A government program, such as Medicaid, Medicare, or

Tricare• Health insurance purchased by an individual or family


What is not minimum essential coverage?

• A “limited benefit” plan that covers only a particular condition, such as a cancer-only policy• Self-funded student plans are minimum essential

coverage

• A medical discount plan

• A plan that pays a fixed amount per day (example: a policy that pays $250 for each day someone is sick, but nothing else)

• DC Alliance


Exemptions from the Individual Responsibility Requirement

• Some people are exempt from individual responsibility, but many will need to get a certificate from HHS showing that they are exempt

• Others will claim their exemption when they file taxes

• Exemptions are time-limited


1. People with a coverage gap of less than three months2. People with certified financial hardships3. People with incomes below the minimum tax filing

threshold 4. People whose premiums would be more than 8% of their

income 5. Those who are incarcerated

6. Those who are not lawfully present in the United States 7. Religious sects opposed to accepting insurance benefits8. Members of recognized health care sharing ministry9. Federally recognized Indian Tribes

Who is exempt from the individual responsibility requirement?


In 2014: • $95/adult, $47.50/child• Up to $285 per family or 1% of family income,

whichever is greater

In 2016: • $2,085/family or 2.5% of family income

Penalties for Going without Coverage (If Not Exempt)


Handling Questions about Individual Responsibility

Refer to consumers to the HHS call center if they have questions about the individual responsibility requirement.


Milestone Dates for DC Health Link

• Enrollment starts October 1, 2013

• Coverage begins as early as January 2014

Documents

About These Materials Families USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for