THE ACA, ELIGIBILITY & ENROLLMENTShanna Hanson, FHFMA

100 Years Ago (1906)

Life expectancy 47 Bathtub 14% Telephone 8% Cars 8,000 Paved roads 144 miles Speed limit 10 mph CA 21st most populated

state Births at home 95%

Avg worker $200-$400 per year

Drs 90% no college Women washed hair

once a month Las Vegas pop. 30 High school grads 6% Marijuana, heroin,

morphine all legal

Health Coverage Memory Lane 19th Century: Little or no money 1930’s: Insurance 1962: Medicare 1965: Medicaid – Low-Income Families; ABD

– 1986: Pregnant Women and Infants (State Option)– 1989: Pregnant Women and Children (Mandated)– 1990: Children 6-18 (Phased In)– 1997: SCHIP

2010: PPACA 2014: TOMORROW!!!

Objectives

Review areas of eligibility and enrollment process impacted by the ACA, regardless of expansion

Examine what changes and how

Help you prepare your staff and facilities for changes

Today’s Agenda

Language is Important

States May vs. States Must

State Option vs. Required by States

Proposed vs. Final (Rules)

MAGI – Modified Adjusted Gross Income

Medicaid, Marketplace or both?

Marketplace (a.k.a., Exchange)– FFM – Federally Facilitated Marketplace

– FSP – Federal State Partnership Marketplace

– State-Based Marketplace

Language is Important

QHP – Qualified Health Plan. Insurance coverage sold through the Marketplace, subsidized or not.

APTC – Advanced Payment of Tax Credits. Subsidies received for QHP coverage in the Marketplace.

IAP – Insurance Affordability Programs. Medicaid, CHIP, APTC Subsidized QHP.

IPA – In-Person Assister. State program, separate from the Navigator program.

CAC – Certified Application Counselor Unfunded assister.

Expansion vs. Non-Expansion

Overview Supreme Court Decision

– Can’t penalize a state that does not expand Medicaid to 133% of Federal Poverty Level.

No other provisions of the law affected. – Example: coordination with the

Marketplace, including use of standard income eligibility methods, apply.

Expansion vs. Non-Expansion “So What?”

Impact on Medicaid Program Administration State policies and procedures will change

Materials published

Training provided

Culture shifts

State Medicaid systems must communicate electronically with the Marketplace

Coverage gap in states that choose not to expand

Other expansion models being considered

Impact of ACA on Eligibility and Enrollment

Application

Assistance

Presumptive Eligibility

Eligibility

Verifications

Technology

Process designed to be more consumer friendly Forms: single streamlined, multi-benefit

or supplemental Interview: no face-to-face for MAGI Reconsideration: 90 days without new

application Signatures: electronic, phone, fax, other Submission: online, phone, in person,

mail or IAP agency (no “wrong door”)

Application

No Wrong Door!

Application “So What?”

Path to eligibility will be easier, less burdensome, and take less processing time.Federal government published three applicationsAdditional supplemental forms may be neededOther application options existApplication assistance is a necessity

– Massachusetts: less than 1 in 18 finish online

Approved!

How Many Assisters Do We Need?

2.25 hours estimated per consumer 211,000 consumers 475,445 total hours of assistance Assuming assisters are using 85% of their time over

six months of open enrollment to help consumers 884 hours per assister 475,445 / 884 = 538 assisters needed

Arkansas

New Hampshire $73,000 per assister estimated, plus overhead costs $600,000 grant 8 or less navigators

Georgetown University Health Policy Institute Center for Children and Families

Assister by Marketplace Type

Federally Facilitated State-federal Partnership State-based

Navigator: program development

Federal government Federal government State

Navigator: program management

Federal governmentFederal government with

state participationState

Navigator: funding

Federal government awards grants to a

minimum of two entities in the state, one of which must be a community-

based organization

Federal government awards grants to a

minimum of two entities in the state, one of which must be a community-

based organization

State can use federal exchange establishment grants for planning, but cannot use that funding

for operations

In-person assister: program development

Will not have them Required Optional

In-person assister: program funding

Not applicable

State can use federal exchange establishment grants to establish and operate the program

State can use federal exchange establishment grants to establish and operate the program

Certified Application Counselor: program development

Required for marketplace, optional for Medicaid

Required for marketplace, optional for Medicaid

Required for marketplace, optional for

Medicaid

Certified Application Counselor: funding

None None None

Navigator and IPA Duties

1. Maintain expertise2. Maintain a fair, accurate and

impartial manner3. Facilitate selection of a QHP4. Provide referrals for enrollees5. Provide information in a culturally and linguistically

appropriate manner6. Perform outreach and education

CAC Duties

Marketplace (All)

Provide information.

Assist individuals to apply for coverage.

Help to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs.

Medicaid/CHIP (Some or All)

Provide information.

Help individuals complete an application or renewal.

Work with the individual to:– Provide documentation– Submit to the agency– Interact with the agency– Respond to agency requests– Manage their case

Marketplace CAC Certification Requirements

1. Registers

2. Is trained prior to providing application assistance

3. Complies with applicable authentication and data security standards, and with the privacy and security standards

4. Provides application assistance in the best interest of applicants

5. Complies with any applicable state law(s)

6. Provides information with reasonable accommodations

7. Enters into an agreement

Authorized Representatives

Designated by the applicant/beneficiary

Has the legal authority to interact on behalf of the applicant/beneficiary

Can sign the application Receives notices Individual or organization Must be allowed by the state

Hospital Enrollment “So What?”

1. Possibility of larger staff focused on assistance

2. Staff space allocations

3. Centralized or decentralized

4. Privacy for applicants

5. Performing tasks outside of your core business

6. Initial and ongoing training

7. Staff certification

8. Staying current with program and policy changes

9. Employing the most efficient and effective processes

Presumptive Eligibility

Presumptive Eligibility (PE) Enrollment by “Qualified Hospitals”– Participate as a Medicaid provider; – Notify state Medicaid agency of its decision to make PE

determinations; – Agree to make determinations consistent with state policies

and procedures; – At state option, assist individuals in completing and submitting

the full application and in understanding any documentation requirements; and

– Not be disqualified by the state Medicaid agency.

PE Expansion Groups

Presumptive Eligibility “So What?”

Provider payment during temporary eligibility period– Payment stands even if person found ineligible

State rules will vary, which may make PEmore or less attractive to hospitals

Risk of becoming uninsured after PE period Staffing, logistics, privacy, training

and certification

Eligibility

MAGI-Based Medicaid: Collapse into 4 groups MAGI-Excepted Medicaid: Aged, disabled, etc. Optional Groups: BCCT, working disabled

(exempt from MAGI) Emergency Medicaid: No changes Retroactive Coverage: Up to three months Spend down in 209(b) States not Medically Needy:

Aged, blind, disabled

Eligibility

Maintenance of Effort: 9/30/19 for children Children

– Highest level for age group– 185% Federal Poverty Level for infants

Enrollment While Pending (e.g., disability): – MAGI-based or QHP enrollment while

pending for MAGI-excepted coverage– Medicaid is retroactive, QHP coverage is not– MAGI-excepted Medicaid would be a

secondary payer for overlapping eligibility

Eligibility

Criteria MAGI-Based Medicaid/CHIP Qualified Health Plan

Household Tax household with exceptions Tax household

Income Tax rules with exceptions Tax rules

Disregard 5% Not applicable

Budget Period Point in time (current month)

Annual based on last tax return

Start Date Up to 3 months retroactive Prospective

Eligibility “So What?”

States may drop and/or change Medicaid programs when the Maintenance of Effort expires 12/31/13, except for children

Program options will impact:– Process the applicant goes through– Cycle time – Payment to the provider

Verifications

What– Age, DOB, Household Size: States “may” verify– Income: Process and sequence could vary– Pregnancy: Self-attestation

How– Data-driven Process: Electronic sources– Documentation Submission: Online, phone, in person,

or via mail– Electronic Data Matches: States decide usefulness,

frequency and time-frame (could be after enrollment)

Verifications

How Cont’d– Self-Attestation: Permitted, except as required by law, or not

permitted by law– When Documentation is Permitted: Not reasonably compatible– When State Law Does Not Permit Self Attestation: State option

to accept self-attestation unless ACA does not permit Reasonably Compatible: Both attestation and electronic

information are either above or below the eligibility level Reasonable Opportunity Period: 90 days for Marketplace;

differs for Medicaid

Verification “So What?”

Verifications plans will be state specific State policy decisions will be based on their

verification plan Transparency

Technology

Open enrollment: 10/1/2013 - 3/31/2014 Online application system must support

single streamlined application Electronically Pass Accounts: Medicaid

and the Marketplace FFM Medicaid “Determination” or “Assessment”

– Medicaid eligibility determination or – Medicaid eligibility assessment (at the state’s option)

Implement state access to “The Hub” Systems must support new renewal process

Technology “So What?”

Open enrollment without the technology to support it will create backlogs and frustration.

State rules dictate the type of Medicaid decisions that can be made by the FFM.

A lot to do. Will states be ready?

Reviewed six areas of the eligibility process impacted by ACA, regardless of expansion.

Examined what changes and how. Gave you points to ponder as you begin to prepare

your staff and facilities for the changes ahead.

SApplicationSAssistanceSPresumptive Eligibility

SEligibilitySVerificationsSTechnology

Wrap-Up

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