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DMA Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit Carolyn McClanahan Chief, Medicaid Eligibility Division of Medical Assistance.

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Presentation on theme: "DMA Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit Carolyn McClanahan Chief, Medicaid Eligibility Division of Medical Assistance."— Presentation transcript:

1 DMA Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit Carolyn McClanahan Chief, Medicaid Eligibility Division of Medical Assistance April 22, 2014

2 DMA Health Care Reform Legislation Federal –The federal Patient Protection and Affordable Care Act, P.L , (ACA) as amended –March 23, 2010 – signed by President Obama

3 DMA Summary Provisions Expanded coverage optional for states Implementation of Health Benefit Marketplace for uninsured (formerly called “exchange”) Medicaid/NCHC Eligibility Changes Enrollment streamline and simplification

4 DMA Expanded Coverage Optional for States Original federal legislation required Medicaid expansion to most individuals up to 133% (138%) fpl in new eligibility group Included childless adults, caretakers above current coverage limit Did not include age 65+, pregnant women, individuals with Medicare Supreme Court decision – Congress could not require states to expand – must be optional for states

5 DMA Expanded Coverage Optional for States NC Session Law NC will not expand Medicaid as provided in ACA NC will maintain the current coverage groups

6 DMA Summary Provisions Expanded coverage optional for states Implementation of Health Benefit Marketplace for uninsured (formerly called “exchange”) Medicaid/NCHC Eligibility Changes Enrollment streamline and simplification

7 DMA Implementation of Health Benefit Marketplace Federal Health Benefit Marketplace created: –States can build State Marketplace –States can build Partnership with Federally Facilitated Marketplace (FFM) –States can use the FFM NC Session Law NC will utilize the Federally Facilitated Marketplace

8 DMA Implementation of Health Benefit Marketplace Individuals/families can purchase insurance Income < 400% fpl – may qualify for Advance Payment Tax Credits (APTC)/cost-sharing assistance –Must have income above 100% fpl Eligibility determination for APTC and cost-sharing similar to Medicaid/NCHC Household/income based on IRS rules –Income eligibility based on MAGI (Modified Adjusted Gross Income)

9 DMA Summary Provisions Expanded coverage optional for states Implementation of Health Care Marketplace for uninsured (formerly called “exchange”) Medicaid/NCHC Eligibility Changes Enrollment streamline and simplification

10 DMA Medicaid/NCHC Eligibility Changes No changes to ABD/MQB eligibility –Excluded from MAGI methodology All Family & Children’s Medicaid programs affected –Use tax definition of household and income –MAGI income methodology New coverage group –Former foster care children up to age 26

11 DMA Eligibility Change: IRS – based methodology MAGI – a methodology for how income is counted and how household composition and family size are determined Household composition – tax household –includes stepparent, if in tax household –Includes siblings (biological, adopted, step) Income – based on federal tax rules for determining adjusted gross income (with some modifications) No asset test or disregards (except 5% disregard across the board)

12 DMA Eligibility Change: New questions To help determine household composition: Is the individual a tax filer? Does the individual expect to be claimed as a tax dependent?

13 DMA Eligibility Changes: If not tax filer or tax dependent, build household similar to tax household Household - adult: –Individual –Spouse –Natural, adopted or step children Household – child: –Individual –Natural, adopted, step parent –Natural, adopted, step siblings Child: individual under age 19 or, at state option, 19 or 20 and a full-time student

14 DMA Eligibility Change: Income May disregard income of child/tax dependent if do not plan to file taxes Child support is non-countable income Social security – countable based on amendment to ACA

15 DMA Eligibility Change: MAGI Taxable Adjusted Gross Income (AGI) with a few modifications Disregards/exclusions –States cannot give current disregards Earned income disregards ($90, 27-1/2 %, child care) –Only disregard is 5% from the MAGI calculation

16 DMA MAGI-Equivalent Income Limits Income limits adjusted due to difference in deductions Purpose: to “hold harmless” eligibility standards so, as a group, individuals do not lose eligibility CMS – contracted with vendor to provide calculations for states Revised income limits: –Example: current 185% may be converted to 192% (not actual converted amount) –Should receive the converted income limits sometime later this month

17 DMA Summary Provisions Expanded coverage optional for states Implementation of Health Care Marketplace for uninsured (formerly called “exchange”) Medicaid/NCHC Eligibility Changes Enrollment streamline and simplification

18 DMA Streamline/Simplification ACA mandates individuals may apply for all insurance affordability programs: –In person –Mail –Electronic –Phone Insurance affordability programs: –Medicaid –CHIP (NCHC) –APTC (Advance Payment of Tax Credits)/Cost-sharing

19 DMA Streamline/Simplification States and Marketplace: must have web portal for applications “No Wrong Door” - Individuals may apply at any agency/site for all insurance affordability programs

20 DMA Streamline/Simplification One application for all insurance affordability programs CMS is developing the model paper and on-line application Individuals who only want medical coverage must have streamlined model application available States can get alternate application approved – must submit State Plan Amendment (SPA)

21 DMA Streamline/Simplification Must rely on electronic data for verification Request info from applicant only if not available electronically or discrepancy Move to “real-time” eligibility determinations as much as possible Experience should be as seamless as possible for applicant – no duplicate requests for information Renew coverage based on information available

22 DMA Final: Time Frames October 1, 2013 –Open enrollment for insurance affordability programs –Must accept single streamlined applications and apply new rules –Must be able to transmit information to Marketplace –Evaluate under current rules for eligibility prior to 1/1/14 January 1, 2014 –Coverage under insurance affordability programs can begin


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