2 Today’s Agenda Background New categories of eligibility 5 aspects of eligibility – what’s changed?Applications and enrollmentIssues to watch
3 BackgroundGoal of the Patient Protection Affordable Care Act (ACA) is to provide all Americans with quality, affordable health insuranceExpand MedicaidIndividual and Employer RequirementsInsurance ReformsHealth Insurance ExchangeFederal Tax Subsidies
4 Medicaid ExpansionFor States that opt-in, the ACA expands Medicaid coverage to a new eligibility population that includes single adults, up to 138% of the federal poverty level (FPL).Prior to the ACA, non-disabled single adults were excluded from Medicaid coverage, unless States obtained a waiver to cover them. NY implemented Family Health Plus under an 1115 waiver.42 U.S.C. § 1396a(a)(7); 42 C.F.R. § 435; N.Y. Soc. Serv. § L. 336
5 TimelineOctober 1, 2013 – MAGI population can apply for Medicaid through the New York State of Health & receive eligibility determinations using new MAGI rules, but coverage through Medicaid Managed Care plans will not begin until January.Individuals can shop for QHPs on the exchange.December 31, 2013 – No new FHP applications will be taken.January 1, 2014 – Coverage begins for PHI and QHPs.April 1, 2014 – New MAGI budgeting applies upon renewal for all MA recipients.New York State of Health aka exchange, marketplace.State encourages new MA applicants to still apply through local districts until January 1, For people who go through the exchange, it will be a 2-step process. They’ll have to go in December to pick a plan and coverage doesn’t start until January.They approximate 2- 3 years before all MA applicants (non-MAGI populations) will be able to go to the exchange.
6 New Eligibility Categories MAGIPregnant womenChildren under 19Parents/caretaker relativesChildless adults:Not pregnant19 – 6519 & 20 year olds living with parentsChild in foster care (Chaffee)Non-MAGIAge 65 or older;Certified disabledTANF, SSI, Foster Care children, adopted child receiving medical subsidy, child for whom kinship or guardianship assistance payments are madeSpend down, LTC needs, MBI, MSP, cobra continuation, PickleCancer programs, Former Foster Care, waiver programsResidents in adult homes, treatment centers, OMH facilitiesIMPORTANT: if the applicant is both MAGI and non-MAGI, they can choose MAGI as long as they do not have Medicare. Ex: disabled mom w/o medicare coverage with a minor child. Can choose MAGI budgeting.42 U.S.C. § 1396a(a)(10)(VIII); 42 C.F.R. § (j); N.Y. SSL § 366(b)
7 Can Choose MAGI or non-MAGI Certified disabled, but not yet receiving Medicare.Parent/caretaker relatives, even if they are disabled and/or over 65, and start receiving Medicare.Disabled children, unless they are in a waiver program.
8 Five Eligibility Criteria ResidencyImmigration StatusCategoryIncomeResourcesCategories = eligibility group, disability status, age, living with minor children in the h/h, no minor children in the h/h
9 1. Residency Old Rule = Must be a New York Resident to receive Medicaid in New York.N.Y. Soc. Serv. L. § 366-aResident = intend to remain in New York “permanently or indefinitely.”42 C.F.R. §New Rule = NO CHANGE. Must be a New York Residentto receive Medicaid in New York.
10 2. Immigration Status Old rule = qualified immigrant including PRUCOL. Undocumented immigrants eligible for emergency MA.New rule = NO CHANGE. PRUCOL immigrants still eligible forMA. Undocumented immigrants eligible for emergency MA.As of January 2014, undocumented immigrants can apply for emergency Medicaid through the ExchangeAliessa, et al. v. Novello, holding that denying Medicaid eligibility for PRUCOLs was unconsitutionalNOTE: ineligible immigrants (ex: DACA were explicity shut out from the exchange) are not subject to the individual mandate.NYSSL 122(c); Aliessa, et al. v. Novello (96 N.Y. 2d 418); 8 USCA 1611(b)(1)(A); 1621.
11 3. CategoryOld Rule = various categories depending on age, disability status, living with children, etc.New rule = 4 categoriesPregnant womenChildrenParents/caretaker relativesChildless adults1. 42 CFR § ; CFR § ; CFR § CFR §
12 Category (cont’d): Household Size MAGI household is the IRS filing unitExceptions for children:Children living with relatives who are not their parents;Children living with both parents, although the parents file separately;Children claimed as dependents by non-custodial parents.Pregnant women counted as self + number of expected childrenMarried spouses living together are in each other’s household, regardless of whether they file jointly or separately.Example: If a child is claimed as a dependent by the non-custodial parent, the child’s household consists of the child, sibling and the parent living with them.42 CFR (d); 42 CFR (b); 42 CFR (f)
13 Category (cont’d): Household Size If an individual is claimed as a tax dependent and not the spouse or child of the taxpayerORIf an individual is not expected to file tax return and not claimed as dependent in that year,The household size would include:Self, spouse, and children less than 19 years old (or, if full-time student, less than 21 years old)42 C.F.R (f)
14 Household Case Example # 1 James (the taxpayer) and Alexis (James’s wife) live together with two minor children, John and Susan, as well as James’s Aunt Patricia (who does not file taxes). James claims all of them as dependents.
15 Household Case Example Q. What is James’ household size?A. James’ household size is five. His household includes James plus his four dependents.
16 Household Case Example Q. What is the household size of thedependents?A1. As long as Alexis and James are filing jointly, the household size for Alexis, John and Susan (dependents) is five, the same as James (taxpayer).
17 Household Case Example (cont’d) A2. Aunt Patricia’s household is a household of one because Aunt Patricia has no parents, spouse or siblings living in the same household.
18 Household Case Example #2 James and Alexis are separated. Alexis lives with their children, John and Susan. Alexis also lives with her new child, Mary. James claims John and Susan as a dependent on his taxes. Alexis claims Mary as her dependent.
19 Q. What is Alexis’ household size? A. Alexis’ household size is two – Alexis and her tax dependent, Mary.
20 Q. What is James’ household size? A. James is a household of three – James and his two dependents, John and Susan.
21 Q. What is John’s household size? John household size is four – John, Susan, Alexis and Mary.Q. What is Susan’s household size?A. Susan’s household size is four – Susan, John, Alexis and Mary.
22 Q. What is Mary’s household size? A. Mary’s household size is two – Mary and Alexis.
23 4. Income Old rule = 10 income categories New rule = 5 income categoriesPregnant women42 CFR § ; N.Y. Soc. Serv. L. §366(1)(b)(2);Infants 42 CFR § ; N.Y. Soc. Serv. L. §366(1)(b)(2);Children 42 CFR § ; N.Y. Soc. Serv. L. §366(1)(b)(3);Parents 42 CFR § ; N.Y. Soc. Serv. L. §366(1)(b)(4);Childless Adults42 CFR § ; N.Y. Soc. Serv. L. §366(1)(b)(1);Income levels for MAGI groups already at or above 133% FPL must be converted to MAGI equivalents. This was done by CMS.The reason why children and infants are separate here is because NY already covered infants under1 year at 200% of FPL. For MAGI populations that already had coverage at or above 133%, CMS converted to a MAGI equivalent.
24 Income (cont’d) Infants = 223% N.Y. Soc. Serv. L. §366(1)(b)(2) Pregnant women = 223% FPL N.Y. Soc. Serv. L. §366(1)(b)(2)Infants = 223% N.Y. Soc. Serv. L. §366(1)(b)(2)Children = 154% (with some exceptions) N.Y. Soc. Serv. L. NYSSL §366(1)(b)(3)Parents = 138%; 155% = wrap N.Y. Soc. Serv. L. NYSSL §366(1)(b)(4)Childless Adults = 138%N.Y. Soc. Serv. L. §366(1)(b)(1)Income levels for MAGI groups already at or above 133% FPL were converted to MAGI equivalents. States were required to establish a MAGI equivalent income standard that takes into account the average amount of income disregards that will no longer applied for an individual category under the MAGI methodology. NY elected to have CMS calculate necessary MAGI utilizing census data and information on New York’s income disregards. CMS provided the 223% #.
25 Family Health Plus (FHP) FHP used to cover parents living with children under 21 andchildren 19 – 20 years old living with parents, up to 150%FPL.Family Health Plus program will end on January 1, 2014.People with children who are between 138% -150% of FPL willneed to enroll in a silver-level plan through the Exchange andwill pay NO premiums.N.Y. Soc. Serv. L. § 367-a(3)(e); NEW YORK STATE EXECUTIVE BUDGET Art. VIIPart D § 14, 14a, 15, 16.
26 Exceptions to 154% FPL for MAGI-children Children 19 or 20 living with parents will be eligible for MAup to 155% of FPL through September 2019.N.Y. Soc. Serv. L. § 366(a)(9)(b) (7)A child under 21 years of age and who was in foster careunder the responsibility of the State on his or her 18thbirthday is eligible for Medicaid with no income test.N.Y. Soc. Serv. L. § 366(a)(9)(b)(5)Distinguish this and former foster care rule non-MAGI rule. If you are under 26, were in receipt of MA at the time of aging out of foster care at age 18 in New York or another state, you will continue to receive full Medicaid as a non-MAGI.
27 Income (cont’d) MAGI MAGI is Modified Adjusted Gross Income is based on IRS rules.Child support is not considered income because it is not taxable. This money has already been taxed once.Section 36B(d)(2) of Internal Revenue code of 1986; 42 C.F.R. § (d); 42 C.F.R. § (e)
28 Gross IncomeGross income = wages, SS income, investment income, unemployment, pensions, IRA distribution, alimony, and income from self-employment,
29 Not Income Child Support Income from child or tax dependent who is not expected to be required to file a tax return in the taxable year for which MA eligibility is determined.Medicaid rules apply to lump sums, and certain educational scholarships and payments to Native Americans.Lump sum is income in the month received.Scholarships, awards and fellowships grants used for education purposes and not for living expenses are excluded as income.Distribution from Alaska Native Corporation and settlement trusts, from property held in trust subject to Federal restrictions, located within a Federal reservation, from rents, leases, rights of way, royalties, from native land, etc. is exempt income. 42 C.F.R. § (e)Sec. 36B(d)(2) of IRC of 1986; 42 C.F.R. § (d); 42 C.F.R. § (e)
30 Self-Employment Income Self employment income is income after expenses claimed on schedule C.
31 Adjustments Adjustments = alimony, moving expenses, student loan interest, and self-employed health insurancecontributions
32 Income Disregards Old Rule = Many disregard rules. New Rule = Only 1 disregard: 5% of yourModified Adjusted Gross Income. 133%becomes 138%42 U.S.C. § 1396a(14)(I)(i); 42 C.F.R. § (d)(1)
33 5. Resources Old Rule – No Resource Test New Rule – NO CHANGE. No ResourceTest42 U.S.C. § 1396a(C); 42 C.F.R. § (g)
34 Current Medicaid Rules Eligibility ExampleAlexis is a single mother with 2 children Susan age 5 and John age 3. Alexis is employed, earning $24,000 a year. She also receives $4,000 per year in child support and pays $3,000 per year for child care.Current Medicaid RulesFamily size: 3Income:Wage $24,000Child support $4,000Total Income: $28,000Deduction: $90 per month for earning, $100 per month for child support, and child care expenses: $5,280Medicaid income: $22,720FHP income: $28,000Children Medicaid Eligible, Mom eligible for Family Health PlusMAGI RulesFamily size: 3Total Countable Income: $24,000All Three Medicaid eligible
35 Income & Benefit Levels for MAGI Groups Courtesy of EJCExplains benefit & income levels for each category under MAGI budgetingCourtesy of Empire Justice Center
36 Medicaid Benchmark Benefit ACA establishes Medicaid Benchmark Benefit for newly eligible MAGI applicantsMedicaid benefit will not be uniform; benchmark benefit is not “full” MedicaidBenchmark benefit includes all covered Medicaid benefits except long-term care
38 ApplicationsOctober 1, 2014 – new MAGI Medicaid applicants can apply through the NY State of Health via:OnlineNavigatorsCertified Application CounselorsBrokersBy MailState says they are approximately 2 – 3 years out before being able to take non-MAGI applications through the exchange.Applications will be processed electronically, regardless of how received. Online acct will be started for that person, etc.42 C.F.R. § (a)
39 Application TimelineOctober through December 2013, MAGI applicants will have a two-step process:Receive an eligibility determination,Return in December to pick a plan.Coverage will not begin until January 2014.FFS will pick up bills incurred after the eligibility determination and before plan coverage starts.Advocate tip: People should continue to apply through localdistrict until January 1, 2014.Applications for retro coverage will be forwarded to local districts for old rules & LDSS will follow-up with applicant.
40 In-Person Assistors & Navigators The old “Facilitated Enrollers” have been replacedwith “In Person Assistors” and “Navigators,” whocounsel applicants and submit applications directly.IPA/Navigators map included in resource list
41 VerificationData-matching: States must develop secure, electronic interfaces to allow for data-matching and eligibility determinations. States must use data-matching to the maximum extent practicable.Self-attestation: Exchange may accept attestation of information and conduct database verification needed to determine eligibility without further documents.42 CFRReasonable Compatibility: Standard for assessing whether verification can be considered complete, or if additional information is necessary. When data obtained is “reasonably compatible” with an applicant’s attestation, State agencies are prohibited from requiring additional documentation.42 C.F.R (c)Examples of data-matching. Exchange will be able to verify income with IRS, verify immigration status.
42 Renewal & ReportingRenewal – State must use available information to facilitate annual re-determination process.42 CFRReporting – Individuals must report changes with respect to eligibility standards through the same modalities they can apply for coverage.42 CFR (c)Recipients still have an affirmative duty to report changes in eligibility. NYCRR
43 Pop QuizBob and Brenda are married. They have two children, Arthur age 2 and Hank age 19. Bob claims Brenda, Arthur and Hank as his dependents. Bob and Brenda’s income is 155% of FPL for a household of four. Arthur works and earns $5,000 per year and isn’t required to file taxes. Brenda’s mother, Beatrice also lives with them. Beatrice is 75 years old. She received $500 per month Social Security Retirement and Medicare. Beatrice does not file taxes.Household size?Bob, Brenda, Arthur and Hank = Household of fourBeatrice = Household of oneBenefit?Bob and Brenda are eligible for FHP wrap.Arthur is eligible for CHIP.Hank is eligible for full Medicaid.Beatrice gets full Medicaid.Category?Bob and Brenda are MAGI as parents.Arthur is MAGI as a child under 18.Hank is MAGI as a 19 year old living with his parents.Beatrice is non-MAGI.
44 Issues to Watch How is it working? - What data is collected? - What notices do applicants receive?- How are they dealing with mixed households?- How are they treating applicants with sporadicincome?