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Prepared by Families USA for use in the District of Columbia About These Materials Families USA developed these materials under contract with DC Health.

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Presentation on theme: "Prepared by Families USA for use in the District of Columbia About These Materials Families USA developed these materials under contract with DC Health."— Presentation transcript:

1 Prepared by Families USA for use in the District of Columbia About These Materials Families 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 for assistance with adapting these

2 ESA Policy Training Day 4

3 Prepared by Families USA for use in the District of Columbia The Verification Process

4 Prepared by Families USA for use in the District of Columbia Changes to Verification Current Medicaid rules: Documentation required for most eligibility factors New rules: Use electronic data sources and self- attestation as much as possible Use paper documentation as a last resort

5 Prepared by Families USA for use in the District of Columbia Electronic Data Sources DC Health Link will get data from two hubs, which include several sources each: Federal data hub Local data hub DC Health Link will get this information automatically. You will not need to know which source to get information from.

6 Prepared by Families USA for use in the District of Columbia The Federal Data Hub Connects DC Health Link to federal government data sources Data sources include, among others: Social Security Administration Internal Revenue Service (IRS) The Work Number Department of Homeland Security

7 Prepared by Families USA for use in the District of Columbia The Local Data Hub Connects DC Health Link to local data sources Data sources include: DMV ACEDS Department of Employment Services

8 Prepared by Families USA for use in the District of Columbia How DC Health Link Uses Electronic Data Sources 1.Checks federal and local data hubs 2.Pre-populates information in application 3.Asks applicant to confirm or change pre- populated information and add additional information 4.Asks for documentation if needed

9 Prepared by Families USA for use in the District of Columbia Important Things to Remember about Electronic Data Sources Some electronic data will be months old Always remember to check pre- populated data If a data source is temporarily unavailable, DC Health Link will automatically check other data sources if one hub is down

10 Prepared by Families USA for use in the District of Columbia When is paper documentation needed? When electronic data sources have no information for applicant When electronic data sources are not “reasonably compatible” with applicant’s self-attestation When a non-applicant does not provide a Social Security number

11 Prepared by Families USA for use in the District of Columbia New Ways of Accepting Documentation Accept scanned or photocopied versions of all documentation, including citizenship and immigration status Documentation can be submitted: Online through “My Account” In person By mail By fax By

12 Prepared by Families USA for use in the District of Columbia Timeline for Providing Documentation: Medicaid If verification needed for an eligibility factor other than citizenship/immigration status: 45 days to provide documentation Applicant does not receive Medicaid during this time If verification needed for citizenship/immigration status: 90 days to provide documentation Applicant receives Medicaid during this time

13 Prepared by Families USA for use in the District of Columbia Timeline for Providing Documentation: DC Health Link Applicant has 90 days after receiving notice If inconsistency is not resolved in this time, financial assistance level may change and/or coverage can be terminated

14 Prepared by Families USA for use in the District of Columbia What if applicants cannot provide documentation? In some circumstances, applicants cannot provide documentation For example, in cases of homelessness or domestic violence ESA supervisory staff can waive paper documentation requirements on a case-by- case basis

15 Prepared by Families USA for use in the District of Columbia Review: Question #1 TRUE or FALSE: Applicants providing documentation of citizenship or immigration status must bring the original version into an ESA service center.

16 Prepared by Families USA for use in the District of Columbia Answer: Question #1 FALSE Scanned and photocopied versions of all documents, including citizenship and immigration status, are accepted.

17 Prepared by Families USA for use in the District of Columbia Review: Question #2 TRUE or FALSE: ESA workers will need to remember which data sources are in which hub and choose which hub to ask for information when electronic data is needed.

18 Prepared by Families USA for use in the District of Columbia Answer: Question #2 FALSE DC Health Link automatically checks the right hubs and data sources for you.

19 Prepared by Families USA for use in the District of Columbia Verifying Household Composition Electronic data sources are not available for household composition, so DC Health Link will accept self-attestation unless: Two tax filers who do not file jointly say they will claim the same dependent Two people who do not file taxes claim that the same person lives with them In these cases, documentation is required.

20 Prepared by Families USA for use in the District of Columbia Tax Forms to Document Household Composition Tax forms are the strongest type of documentation Form 8332 Custodial parent allows non-custodial parent to claim child Form 2120 Multiple taxpayers supported dependent Form indicates which person gets to claim dependent

21 Prepared by Families USA for use in the District of Columbia Other Documentation of Household Composition If neither person has tax forms, use: School or medical records Childcare records Statements from non-relatives Leases Mail to or regarding the person being claimed Records of religious or recreational activities

22 Prepared by Families USA for use in the District of Columbia Five Steps for Verifying Income 1.DC Health Link checks IRS data If potentially eligible for premium tax credits, application will ask for expected annual income If potentially eligible for Medicaid, and IRS data is not available or applicant disagrees with IRS data, continue with steps DC Health Link checks federal and local data hubs and pre-populates application

23 Prepared by Families USA for use in the District of Columbia Five Steps for Verifying Income (cont’d) 3.Applicant confirms or changes pre- populated information 4.DC Health Link asks about any additional sources of income 5.DC Health Link calculates total income and asks applicant to confirm

24 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility Reasonable compatibility: any difference between self-attestation and electronic data sources is either small or does not make a difference in eligibility

25 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility for Income: Medicaid As long as both self-attestation and electronic data sources show household income is below Medicaid eligibility level, the information is reasonably compatible.

26 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility for Income: DC Health Link If attestation of household income is above electronic data source amount or is no more than 10% below Reasonably compatible DC Health Link uses self-attestation to calculate premium tax credits and cost-sharing reductions If attestation is more than 10% below electronic data sources Not reasonably compatible Documentation is needed

27 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility between Medicaid and DC Health Link When self-attestation is above Medicaid eligibility limit and electronic sources are below, use self-attested data When self-attestation is below Medicaid eligibility limit and electronic data sources are above: Not reasonably compatible, unless the difference is less than 10% Documentation is needed

28 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility: Example #1 Sasha is 35 and has no one else in her household. Electronic data sources say her income is $23,000 (200% of poverty) She says her income is $9,000 (128% of poverty) Is this reasonably compatible?

29 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility: Example #1 Yes, this is reasonably compatible. Even though there is a difference of 72% of poverty between self-attestation and data sources, this is reasonably compatible because both are below the Medicaid eligibility level for childless adults.

30 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility: Example #2 Christine is 48 and has no one else in her household. Electronic data sources say her income is $36,900 (320% of poverty) She says her income is $33,200 (289% of poverty)

31 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility: Example #2 No, this is not reasonably compatible This is not reasonably compatible because she is eligible for premium tax credits and her attestation is more than 10% below what electronic data sources report.

32 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility: Example #3 Bernie is 35 and intends to claim his 10-year-old son, Marcus. He has no one else in his household. Electronic data sources say his income is $34,432 (about 222% of poverty for a family of two) He says his income is $33,036 (about 213% of poverty) Is this reasonably compatible?

33 Prepared by Families USA for use in the District of Columbia Reasonable Compatibility: Example #3 Yes, this is reasonable compatible. Because self-attestation is less than 10% below electronic data sources, the information is reasonably compatible.

34 Prepared by Families USA for use in the District of Columbia Documentation of Income Documentation of income includes: Most recent paystubs Letter from employer Award letters (such as Social Security) Documentation of non-wage income, such as interest, dividends, annuities Documentation of any planned adjustments to income

35 Prepared by Families USA for use in the District of Columbia Verifying Citizenship and Immigration Status DC Health Link uses federal data hub to verify citizenship and immigration status If verification is not possible: Applicant has a 90-day “reasonable opportunity period” to provide documentation Applicant gets coverage based on income during this time

36 Prepared by Families USA for use in the District of Columbia Documentation of Citizenship Two types of documentation: 1. Primary 2. Secondary Applicant can provide: Primary documentation by itself Secondary documentation plus another form of ID

37 Prepared by Families USA for use in the District of Columbia Documentation of Immigration Status DC Health Link will need: 1.Nine-digit alien number 2.Copy of something that shows immigration status

38 Prepared by Families USA for use in the District of Columbia Verifying Residency Verification needed only for those over age 19 DC Health Link checks: Department of Employment Services Department of Motor Vehicles The BENDEX file Residency verified even if sources show a different DC address

39 Prepared by Families USA for use in the District of Columbia Documentation of Residency Paper documentation of residency: Current driver’s license Current lease Current rent receipt Current utility bill Current letter from landlord Homeless applicants are not required to provide paper documentation

40 Prepared by Families USA for use in the District of Columbia Verifying Incarceration Status DC Health Link will accept self-attestation of incarceration status for the applicant and applicant’s household members.

41 Prepared by Families USA for use in the District of Columbia Verifying Age DC Health Link checks federal data sources Verification needed only if difference between attested age and electronic data sources affects eligibility Example: a person who has income of 250% of poverty and could qualify for Medicaid as a child, but not as an adult

42 Prepared by Families USA for use in the District of Columbia Documentation of Age Birth certificate Driver’s license Other government-issued photo ID Other photo ID with name and date of birth

43 Prepared by Families USA for use in the District of Columbia Verifying Pregnancy Application accepts attestation of: Pregnancy Number of children the pregnant woman expects to deliver

44 Prepared by Families USA for use in the District of Columbia Verifying Caretaker Relative Status Application accepts attestation that an applicant is a caretaker relative.

45 Prepared by Families USA for use in the District of Columbia Review: Availability of Other Coverage Availability of other coverage affects: Eligibility for premium tax credits and cost- sharing reductions Match rate that DC receives for certain pregnant women and children Coverage can come from: Other government programs (for example, Medicare or the VA) An employer (or a family member’s employer)

46 Prepared by Families USA for use in the District of Columbia Verifying Availability of Other Coverage Government coverage DC Health Link will check for eligibility determination for other programs If found, applicant must provide documentation that coverage has been cancelled Employer coverage Electronic data available for some federal employees DC Health Link relies on information provided by applicant and employer

47 Prepared by Families USA for use in the District of Columbia Verifying an Applicant’s Social Security Number DC Health link will check federal data hub for match If no match is found, applicant must provide documentation or resolve the inconsistency with the Social Security Administration

48 Prepared by Families USA for use in the District of Columbia Verifying American Indian Status Important for: Treatment of income in Medicaid Ability to enroll in DC Health Link at any time Higher levels of cost-sharing reductions DC Health Link does not currently have an electronic data source for this information Applicant must provide documentation

49 Prepared by Families USA for use in the District of Columbia Documentation of American Indian Status Any formal documentation that verifies American Indian status from: A tribe Indian Health Services (IHS) Bureau of Indian Affairs

50 Prepared by Families USA for use in the District of Columbia Documentation of American Indian Status For those born outside of the U.S.: Form 1-94 with a notation of “S1-3” Permanent Resident Card stamped “S1-3” Temporary stamp coded “S1-3” in a Canadian passport Tribal record or document certifying at least 50% American Indian blood, and satisfactory evidence of birth in Canada (cont’d)

51 Prepared by Families USA for use in the District of Columbia Review: Question #1 Travis and Maggie have one daughter, Lindsay, who is three. They say their income is $20,000 (102% of poverty for family of three). Electronic data sources say their income is $39,000 (200% of poverty for a family of 3). Is this information reasonably compatible?

52 Prepared by Families USA for use in the District of Columbia Answer: Question #1 YES, the information is reasonably compatible. Both sources of information say their income is below the Medicaid eligibility threshold, so their information is reasonably compatible.

53 Prepared by Families USA for use in the District of Columbia Review: Question #2 Tomas gives you an address in SE. DC Health Link finds an address for Tomas in NW. TRUE or FALSE: Tomas must provide documentation to prove his residency.

54 Prepared by Families USA for use in the District of Columbia Answer: Question #2 FALSE Even though the addresses are different, both Tomas and the data sources say he is a DC resident, so he does not need to provide documentation.

55 Prepared by Families USA for use in the District of Columbia Review: Question #3 DC Health Link cannot verify Ivan’s immigration status, but his SSN and all other Medicaid eligibility factors are verified and he is otherwise eligible. TRUE or FALSE: Ivan cannot get covered by Medicaid until his immigration status is verified.

56 Prepared by Families USA for use in the District of Columbia Answer: Question #3 FALSE Ivan has 90 days to provide documentation of immigration status, and he can get Medicaid during this time.

57 Prepared by Families USA for use in the District of Columbia Recap: The Verification Process What you will do: Enter information into the application Help applicant check pre-populated information Explain documentation requirements Verify documentation What DC Health Link will do: Check all electronic data sources automatically Pre-populate application Check for reasonable compatibility Let you know when documentation is needed

58 Prepared by Families USA for use in the District of Columbia Case Processing

59 Prepared by Families USA for use in the District of Columbia The “Happy Path” Eligibility determined when: Necessary eligibility factors are verified electronically Information is reasonably compatible with what the applicant says on the application

60 Prepared by Families USA for use in the District of Columbia Dealing with Inconsistencies Before asking for documentation: Check for typographical or clerical errors Contact the applicant about possible application mistakes

61 Prepared by Families USA for use in the District of Columbia Reasonable Opportunity Periods: Medicaid If verification needed for something other than citizenship/immigration status: 45 days to provide verification Applicant does not get Medicaid during this time If verification needed for citizenship/immigration status: 90 days to provide verification Applicant gets Medicaid during this time

62 Prepared by Families USA for use in the District of Columbia Reasonable Opportunity Periods: DC Health Link If documentation is needed: Applicant has 90 days to: Provide documentation that resolves the inconsistency with the data source 90-day period can be extended by 30 days if applicant makes a good faith effort to get documentation Documentation requirement can be waived in special circumstances (except for SSN and citizenship/immigration status)

63 Prepared by Families USA for use in the District of Columbia Coverage while Dealing with Inconsistencies If otherwise eligible, applicant can receive premium tax credits during reasonable opportunity period Must pay back tax credits if found ineligible If otherwise eligible, applicant can receive Medicaid if citizenship/immigration status is the only inconsistency

64 Prepared by Families USA for use in the District of Columbia MAGI-Eligible Applying for Non-MAGI Medicaid Can receive premium tax credits or Medicaid based on income while waiting for a determination – this helps someone waiting for Medicaid based on disability. Will not have to pay back premium tax credits taken while waiting

65 Prepared by Families USA for use in the District of Columbia Retroactive Medicaid Eligibility Just like now, Medicaid starts three months prior to the date of application if the person was eligible during that time Ask the person to submit any back bills for payment

66 Prepared by Families USA for use in the District of Columbia Reporting Changes

67 Prepared by Families USA for use in the District of Columbia The Importance of Reporting Changes Enrollees must tell DC Health Link when information provided on their application changes Even a small change can affect eligibility If changes are not reported, enrollees may: Not be getting as much help as they could Have to pay back money at the end of the year Be incorrectly receiving Medicaid benefits

68 Prepared by Families USA for use in the District of Columbia Example: Alejandro Alejandro is single and has no dependents. When he applied, his income was at 265% of poverty. A few months later, his hours are cut at his job, and his income goes down. Why is it important for Alejandro to tell DC Health Link about this change?

69 Prepared by Families USA for use in the District of Columbia Why Alejandro Should Report the Change Alejandro should report the drop in his income because: He could now be eligible for Medicaid and would not need to pay monthly premiums, OR He could be eligible for a bigger premium tax credit and cost-sharing reductions

70 Prepared by Families USA for use in the District of Columbia When to Report a Change Enrollees must update DC Health Link if they experience changes in: Income Household size Address or state of residence Employer coverage Eligibility for other coverage Student status Incarceration status Immigration status How they expect to file taxes

71 Prepared by Families USA for use in the District of Columbia Income Thresholds for Reporting Changes Medicaid enrollees: Must report any change (no threshold) DC Health Link plans with premium tax credits: Only required to report changes in income of more than $150 per month ($1,800 annually) Should report smaller changes too because any income change can affect premium tax credit amount

72 Prepared by Families USA for use in the District of Columbia Example: Teresa Teresa is enrolled in a DC Health Link plan and receives premium tax credits. Every year, Teresa’s boss gives her a bonus. The exact amount varies from year to year, but it is usually around $1,000. Teresa asks if she needs to report the bonus when she finds out the amount. How would you respond?

73 Prepared by Families USA for use in the District of Columbia Should Teresa report the change? Teresa has a DC Health Link plan with premium tax credits, so she must report changes of more than $1,800 per year Her bonus will be below this threshold, so she is not required to report change It is a good idea to report anyway so she does not end up owing back any of her premium tax credit

74 Prepared by Families USA for use in the District of Columbia Review: Question #1 TRUE or FALSE: Consumers may not end up getting the full amount of assistance they are eligible for if they do not report changes in income.

75 Prepared by Families USA for use in the District of Columbia Answer: Question #1 TRUE For example, someone may be paying premiums for a DC Health Link plan but be eligible for Medicaid.

76 Prepared by Families USA for use in the District of Columbia Review: Question #2 TRUE or FALSE: Because people with DC Health Link plans and premium tax credits are not required to report changes of less than $150 per month, a change of $100 that was not reported would not affect the value of the premium tax credit a person could get.

77 Prepared by Families USA for use in the District of Columbia Answer: Question #2 FALSE Premium tax credit amounts are based on annual income. Any change in income can change the amount of the premium tax credit a person gets, even if the change is below $150 per month.

78 Prepared by Families USA for use in the District of Columbia How DC Health Link Handles Changes 1.When an enrollee reports a change to DC Health Link 2.When DC Health Link gets information about a change from electronic data sources There are two ways DC Health Link finds out about a change: Prepared by Families USA for use in the District of Columbia

79 How to Report a Change Enrollees can report changes by: Using “My Account” online Calling the customer service call center Getting help from ESA, either in person or over the phone Mailing information to ESA

80 Prepared by Families USA for use in the District of Columbia The Process for Reporting Changes 1.Enrollee reports the change within 30 days 2.DC Health Link sends a notice to the enrollee: Confirming that the change report was received Requesting documentation, if needed Explaining how the change affects eligibility 3.If a change affects eligibility, DC Health Link will ask the consumer to enroll in new coverage or explain how the amount of their premium credit is changing

81 Prepared by Families USA for use in the District of Columbia When DC Health Link Finds a Change DC Health Link will check electronic data sources to find changes For example, DC records will show if a household member who was eligible for premium tax credits has enrolled in Medicaid If DC Health Link finds a change the enrollee has not reported, a notice will be sent to the enrollee to get confirmation

82 Prepared by Families USA for use in the District of Columbia Change Reporting Timeline: Medicaid Enrollee has 15 days to respond to a notice with documentation if the change is incorrect If enrollee does not respond, eligibility is re-determined

83 Prepared by Families USA for use in the District of Columbia Change Reporting Timeline: DC Health Link Enrollees have 30 days to confirm or disagree with change If enrollee disagrees, given 90 days to provide documentation and coverage continues If enrollee does not respond, eligibility re- determined only if change is not related to: Household size Income

84 Prepared by Families USA for use in the District of Columbia When Changes to Tax Credits Will Go into Effect Changes to premium tax credits and cost-sharing reductions will be made: At the end of the month, if redetermined by the 15 th of the month At the end of the next month, if redetermined after the 15 th of the month

85 Prepared by Families USA for use in the District of Columbia When Coverage Will End: Medicaid If a Medicaid enrollee is no longer eligible, coverage will end: At the end of the month, if 15 or more days left in the month from the date of re- determined At the end of the next month, if less than 15 or more days left in the month from the date of re-determined

86 Prepared by Families USA for use in the District of Columbia When Coverage Will End: DC Health Link If a DC Health Link enrollee is no longer eligible or cancels their coverage, it will end: At the end of the month after the month in which eligibility is re-determined When the enrollee requests coverage to end, if the request is submitted at least 14 days in adv ance

87 Prepared by Families USA for use in the District of Columbia Example 1: Pia Pia is currently getting premium tax credits. Pia loses her job and gets a notice from DC Health Link telling her that data sources say that she is receiving a certain amount in unemployment. The amount Pia is receiving in unemployment is actually higher. What should Pia do?

88 Prepared by Families USA for use in the District of Columbia Example 1: What should Pia do? Let DC Health Link know that the information from the electronic data sources is wrong within 30 days to make sure the amount she is receiving in premium tax credits is correct.

89 Prepared by Families USA for use in the District of Columbia Example 2: Santiago Santiago has Medicaid and gets a notice from DC Health Link saying that data shows his income has increased. TRUE or FALSE: If Santiago does not respond to the notice, his eligibility for Medicaid will not be re- determined.

90 Prepared by Families USA for use in the District of Columbia Example 2: Answer FALSE Since Santiago has Medicaid, DC Health Link will re-determine his eligibility even if he does not respond to the notice.

91 Prepared by Families USA for use in the District of Columbia Things to Remember When consumers apply for coverage, tell them they must inform DC Health Link of any changes within 30 days Tell consumers they may receive notices about changes that DC Health Link identifies through data sources and must respond within 30 days DC Health Link will determine if a change affects eligibility and tell the consumer what to do ESA is one of the ways consumers can get help reporting changes


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