THE AFFORDABLE CARE ACT September 17 th, 2013 Heather Howard Director, State Health Reform Assistance Network Lucinda Jesson Commissioner, Minnesota Department of Human Services

Overview Setting the stage The Affordable Care Act State of implementation SCOTUS decision Optional Medicaid expansion Exchange development Eligibility Appeals

Affordable Care Act (ACA) Mandate + Subsidies + Medicaid expansion + Insurance reform + System Reforms (prevention and payment)+ Taxes = Health Reform

Affordable Care Act (ACA) Health Insurance Exchanges will offer a marketplace for individuals and small businesses to compare policies and premiums Medicaid eligibility expanded to include all individuals and families with incomes up to 133% of Federal poverty level (FPL) Requirement to purchase insurance, coupled with insurance reforms and subsidies for families with incomes up to 400% FPL Simplified Eligibility & Enrollment – No Wrong Door

Medicaid Has Many Vital Roles In Our Health Care System Health Insurance Coverage 31 million children & 16 million adults in low-income families; 16 million elderly and persons with disabilities State Capacity for Health Coverage Federal share can range from %; For FFY 2012, ranges from % MEDICAID Support for Health Care System and Safety-net 16% of national health spending; 40% of long-term care services Assistance to Medicare Beneficiaries 9.4 million aged and disabled 20% of Medicare beneficiaries Long-Term Care Assistance 1.6 million institutional residents; 2.8 million community-based residents

Changes in Uninsured Rate for Nonelderly Adults and Children, Changes in uninsured rate for both nonelderly adults and children are statistically significant (p<0.05). SOURCE: KCMU/Urban Institute analysis of the ASEC Supplement to the CPS, % 22.0% 10.9% 10.0%

400% FPL and Above Characteristics of the Nonelderly Uninsured, 2010 The federal poverty level was $22,050 for a family of four in Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS. Total = 49.1 million uninsured 1 or More Full-Time Workers No Workers Part-Time Workers % FPL <100% FPL % FPL Children Parents Adults without Dependent Children Family Status Family IncomeFamily Work Status

Uninsured Rates Among Nonelderly by State,

Exchange Decisions Map Source: kff.org/statedata

State Implementation Activity Exchange Activity 16 states and D.C. have declared State-based Exchange and have been conditionally approved by HHS 7 states planning for Partnership Exchange and have been conditionally approved by HHS 27 will default to the Federal Exchange Grants 48 states and D.C. have received Exchange planning grants 36 states and D.C. have received Exchange Establishment grants Total of $3,836,179,544 awarded Source: kff.org/statedata

Federal Appeals Regulations Overview Proposed rules require states to coordinate MAGI Medicaid/CHIP and Qualified Health Plans and Advance Premium Tax Credits/Cost Sharing Reductions for Appeals State option to delegate State Medicaid Agency Appeals Authority to the Exchange Establish Exchange appeals process including HHS appeals

Steps in the Appeals Process NOTICE OF APPEAL RIGHTS 1 4 DESIGNATION OF AUTHORIZED REPRESENTATIVE HEARING SCHEDULING/ NOTICE OF HEARING 79 APPEALS HEARING MODALITY & ADJUDICATORS 10 EXPEDITED APPEALS HEARING 11 HEARING DECISION REQUEST FOR APPEAL 2 NOTICE OF RECEIPT OF APPEAL REQUEST 36 INFORMAL RESOLUTION Step-by-Step Appeals Process EVIDENCE PACKET 812 POST- HEARING 5 DISMISSALS/ WITHDRAWALS

Delegation Authority: State Options EntityDelegation Option State Medicaid Agency may delegate Medicaid appeals authority to… State-Based Exchange (if a government agency or public authority which maintains personnel standards on a merit basis) HHS Appeals Entity (FFE Determination Model) 3 rd Party State Agency State-Based Exchange may delegate APTC/CSR appeals authority to… HHS Appeals Entity State Medicaid Agency * 3 rd Party State Agency * * Not specifically discussed in proposed regulations, but not prohibited.

Medicaid, CHIP, and Exchange Appeals: Legal Authority Medicaid: Social Security Act §1902(a); 42 C.F.R.§ et seq. (NPRM and Existing Regulations); Goldberg v. Kelly CHIP: Federal Law 42 C.F.R.§ – (NPRM and Existing Regulations) Exchange: ACA§1411(f)(1) – Federal Appeal Exchange: 45 CFR§ et seq.

Approach for State Appeal Process Design Identify delegation approach and appeals process features. Assess federal requirements for the IAP Appeal Process (final rules forthcoming). Assess appeal process requirements in state statute and regulation, as well as current state process/practice. Identify and resolve open policy, IT infrastructure, and personnel decisions for each appeal process feature. Document operational requirements (e.g., needed legal/regulatory changes, inter-agency agreements, development of internal guidance/policy manuals and personnel training materials, hiring and training of personnel, IT system builds, etc.)

Steps in the Appeals Process: State Tool Example NOTICE OF APPEAL RIGHTS 1 4 DESIGNATION OF AUTHORIZED REPRESENTATIVE HEARING SCHEDULING/ NOTICE OF HEARING 79 APPEALS HEARING MODALITY & ADJUDICATORS 10 EXPEDITED APPEALS HEARING 11 HEARING DECISION REQUEST FOR APPEAL 2 NOTICE OF RECEIPT OF APPEAL REQUEST 36 INFORMAL RESOLUTION EVIDENCE PACKET 812 POST- HEARING 5 DISMISSALS/ WITHDRAWALS Step-by-Step Appeals Process

Informal Resolution: Legal Requirements Required for HHS Appeals Option for State Medicaid Agency and SBE Medicaid agency must establish a secure electronic interface with the Exchange or Exchange appeals entity through which 1) the Exchange can notify the Medicaid agency that an APTC/CSR eligibility appeal has been filed triggering a Medicaid fair hearing request and 2) electronic account, including any information provided by the individual to the Medicaid agency or Exchange, can be transferred between programs. Medicaid agency must ensure that as part of hearing, it does not request information or documentation from the individual already included in her electronic account or provided to the Exchange or Exchange appeals entity. Exchange appeals entity must minimize burden on consumer by not requesting that he or she provide duplicative information or documentation previously provided during the application or IR process.

Many Types of Appeals Individual Eligibility Health Plan Purchase Tax Credits Cost Sharing Help Level of Benefits Tax Credits Cost Sharing Help SHOP Appeals Employer SHOP Appeal Employee SHOP Appeal Individual Mandate Exemption Employer Shared Responsibility

Possible Scenarios

Questions?