PEAL Center PRESENTER ANN BACHARACH PA HEALTH LAW PROJECT FEBRUARY 9, 2015 "Children’s Health Coverage through Medicaid, CHIP and the Marketplace" Webinar will begin at NOON If you have not received an with the PowerPoint download a copy at: 1

PEAL Center PRESENTER ANN BACHARACH PA HEALTH LAW PROJECT FEBRUARY 9, 2015 Children’s Health Insurance in the Brave, New World of the Affordable Care Act 2

Good News!!! Children in Pennsylvania have access to health insurance  It may be free – Medical Assistance and CHIP  It may be low-cost – CHIP and Marketplace  It may be at-cost - Marketplace 3

Overview Coverage  Medical Assistance, CHIP and Marketplace Special Situations New rules for eligibility Child to Young Adult How to Apply Where to go for help 4

Coverage – Medical Assistance Free for children  No premiums, no co-payments Staircase of eligibility  Babies up to 1 st birthday – 220%  Children age 1 to 6 th birthday – 162%  Children age 6 to 19 th birthday – 138% Administered by Department of Human Services (formerly Department of Public Welfare) Delivered through managed care plans – HealthChoices Can have other private insurance – MA as secondary coverage 5

Coverage – Medical Assistance Benefits – children under 21 are entitled to all medically necessary services  Physical health care services  Well and sick visits, hospital and ER care, prescription drugs, lab tests and radiology  Durable medical equipment, home health care, shift nursing, OT, PT and Speech, assistive devices  Behavioral health care services  In patient, partial hospitalization, and outpatient services, family-based mental health services, mobile therapy, prescription drugs 6

Coverage - Medical Assistance Special Situations - CYSCHN Children and Youth with special health care needs  Meet the Supplemental Security Income (SSI) disability criteria for children  Eligibility based only on the child’s income Up to age 18 Sometimes called “family of one”, “children with special health care needs” “PH-95” Disability category – rules remain the same as before expansion of Medicaid 7

Coverage – Medical Assistance Special Situations – Former Foster Youth Special eligibility for foster care youth who have aged out  On January 1, 2014, all youth who turned 18 in foster care between 2007 and 2013 became eligible for Medicaid without counting income.  Youth who were in foster care and enrolled in Medicaid on their 18 th birthday are eligible for Medicaid until age 26  Youth who were in foster care and Medicaid in any state at age 18 or older 8

Coverage - Former Foster Youth Youth are presumptively eligible for this category of Medicaid and should be automatically enrolled as they age out of foster care  Under 21, EPSDT  Over 21, adult benefits Group of youth who have aged out but are still under 26 will have to apply.  Application will ask if in foster care  Online - only if someone is between 18 and 26  On paper for each applicant  Should result in automatic enrollment 9

Coverage – Medicaid Expansion Expands eligibility for non-elderly, non-disabled adults 19 – 64 As many as 600,000 Pennsylvanians Income less than 138% of poverty Healthy PA waiver  Three benefits packages  Healthy, Healthy Plus, Healthy PA Private Coverage Option (PCO)  Likely to be modified by Wolf Administration 10

Coverage – CHIP Eligibility above Medical Assistance levels Free  Income up to 213%  No premiums, no co-payments Low-cost  Income between 213% and 319%  Premiums $51 and $81 per month  Co-payments $5 for PCP, $10 specialist, $6 generic drug, $25 ER visit Full-cost  Income above 319%  Premium $226 per month  Co-payments $15 for PCP, $25 specialists, $10 generic drug, $50 ER visit Administered by Insurance Department Delivered through managed care plans Cannot have other insurance 11

Coverage – CHIP Benefits  Equivalent to very good employer coverage  Benefits include, with some limits:  Primary and specialty care  Hospital and emergency room visits  Lab work and radiology  Prescription drugs, eyeglasses, hearing aids, DME supplies  OT, PT, Speech therapies, Home health care – with limits  Not an entitlement – no requirement to cover all medically necessary services 12

Coverage – Marketplace Plans Eligibility to buy a plan  Reside in Pennsylvania  Be lawfully present  Not be incarcerated Eligibility for Premium Tax Credits  Income between 100% and 400% of poverty*  Additional cost-sharing reductions between 100% and 250%  Not have an offer of employer-based coverage  File income taxes for the year in which the credit is used  Not eligible for Medical Assistance, CHIP or Medicare * Can be below 100% if not eligible for Medical Assistance due to five year immigration requirements 13

Coverage – Marketplace Plans All plans cover Essential Health Benefits 10 areas of coverage:  Outpatient care  Emergency room care  Inpatient care  Prenatal and postpartum care  Mental health and substance use disorder services  Prescription drugs  Services and devices to help you recover if you are injured, or have a disability or chronic condition. (PT, OT, Speech, psychiatric Your lab tests  Preventive services including counseling, screenings and vaccines and care for managing a chronic disease.  Pediatric services: Including dental care and vision care 14

Coverage – Marketplace Plans Highest Premiums & Lowest Cost Sharing* Lowest Premiums & Highest Cost-Sharing 15

NEW RULES FOR ELIGIBILITY MAGI 16

MAGI MAGI stands for Modified Adjusted Gross Income  Adjusted gross income + foreign income + tax-exempt interest + Social Security benefits* New rules for eligibility for Medical Assistance, CHIP and Marketplace Based on IRS tax rules for household and income Not surprisingly – complex Applies to non-disabled, non-elderly households  Does not apply to children with special health care needs Systems for applying will know who to count and how to count * Children’s Social Security benefits most often do not count unless child has earned income above certain thresholds. 17

MAGI What are the differences between old rules and MAGI? Household composition  Household is tax household – tax filer + tax dependents  If not filing taxes – non-filer rules Income  Child support received, veterans’ disability benefits, workers compensation - no longer count as income  Generally, income counts unless it’s tax exempt 18

MAGI Non-filer household rules  For adult – adult + spouse and children living with adult  For children – child + parents and siblings living with child Some special exceptions for children in Medicaid  Children living with both parents who are not married to each other  Children not living with a parent  Children who are living with one parent but claimed by non- custodial parent  Apply non-filer rules 19

How to Apply 20

Applying for Marketplace plans Online: Healthcare.gov By phone: (available 24/7) FFM By mail:Paper application (available through Healthcare.gov) – not recommended In person:Navigators & Certified Application Counselors (“CACs”) When:Special Enrollment Period only (next open 2014: Nov 15, 2014 – Feb. 15, 2015 enrollment) 21

Applying for Medicaid and CHIP COMPASS – Pennsylvania’s online application   COMPASS includes the new rules New paper application – PA 600 HC  t/documents/document/p_ pdf t/documents/document/p_ pdf Over the phone – (business hours) DPW Apply directly to CHIP plans  for plans 22

Where to go for help PA Health Law Project Ann Bacharach – Helpline – For advice on applying, enrolling, renewal, obtaining services For clients who need a lawyer to represent them at hearings and appeals 23