1. ACA Expanded Medicaid Armchair Chat
7/19/2018 6:52 PM
ACA Expanded Medicaid Armchair Chat
Patricia A. Nelson-Reade, Esq., R.N.
Nelson-Reade Law Office, P.C.
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

2. ACA’s provisions contain:
7/19/2018 6:52 PM
ACA’s provisions contain:
Consumer protections in health insurance contracts
Access to medical insurance
Expansion of Medicaid for low income individuals
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

3. Consumer protections in health insurance contracts
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Consumer protections in health insurance contracts
Prohibition of lifetime coverage for essential health benefits (2010)
Prohibition of coverage denial for preexisting conditions (2014)
For individuals and small groups, insurers cannot charge higher rates due to gender or health status (2014)
Prohibition of annual $ limit on total amount of coverage for essential health benefits (2014)
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

4. Access to medical insurance
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Access to medical insurance
Individual Mandate - without exemption, individuals must pay a penalty for failure to purchase insurance (new line 62 on draft)
Exchanges for ACA coverage – bronze (60%) - platinum (90%) based on cost sharing %
Tax credit for persons with MAGI between 100% to 400% FPL – sliding scale
Additional cost sharing reduction for MAGI <250% FPL (silver plans only)
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

5. Employer Mandate - (2015) (phase 1)
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Employer Mandate - (2015) (phase 1)
Businesses with 100 or > FTE employees subject to “shared responsibility payment”
Businesses with FTE employees delayed to 2016
Offer affordable health insurance or pay a penalty
60% or > of covered health expenses
Employees should not pay >9.5% of household income for employee coverage
Penalty for failing to offer insur.-$2,000 FTE employees – 30
$3,000 penalty for employees having to pay >9,5% of household income who purchase insurance on Exchange with tax credit
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

6. U.S. Supreme Ct. - expanded Medicaid optional for States
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Expanded Medicaid
U.S. Supreme Ct. - expanded Medicaid optional for States
– Feds pay 100% then gradually decreases to 90% in 2020
Expands Medicaid coverage to low income individuals age 19-64
Income limit 133% with 5% disregard so 138%
No asset test
28 States have implemented Medicaid expansion
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

7. Can differ from traditional Medicaid
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States have flexibility to determine what benefits to offer newly eligible MAGI population
Alternative Benefit Plan (ABP) –Section 1937 of Social Security Act (DRA of 2005)
Can differ from traditional Medicaid
Can differ for groups of newly eligible individuals to meet needs
States look at population demographics and costs to determine benefits
Can revisit ABP and change benefits
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

8. 7/19/2018 6:52 PM
Section 1937, enacted in 2005 for traditional Medicaid, gives State options to offer “benchmark” or “benchmark-equivalent” coverage
Standard Blue Cross/Blue Shield PPO offered through Federal Employees Health Plan
State employee coverage available to state employees
Commercial HMO with largest insured commercial, non-Medicaid enrollment in state
Secretary-approved coverage, such as Medicaid State plan
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

9. 7/19/2018 6:52 PM
Section 1937 benchmark options = minimum standards, states can add benefits
Must also cover 10 EHBs –ambulatory patient services; emergency services; hospitalization; maternity and newborn; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision.
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

10. 7/19/2018 6:52 PM
Mental Health Parity and Addition Act of 2008 applies to ABP – requires co-pays, deductibles and treatment limitations applicable to mental health or substance use disorder to be no more restrictive than other medical/surgical benefits
For children < 21, must include Early and Periodic Screening, Diagnostic and Treatment services
MAGI plan may offer > behavioral/preventative services, habilitation services
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

11. Medically frail or with special medical needs (438.50(d)(3))
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Certain populations exempt from mandatory enrollment in an ABP – 40 CFR
Examples:
Blind or disabled
Medicare recipients
Pregnant women
Individual in hospital, nursing facility, ICF for individuals with intellectual disabilities or other medical institution which has cost of care
Medically frail or with special medical needs (438.50(d)(3))
States with different ABP must offer voluntary choice to enroll and disenroll in ABP
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

12. CMS Letter to State Medicaid Directors 2/21/14
7/19/2018 6:52 PM
CMS Letter to State Medicaid Directors 2/21/14
Some states include long-term services and supports (LTSS) in their ABPs
CMS concerned that estate recovery rules may discourage enrollment
Guidance on application of transfer penalty/lien/estate recovery/other LTSS rules of Section 1917 to MAGI new eligibility group
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

13. CMS Letter to State Medicaid Directors 2/21/14
7/19/2018 6:52 PM
CMS Letter to State Medicaid Directors 2/21/14
Post-eligibility treatment of income rules (42 CFR et. seq.) apply to discrete categories of individuals – institutionalized individuals and individuals receiving home and community based services under a waiver – for categorically needy and medically needy individuals
MAGI individuals not described, therefore MAGI individuals receiving LTSS may not have liens on their property
Scope of post-eligibility income calculation rules does not include MAGI individuals eligible for LTSS CMS considering rulemaking to expand application
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

14. CMS Letter to State Medicaid Directors 2/21/14
7/19/2018 6:52 PM
CMS Letter to State Medicaid Directors 2/21/14
Section 1917(b)(1)(B) - estate recovery for persons receiving services at 55 or older is not limited in application to individuals subject to post-elig. income rules or to LTSS, therefore MAGI individuals receiving services at 55 or older are not exempt from estate recovery
CMS “intends to thoroughly explore options” and “use available authorities” to eliminate estate recovery for all benefits other than long term care and related services for MAGI individuals
In meantime, States have some existing authority to limits scope of recovery – ex. limit to LTSS
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

15. CMS Letter to State Medicaid Directors 2/21/14
7/19/2018 6:52 PM
CMS Letter to State Medicaid Directors 2/21/14
Transfer penalties apply to MAGI individuals
Under ACA, MAGI individuals cannot have an asset test for purposes of eligibility
Transfer penalties for traditional Medicaid recipients apply to MAGI individuals for LTSS- although assets disregarded for eligibility, transfer penalties apply to coverage for certain services
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

16. CMS Letter to State Medicaid Directors 2/21/14
7/19/2018 6:52 PM
CMS Letter to State Medicaid Directors 2/21/14
Following rules not limited to eligibility categories or which method is used to determine eligibility and therefore traditional Medicaid rules apply to MAGI
Annuities, promissory notes and life estates
Trust rules – apply traditional Medicaid rules for MAGI individuals seeking LTSS
Home equity limitation - States must deny LTSS coverage to MAGI individuals whose home equity exceeds the limits consistent with traditional Medicaid
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

17. Cost of care post eligibility
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MAGI
Lump sum income
Cost of care post eligibility
Increasing income to maintain MAGI eligibility
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

18. MAINE – NO EXPANSION AND ACTUAL REDUCTIONS
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MAINE – NO EXPANSION AND ACTUAL REDUCTIONS
MAGI – new income and asset rules for pregnant women, children, parents/ guardians of children
Traditional Medicaid rules for disability and elderly groups
No ACA tax subsidy for adults with <100% FPL
Mayhew v. Burwell, U.S 1st Cir. Court of Appeals, No (11/17/14) – Maine made a number of cuts to its Medicaid program. CMS disapproved the elimination of year old “children” because it violated ACA’s maintenance of effort provision for children. “Maine” argued that the MOE provision violated the Spending Clause and Maine’s right to equal sovereignty under the Constitution. Maine lost and is considering an appeal
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.