1. Medicaid Changes in Maryland under the Affordable Care Act
Lorie Mayorga
Deputy Director, Eligibility Policy
Department of Health and Mental Hygiene

2. Changes to Medicaid
Medicaid expansion: new eligibility for non-disabled, non-elderly, childless adults up to 138% of the Federal Poverty Level
Certain populations transition to simplified eligibility rules based on income only
Primary Adult Care population automatically transitioning to full Medicaid effective January 1st
Former foster youth eligible for Medical Assistance up to age 26, regardless of income effective January 1st

3. Medicaid Regulations
Medical Assistance Fair Hearing Appeals, COMAR
Approved effective October 1, 2013 by the Joint Committee on Administrative, Executive & Legislative Review Committee (AELR)
Emergency Regulations same as proposed
Proposed regulations published October 18, 2013
Medical Assistance Eligibility, COMAR
MCHP, COMAR
MCHP Premium, COMAR

4. Medicaid/MCHP Premium Eligibility
Individuals must still meet Medicaid/MCHP Premium’s non-financial eligibility criteria
Citizenship/immigration status
Residency
MHBE will make determinations on income-based Medicaid only for the following groups:
children
pregnant women
parents and caretaker relatives of dependent children
non-elderly, non-disabled childless adults
Generally, the tax definitions of household size and MAGI-based income apply

5. Medicaid: Household Size, COMAR 10.09.24.06-1B
Household size must be calculated for each household member, as it can vary even within the household
Example:
Lee and Amanda are married. Amanda is pregnant with twins.
Amanda’s household size: 4 (Amanda + the twins + Lee)
Lee’s household size: 2 (Lee and Amanda; the twins are not included in Lee’s household)

6. Household Size: Medicaid Exceptions
The tax rules for household size do not apply for Medicaid/MCHP Premium when:
the applicant is not planning to file taxes (i.e., income below filing threshold)
the individual (child or adult) lives with a grandparent or other caretaker relative, regardless of who claims the individual as a tax dependent
a child under age 21 lives with both parents, but only one parent will claim the child as a tax dependent
a child, under age 21, lives with a custodial parent but will be claimed as a tax dependent by the non-custodial parent

7. Household Size—Exceptions cont’d
In those situations, the (traditional) relationship-based household rules apply:
For adults, a household consists of:
adult applying for coverage
applicant’s spouse, if living with the applicant
applicant’s natural, adopted, and stepchildren under age 21, if living with the applicant
For children under age 21, a household consists of:
the child applying for coverage
any of the child’s parents, stepparents, or adoptive parents living with the child
for households headed by a non-parent caretaker adult, the caretaker adult
any of the child’s siblings, step-siblings, or adoptive siblings under age 21 living with the child

8. MAGI-Based Income for Medicaid/MCHP
Medicaid looks at monthly income
A pro-rated portion of reasonably predictable changes in income may be considered if there is a basis for anticipating the changes
e.g., such as a signed contract for employment, a clear history of predictable fluctuations in income, or other indications of future changes in income
For Medicaid eligibility, MHBE uses the most recently published FPL level in effect for the month when an applicant applies

9. 2013 Monthly Federal Poverty Level Guidelines (DC + all states except for Alaska and Hawaii)

10. MAGI-Based Income Limits for Medicaid and MCHP Premium
Household Income
To be eligible for MAGI Medicaid, applicant’s current monthly household income must meet specified standards
Coverage Groups
FPL
Adults
138%
Medicaid for children under age 1
199%
Medicaid for children ages 1-21
MCHP
211%
MCHP Premium
322%
Parents and Caretaker Relatives
Pregnant Women
264%

11. MAGI Income Rules Whose income is counted?
In general, MAGI income of all individuals in an applicant’s household is counted toward household income, with two exceptions:
Income of children (even over age 21) in household with parent if they are dependents and not expected to be required to file a tax return
Income of most other dependents (not children or spouses) if not expected to be required to file a tax return
A spouse’s MAGI income is always counted even if claimed as a tax dependent

12. Medicaid/MCHP Premium MAGI Income
Special rules for Medicaid/MCHP Premium MAGI
Lump sum payments are counted only in month received
Taxable educational scholarships, awards—continue to be excluded from Medicaid income
Certain types of income for American Indian/Alaska Natives are excluded

13. Changes to MCHP Premium
No exclusionary period for voluntarily dropping employment-based health coverage
Maximum 90 day “lockout” for nonpayment of premium
Enrollment still requires payment of first month’s premium, but now children will receive a period of fee-for-service coverage during the MCO processing period

14. Medicaid/MCHP Premium Eligibility Determinations
Maryland Health Connection determines eligibility only on the basis of MAGI income
If application shows that applicant may be eligible for Medicaid on a different basis, or if the applicant requests a determination for non- MAGI groups, application will be referred to DHMH
Some individuals who would otherwise have required a disability evaluation may now qualify for Medicaid in the adult expansion group

15. Retroactive Coverage
Retroactive coverage rules remain the same: Medicaid will pay providers for services during any of the 3 months before application for individuals who are found eligible for such months
Maryland Health Connection cannot determine eligibility for services furnished before 1/1/14
The single streamlined application allows Medicaid-eligible individuals to indicate that they have bills from the last 3 months
Current eligibility is determined first—no application will be referred for “retro” processing unless applicant is eligible in application month

16. Former Foster Care Individuals: Proposed COMAR 10.09.24.03
Former foster care individuals may be determined eligible under MAGI coverage rules if they are:
(a) Are younger than 26 years old;
(b) Are not eligible and enrolled for coverage under a mandatory Medicaid group other than childless adult; and
(c) Were in a Maryland out-of-home placement, including categorical Medicaid:
(i) On attaining age 18 and leaving out-of-home placement, or
(ii) On attaining age during extended out-of-home placement under COMAR B.

17. Advance Premium Tax Credit vs. Medicaid
APTC/Cost Sharing Reduction
Medicaid/MCHP Premium
Definition of MAGI-based income
IRS definition
IRS definition, except that the following is excluded: income of dependents as long as they are not expected to be required to file a tax return; certain American Indian/Alaska Native income; and educational scholarships and grants. Also, lump sum payments are counted only in the month received.
Data sources used
FTI is checked first; if the FTI is not reasonably compatible, then State data sources are checked automatically
State data sources

18. APTC/CSR vs. Medicaid/MCHP Premium
Applicable FPL
FPL in effect as of the first day of Open Enrollment (always in October)
FPL in effect for the month that coverage is sought
Percentage of FPL
Determined using annual income
Determined using monthly income
Definition of household
IRS definition
IRS definition except when: an applicant does not plan to file taxes; an individual lives with a grandparent or other caretaker relative; a child who lives with both parents is claimed by only one parent; or a child is claimed by non-custodial parent

19. Eligibility Scenarios

20. Scenario One
Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren makes $38,000 per year.
What coverage is each member of the household eligible for?

21. STEP 1: Determine Medicaid/MCHP Premium eligibility
Scenario One
Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren is a salaried employee making $38,000 per year.
STEP 1: Determine Medicaid/MCHP Premium eligibility
There are 3 people in the household; the fact that Lauren does not claim Mitchell as a dependent does not affect the Medicaid household size. The applicable monthly FPL is $1,627.50, so the monthly household income of $3, is at 195% of the poverty line, making both Mitchell and Patrick eligible for MCHP. Lauren, is not eligible for Medicaid because the income is higher than 138%

22. Scenario Two
Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. Before that he was unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters. HIX calculates that Kurt’s annual income is $28,000 per year. Given that the difference between Kurt’s attested income and the annualized income from MABS is greater than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee.
What coverage is Kurt eligible for?

23. Scenario Two STEP 1: Determine Medicaid eligibility
Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. Before that he was unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters. HIX calculates that Kurt’s annual income is $28,000 per year. Given that the difference between Kurt’s attested income and the annualized income from MABS is greater than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee.
STEP 1: Determine Medicaid eligibility
Because Kurt’s employment is seasonal, HIX’s calculations were not correct. The income is corrected during the Inconsistency Period and Kurt is determined eligible for Medicaid.

24. Contact Information
Lorie Mayorga Maryland Health Connection: marylandhealthconnection.gov Customer Service Center: