Health Care Reform and Medicaid/NCHC Eligibility WSS Leadership Summit

1. Health Care Reform and Medicaid/NCHC EligibilityWSS Leadership Summit Carolyn McClanahan Chief, Medicaid Eligibility Division of Medical Assistance April 22, 2014

2. Health Care Reform Legislation • Federal • The federal Patient Protection and Affordable Care Act, P.L. 111-148, (ACA) as amended • March 23, 2010 – signed by President Obama

3. Summary Provisions • Expanded coverage optional for states • Implementation of Health Benefit Marketplace for uninsured (formerly called “exchange”) • Medicaid/NCHC Eligibility Changes • Enrollment streamline and simplification

4. Expanded Coverage Optional for States • Original federal legislation required Medicaid expansion to most individuals up to 133% (138%) fpl in new eligibility group • Included childless adults, caretakers above current coverage limit • Did not include age 65+, pregnant women, individuals with Medicare • Supreme Court decision – Congress could not require states to expand – must be optional for states

5. Expanded Coverage Optional for States • NC Session Law 2013-5 • NC will not expand Medicaid as provided in ACA • NC will maintain the current coverage groups

6. Summary Provisions • Expanded coverage optional for states • Implementation of Health Benefit Marketplace for uninsured (formerly called “exchange”) • Medicaid/NCHC Eligibility Changes • Enrollment streamline and simplification

7. Implementation of Health Benefit Marketplace • Federal Health Benefit Marketplace created: • States can build State Marketplace • States can build Partnership with Federally Facilitated Marketplace (FFM) • States can use the FFM • NC Session Law 2013-5 • NC will utilize the Federally Facilitated Marketplace

8. Implementation of Health Benefit Marketplace • Individuals/families can purchase insurance • Income < 400% fpl – may qualify for Advance Payment Tax Credits (APTC)/cost-sharing assistance • Must have income above 100% fpl • Eligibility determination for APTC and cost-sharing similar to Medicaid/NCHC • Household/income based on IRS rules • Income eligibility based on MAGI (Modified Adjusted Gross Income)

9. Summary Provisions • Expanded coverage optional for states • Implementation of Health Care Marketplace for uninsured (formerly called “exchange”) • Medicaid/NCHC Eligibility Changes • Enrollment streamline and simplification

10. Medicaid/NCHC Eligibility Changes • No changes to ABD/MQB eligibility • Excluded from MAGI methodology • All Family & Children’s Medicaid programs affected • Use tax definition of household and income • MAGI income methodology • New coverage group • Former foster care children up to age 26

11. Eligibility Change: IRS – based methodology • MAGI – a methodology for how income is counted and how household composition and family size are determined • Household composition – tax household • includes stepparent, if in tax household • Includes siblings (biological, adopted, step) • Income – based on federal tax rules for determining adjusted gross income (with some modifications) • No asset test or disregards (except 5% disregard across the board)

12. Eligibility Change: New questions To help determine household composition: • Is the individual a tax filer? • Does the individual expect to be claimed as a tax dependent?

13. Eligibility Changes: • If not tax filer or tax dependent, build household similar to tax household • Household - adult: • Individual • Spouse • Natural, adopted or step children • Household – child: • Individual • Natural, adopted, step parent • Natural, adopted, step siblings • Child: individual under age 19 or, at state option, 19 or 20 and a full-time student

14. Eligibility Change: Income • May disregard income of child/tax dependent if do not plan to file taxes • Child support is non-countable income • Social security – countable based on amendment to ACA

15. Eligibility Change: MAGI • Taxable Adjusted Gross Income (AGI) with a few modifications • Disregards/exclusions • States cannot give current disregards • Earned income disregards ($90, 27-1/2 %, child care) • Only disregard is 5% from the MAGI calculation

16. MAGI-Equivalent Income Limits • Income limits adjusted due to difference in deductions • Purpose: to “hold harmless” eligibility standards so, as a group, individuals do not lose eligibility • CMS – contracted with vendor to provide calculations for states • Revised income limits: • Example: current 185% may be converted to 192% (not actual converted amount) • Should receive the converted income limits sometime later this month

17. Summary Provisions • Expanded coverage optional for states • Implementation of Health Care Marketplace for uninsured (formerly called “exchange”) • Medicaid/NCHC Eligibility Changes • Enrollment streamline and simplification

18. Streamline/Simplification • ACA mandates individuals may apply for all insurance affordability programs: • In person • Mail • Electronic • Phone • Insurance affordability programs: • Medicaid • CHIP (NCHC) • APTC (Advance Payment of Tax Credits)/Cost-sharing

19. Streamline/Simplification • States and Marketplace: must have web portal for applications • “No Wrong Door” - Individuals may apply at any agency/site for all insurance affordability programs

20. Streamline/Simplification • One application for all insurance affordability programs • CMS is developing the model paper and on-line application • Individuals who only want medical coverage must have streamlined model application available • States can get alternate application approved – must submit State Plan Amendment (SPA)

21. Streamline/Simplification • Must rely on electronic data for verification • Request info from applicant only if not available electronically or discrepancy • Move to “real-time” eligibility determinations as much as possible • Experience should be as seamless as possible for applicant – no duplicate requests for information • Renew coverage based on information available

22. Final: Time Frames • October 1, 2013 • Open enrollment for insurance affordability programs • Must accept single streamlined applications and apply new rules • Must be able to transmit information to Marketplace • Evaluate under current rules for eligibility prior to 1/1/14 • January 1, 2014 • Coverage under insurance affordability programs can begin