Nebraska Medicaid and the Impact of the Affordable Care Act on Eligibility

1. Nebraska Medicaid and the Impact of the Affordable Care Act on Eligibility Nebraska Association of Health Underwriters February 18, 2014

2. Introduction and Agenda • Ruth Vineyard, Deputy Director • Nebraska Department of Health and Human Services, • Division of Medicaid and Long Term Care (MLTC) • Our focus today will be on Medicaid Eligibility and the impact of the Affordable Care Act

3. Introduction and Agenda • Agenda Overview • Medicaid Program • Medicaid Eligibility Overview • ACA Impact on Medicaid Eligibility • Current Status of Medicaid and the Marketplace • Questions

4. Division of Medicaid and Long-Term Care • Medicaid and CHIP (Children’s Health Insurance Program) • Home and Community Based Services • State Unit on Aging

5. Medicaid Program • Administered by the Department of Health and Human Services • Provides health care services to eligible elderly and disabled individuals and eligible low-income pregnant women, children and parents • Pays for covered services for those persons who cannot afford to pay for medically necessary services and who meet certain eligibility requirements

6. Medicaid Program • Jointly funded with Federal Government and State dollars • Federal Government sets rules in statute and regulations that give states some flexibility to administer the program • Federal Government has oversight responsibilities to ensure federal dollars are spent consistent with federal regulations • State Medicaid programs are responsible for administration/operations of Medicaid • Medicaid is always the payer of last resort • No open enrollment period

7. Medicaid Eligibility Overview • Medicaid is a means tested program however, individuals must first qualify for a category of eligibility. • People Served and Eligibility Groups Pre-ACA • Aged and disabled • Low-income pregnant women • Children • Parents Individuals who meet a category of eligibility must meet income and for some populations, resource tests.

8. Medicaid Eligibility Overview

9. Medicaid Eligibility Overview

10. Pre-ACA Eligibility Process Enroll in Medicaid Yes Consumer fills out NE application, submits to NE Medicaid Screen application for eligibility criteria such as income or disability Contact applicant for documents to support eligibility criteria Does documentation support eligibility criteria? Transfer Deny Medicaid eligibility No

11. ACA Impact -Medicaid Eligibility • Insurance Marketplace for Each State • Single Streamlined Application • “No Wrong Door” • New Standard Method of Calculating Income • Modified Adjusted Gross Income (MAGI) • No Resource Tests • Real-Time Eligibility Determination • Medicaid Eligible People not Eligible for APTC/CSR with Exchange Plans • Interaction with Insurance Marketplace • Consumer Support • What About the ABD Population?

12. ACA Impact -Medicaid EligibilityMandatory Insurance Marketplace • All states must implement an insurance Marketplace and offer Qualified Health Plans (QHPs) as defined in the ACA • State option for Marketplace model • State Based Exchange (SBE) • Federal Partnership Marketplace • Federally Facilitated Marketplace (FFM) • Nebraska chose an FFM • Significant interaction/coordination required between Nebraska’s Medicaid program and the Federally Facilitated Marketplace

13. ACA Impact-Medicaid EligibilitySingle Streamlined Application • Medicaid and the Marketplace will use the same application • Single Application, created and approved by the Secretary of DHHS • Applications may be completed on-line, on paper, in person or over the phone

14. ACA Impact -Medicaid Eligibility“No Wrong Door” • Individuals can apply at the Marketplace or Medicaid and be routed to the most appropriate coverage for their circumstance • Significant coordination between the Marketplace and Medicaid are required to support eligibility determination, appeals and to answer consumer questions • “Better Door” approach by the Center for Medicare and Medicaid Services (CMS)

15. ACA Impact -Medicaid EligibilityModified Adjusted Gross Income (MAGI) • MAGI is a federally defined, mandated way to calculate income for eligibility determinations • All states and the FFM must calculate income using MAGI • Although minor, there are some differences in the way the FFM and Medicaid programs must calculate income • No resource test required for eligibility. Only current income counts. • Switch to MAGI necessitated significant changes to computer systems and eligibility determination business processes • MAGI only applies to certain eligibility groups (Children, Parent Caretakers, Pregnant Women)

16. ACA Impact -Medicaid EligibilityEligibility Groups • ACA as written by congress mandated Medicaid coverage for all adults 0 – 133% FPL • Supreme Court ruling made this coverage optional, at State discretion (Funding could not be withheld) • Nebraska has opted to not cover this population • The ACA added Former Foster Children as a mandatory eligibility group

17. ACA Impact -Medicaid EligibilityReal-Time Eligibility Determination • ACA requires, where possible, real-time eligibility determination • Key pieces of information, such as income, is electronically verified against a federal data hub to increase speed of eligibility determination. • Previously, paper documentation was used to verify application information • This shift to real-time determination causes a significant impact to Medicaid systems and workflow

18. ACA Impact -Medicaid EligibilityAPTC/CSR • ACA provides Advance Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR) to help individuals with income at or below 400% FPL pay for health costs • If an individual is eligible for Medicaid, (s)he cannot be eligible for APTC/CSR. • This requires all individuals applying for a Marketplace plan, that requests APTC/CSR to undergo a Medicaid eligibility assessment or determination • Significant coordination required between Marketplace and Medicaid

19. “No Wrong Door” – Simple Case Notify consumer and enroll in QHP on Marketplace. Consumer covered by Marketplace No Consumer fills out application, submits to Marketplace Assess for Medicaid: Potentially eligible? Notify consumer, transfer application to Medicaid Transfer Yes Transfer Federal Marketplace OR Transfer State Medicaid Notify consumer, transfer application to marketplace No Consumer fills out application, submits to Medicaid Medicaid determination : Medicaid eligible? Consumer covered by Medicaid Notify consumer and enroll in Medicaid. Yes

20. “No Wrong Door” – Complex Case Notify family, enroll non-Medicaid members in QHP. Some members covered by Marketplace No Family fills out one application, submits to Marketplace Assess each member: Potentially Medicaid eligible? Notify family, transfer only potential Medicaid members Transfer Yes Transfer Federal Marketplace OR Transfer State Medicaid Notify family, transfer only non-Medicaid eligible members to marketplace No Family fills out one application, submits to Medicaid Medicaid determination, each member: Medicaid eligible? Some members covered by Medicaid Notify family, enroll only Medicaid eligible members. Yes

21. ACA Impact -Medicaid EligibilityConsumer Support • No wrong door allows consumers to contact Marketplace or state Medicaid agency to obtain information about eligibility • Necessitates cross-training on Marketplace eligibility and Medicaid eligibility • Requires coordinated tracking of issues to ensure consumers are not bounced between Marketplace help desk and Medicaid help desk

22. ACA Impact -Medicaid EligibilityAid to the Aged, Blind and Disabled (AABD)Population • Eligibility rules unchanged under ACA • AABD population are MAGI exempt • Still requires a qualifying medical condition for eligibility • However, due to ACA mandated single streamline application, AABD applicants must fill out a different form than other Medicaid applicants

23. ACA Impact -Nebraska • New application • New eligibility rules • Changes to business processes • Changes to systems • Training for staff • Significant interaction with Marketplace

24. ACA Timeline -Nebraska Mar 2010 Nov 2012 Oct 2013 Jan 2016 April 2010 Nov 2012 – Oct 2013 Oct 2013

25. ACA Impact -Nebraska • Issues to Watch Moving Forward • FFM Not Ready for Account Transfers • Causing significant additional work for Medicaid eligibility workers • Causing consumer confusion • Causing delays getting people covered • Work-arounds • New “check-box” on application • Medicaid Eligibility Check

26. “Better Door”, Current Status X Notify consumer and enroll in QHP on Marketplace. Consumer covered by Marketplace No Consumer fills out application, submits to Marketplace Assess for Medicaid: Potentially eligible? Notify consumer, transfer application to Medicaid Transfer Yes Transfer Federal Marketplace OR Transfer State Medicaid Notify consumer, transfer application to marketplace No Consumer fills out application, submits to Medicaid Medicaid determination : Medicaid eligible? Consumer covered by Medicaid Notify consumer and enroll in Medicaid. Yes

27. Questions?