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How the Affordable Care Act Affects Eligibility for Traditional Medicaid Programs Webinar January 9, 2014 PowerPoint Presentation
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How the Affordable Care Act Affects Eligibility for Traditional Medicaid Programs Webinar January 9, 2014

How the Affordable Care Act Affects Eligibility for Traditional Medicaid Programs Webinar January 9, 2014

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How the Affordable Care Act Affects Eligibility for Traditional Medicaid Programs Webinar January 9, 2014

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  1. How the Affordable Care ActAffects Eligibility for Traditional Medicaid ProgramsWebinarJanuary 9, 2014

  2. Today’s Presenters Mary Wood Office of Medicaid and Medicare Eligibility Policy and Outreach, Washington State Health Care Authority Janet Walthew Director, Patient Financial Services & Patient Access Northwest Hospital & Medical Center Barbara Gorham Policy Director, Access Washington State Hospital Association

  3. Today’s Presentation Basic Health Plan Washington State Health Insurance Pool Managed Care Auto-Enrollment Renewals Retroactive Coverage Alien Emergency Medical Medicaid for Aged, Blind, and Disabled Spend-down Coverage Questions

  4. Basic Health Program Basic Health Program (BHP) – ended 12/31/13 • BHP recipients received 4 letters on the conversion process • Recipients had 3 ways to apply • Online at • Paper application • Call HBE Customer Support Center at 1-855-923-4633 • It is not too late…families can still apply after 1/1/14 for coverage

  5. Washington State Health Insurance Pool (WSHIP) WSHIP recipients can keep WSHIP coverage or buy new coverage through • If they wanted to keep WSHIP they were automatically renewed. Recipients had the opportunity to switch to a different WSHIP plan during fall open enrollment. • Federal rules define state high risk pool coverage as “minimum essential coverage” for 2014. That means recipients who decide to keep WSHIP coverage in 2014, will not have to pay a penalty. • Non-Medicare WSHIP coverage is scheduled to end 12/31/17.

  6. Managed Care Auto-enrollment In 2014, Medicaid recipients will continue to be auto-enrolled to a managed care plan. In 2015, HCA hopes to implement system changes that would allow individuals to shop and select their Medicaid managed care plan online through the Healthplanfinder. (HPF)

  7. Managed Care Auto-enrollment • Until online shopping is available, recipients can make a change in their plan selection by: • Go online at • Return a HCA 13-862 Enrollment form • Call MACSC at 1-800-562-3022

  8. Renewals • HCA is concerned about the rate of successful renewal completions for family, children and pregnancy cases through the HPF. • Several factors are believed to be involved in the lower rate of completions: • A new system • System issues and availability (especially in the first two months) • System error which require a manual effort to fix

  9. Renewals As you work with individuals and families: • Inform them that there is a new online system and provide the address • Encourage them to try to complete their renewal online for a real-time determination • Individuals not comfortable with the online application can complete an Application for Health Care Coverage (HCA 18-001)

  10. Retroactive Coverage All Medicaid coverage groups (including new adult) have 3 months retro coverage from the month of application. • Answer yes to the question “Do you or anyone you are applying for need help in paying for unpaid medical bills?” • A report will be pulled and retro medical approved by HCA enrollment staff • No real-time determination available for retro coverage

  11. Alien Emergency Medical Program If client is over 65 or on Medicare; apply through or send a HCA 18-001 directly to DSHS. There is no change in AEM applications for this group. For client who fall under MAGI (family, children, and new adult group); apply online or with paper application through Healthplanfinder.

  12. AEM, continued Check one of the boxes in the non-citizen emergency medical section of the application, if an individual: • Has been treated for an emergency medical condition this month or during the previous three months • Needs dialysis or cancer treatment • Needs anti-rejection medication as a result of an organ transplant • Needs nursing home, assisted living, or in-home care

  13. AEM, continued AEM remains a two-step process: • Individual must be determined financially eligible for and related to a Medicaid program. This is decided through HPF for MAGI cases and by DSHS eligibility staff for all other cases. • Individuals must have an emergent medical condition. This is decided by a HCA clinical staff review of medical evidence. No change in medical evidence requirements.

  14. AEM, continued With implementation of new adult group on 1/1/14, many more adults who have emergent medical treatment in a hospital will be eligible for AEM.

  15. Non-MAGI Medicaid • Sometimes referred to as Classic Medicaid • Includes medical for: • SSI cash recipients • Individuals over 65 • Medicare recipients • Medicare Savings Programs • Long-Term Care and Waiver Services (COPES) • These medical coverage groups will be processed by DSHS - no change

  16. Individuals with a Disability • If receiving Medicare, they are considered Classic and will have medical eligibility determined by DSHS – no change • If determined disabled by Social Security but not yet on Medicare, they can be in new adult group. Benefits to individual include: • More comprehensive benefit package • No spenddown • No asset test

  17. Spenddown for Pregnant Women and Children Why would someone choose the spenddown program rather than purchase a Qualified Health Plan (QHP)? • Applying for coverage outside the open enrollment period and do not meet one of the exceptions. • No retroactive coverage look-back period for QHP coverage. Earliest begin date for QHP coverage is month after application month.

  18. Spenddown for Pregnant Women and Children • A report will be generated and worked by enrollment staff at HCA when the following occurs: • Woman marks she is pregnant and has income over 193% FPL • Application is for a child and family income over 312 % FPL • Letter will be generated to household giving spenddown option


  20. For More Information: Mary Wood Washington State Healthcare Authority Janet Walthew Northwest Hospital & Medical Center Barbara Gorham Washington State Hospital Association