About These Materials

1. About These Materials Families USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for a training program for DC eligibility workers. These workers determine eligibility for Medicaid and other benefit programs (including SNAP and TANF). They will help consumers apply for coverage and financial assistance, report changes, renew coverage, and verify the information that is needed to determine eligibility. These workers will not be responsible for helping consumers select health plans. These training materials are posted here as an example that can be adapted for other training programs. They contain information that is specific to the District of Columbia, which would have to be changed if used in another state. Contact Families USA at stateinfo@familiesusa.org for assistance with adapting these materials.

2. ESA Policy Training Day 2

3. MAGI, Non-MAGI, and Eligibility Categories Prepared by Families USA for use in the District of Columbia

4. What is MAGI? • The Affordable Care Act defines how eligibility will be determined for: • Most Medicaid beneficiaries • All people who get premium tax credits and cost-sharing reductions • Modified Adjusted Gross Income (MAGI) is the new way of looking at household composition and income • MAGI won’t be used for certain populations

5. Who are the MAGI groups? • Four groups: • Parents and caretaker relatives • Children • Pregnant women • Adults aged 21-64 without dependent children • About 158,000 beneficiaries

6. Parents and Caretaker Relatives • Includes parents and caretaker relatives and, if living with them, their spouses • One group called 1931 Low-Income Families • Eligible for Medicaid with incomes up to 221% of poverty • Those over age 65 can receive MAGI Medicaid as parents/caretaker relatives

7. Who is a caretaker relative? • Relative (based on blood, adoption, or marriage) with whom dependent child is living who assumes primary responsibility for child’s care • The spouse of a parent or caretaker relative

8. Children • Children under age 19 are eligible with incomes up to 324% of poverty • Children age 19 and 20 are eligible with incomes up to 221% of poverty • System will automatically identify: • Medicaid kids • Targeted Low-Income Children

9. Continuous Eligibility for Children • All children get a full year of Medicaid coverage even if eligibility changes • Children who are hospitalized and turn 21 while hospitalized continue to be eligible for Medicaid until the end of hospital stay

10. Example: Continuous Eligibility Marika and her nine-year-old daughter Chloe have an income at 275% of poverty. Marika has a DC Health Link plan with a premium tax credit, and Chloe has Medicaid. Marika’s hours increase over the summer and her income rises to 350% of poverty. Marika reports the change.

11. Example: Continuous Eligibility (cont’d) DC Health Link updates Marika’s premium tax credit amount to reflect the change. Chloe stays in Medicaid even though she is above 324% of poverty. Marika’s hours return to normal at the end of the summer. She reports the change, and DC Health Link adjusts her premium tax credit amount. Again, Chloe stays in Medicaid.

12. Pregnant Women • Eligible for Medicaid with incomes up to 324% of poverty • Eligibility as pregnant woman ends the month that includes the 60th day postpartum • System will automatically identify: • Medicaid pregnant women • Targeted Low-Income Pregnant Women

13. Continuous Eligibility for Pregnant Women Eligibility continues to the end of the post-partum period even if a pregnant woman’s income goes above 324%of poverty.

14. Adults Ages 21-64 withoutDependent Children • Eligible for Medicaid with incomes up to 215% of poverty • DC expanded Medicaid early • System will automatically identify: • CAM group • Program Code 775 group

15. Presumptive Eligibility for Pregnant Women • Certain Medicaid providers can determine a pregnant woman presumptively eligible for Medicaid without a full application • Presumptive eligibility is for a maximum of 60 days • Beneficiary must also file a full Medicaid application within 60 days • Eligible only for outpatient services

16. Hospital Presumptive Eligibility • Under new rules, all Medicaid hospitals can make presumptive eligibility determinations for MAGI populations • Eligible for all services • Anyone determined presumptively eligible has 60 days to complete an application

17. Non-MAGI Populations • SSI recipients • Deemed newborns • Foster care youth • Project Wish beneficiaries • Former foster care youth up to age 26

18. Non-MAGI Populations (cont’d) • Those who are aged, blind, or disabled • Those seeking long-term services and supports (nursing home and home- and community-based services) • Medicare Savings Program beneficiaries • Dual eligibles • Medically needy/spend-down beneficiaries

19. Former Foster Care Youth New eligibility category • Young adults who: • Are under age 26 • Were in foster care in DC • Were receiving Medicaid when they turned 18 (or were emancipated) or left foster care (after age 18)

20. Why is the distinction between MAGI and non-MAGI important? • In some cases, non-MAGI populations can get additional benefits • Helps determine whether a person is placed in fee-for-service or managed care Medicaid • Determining eligibility for non-MAGI populations sometimes has extra requirements

21. How will you know if someone is in a non-MAGI category? • Answers to screening questions in application or renewal form • Request for a full determination • Submission of supplemental non-MAGI application forms • Agency has information about the person’s non-MAGI eligibility

22. What happens to non-MAGI applications? Goal: Get applicant covered as quickly as possible • If possible, make non-MAGI eligibility determination promptly • If non-MAGI determination will take longer, enroll applicant in either MAGI Medicaid or a DC Health Link plan with tax credits until non-MAGI determination is done Prepared by Families USA for use in the District of Columbia

23. Ron is 49 years old and works part-time earning $15,000 per year. He has some medical conditions that make it difficult for him to do certain daily tasks. When he fills out the application, he answers “yes” to the non-MAGI screening questions. Example: Ron Prepared by Families USA for use in the District of Columbia

24. Ron may be eligible for non-MAGI Medicaid based on having a disability Because disability determinations take time, determine Ron’s MAGI eligibility Ron is eligible for MAGI Medicaid until his non-MAGI eligibility determination is complete Ron’s Application Prepared by Families USA for use in the District of Columbia

25. Review: Question #1 Martin is 21 years old. His income was at 175% of poverty when he applied and got Medicaid. Three months later, he got a second job and his income went up to 230% of poverty. TRUE OR FALSE: Since this change happened during the year, Martin can keep his Medicaid because of continuous eligibility.

26. Answer: Question #1 FALSE Only children and pregnant women have continuous eligibility.

27. Review: Question #2 ESA will determine eligibility for which of the following groups in 2014? • Childless adults aged 21-64 • People with disabilities • Pregnant women • Dual eligibles • The medically needy/spend-down beneficiaries

28. Answer: Question #2 ANSWER: B, D, and E ESA will still determine eligibility for non-MAGI populations, which includes those who are disabled, dual eligibles, and those who are medically needy/spend-down beneficiaries in 2014. Pregnant women and childless adults aged 21-64 are MAGI populations and will use the new system.

29. Review: Question #3 TRUE or FALSE: If an applicant might be eligible for Medicaid on a non-MAGI basis, she must wait until her non-MAGI eligibility has been determined to get coverage.

30. Answer: Question #3 FALSE Applicants who are waiting for a non-MAGI determination should be enrolled in Medicaid or a DC Health Link plan based on their income.

31. Recap of Eligibility Categories • What you will do: • Enter applicant’s information into DC Health Link • Enter changes into DC Health Link • What the system will do for you: • Determine eligibility category for each applicant automatically

32. Overview ofEligibility Factors Prepared by Families USA for use in the District of Columbia

33. Eligibility Factors at a Glance

34. Household Composition • New rules are based on tax household • Special rules for certain family situations and families that do not file taxes

35. Income • New rules are based on tax income • Changes to income disregards and no more deductions

36. Citizenship and Immigration Status

37. Immigration Status and Medicaid • Citizens are eligible for full Medicaid, as are individuals who have an immigration status that makes them a “qualified alien” • Depending their type of immigration status, some people who are “qualified aliens” are subject to the five year bar • Pregnant women and children who are “lawfully present” are also eligible for full Medicaid • Pregnant women and children are exempt from the five year bar

38. Immigration Status and DC Health Link • Must be a citizen or “lawfully present” • More types of immigration status are included in the “lawfully present” category, than in the “qualified alien” category • No five year bar for DC Health Link plans, premium tax credits and cost sharing reductions

39. DC Alliance • For people under 200% of poverty not eligible for Medicaid, including • People subject to five-year Medicaid bar • Some other immigrants, such as DACA • No premiums, but limited benefits • Is not minimum essential coverage • Separate application and face-to-face interview required • Eligibility will still be determined by ESA in 2014

40. Immigrants Have a Choice during the Five-Year Bar Period Immigrants can get: • DC Alliance • DC Health Link plan with premium tax credits and cost-sharing reductions

41. Including Non-Applicants • People should list all household members when they apply for DC Health Link coverage and Medicaid • They should note which members are seeking coverage and list other members as non-applicants

42. Verifying Citizenship and Immigration Status • DC Health Link will automatically attempt to confirm information through electronic data sources • If DC Health Link can’t confirm: • Applicant has 90 days to provide documentation • Applicant receives coverage during that time, if eligible based on the information they provide

43. Documenting Citizenship and Immigration Status • Documentation requirements for citizenship • One form of primary documentation, or • Two forms of secondary documentation: • ID with photo or other identifying information • Other documentation from list • See handout for documentation types • An official government document will be needed to verify immigration status • See handout for list of acceptable documentation

44. Working with Immigrant Applicants Things to consider: • Applying for health coverage is not a “public charge” • Be clear on how information will and will not be used • Be sure that applicants understand what information is required for non-applicants • If citizenship or immigration status cannot be verified right away: • Applicant has 90 days to provide documentation • Applicant receives coverage during that time, if eligible based on other information (eligibility based on other factors must be verified for Medicaid)

45. Review: Question #1 Which of the following groups with incomes below 200% of poverty have a choice between DC Alliance and DC Health Link: • Lawfully present children • Lawfully present adults subject to five-year bar • U.S. citizens • Deferred Action Childhood Arrivals

46. Answer: Question #1 ANSWER: BLawfully present adults subject to the five-year bar • Lawfully present children get Medicaid • U.S. adult citizens get Medicaid • Qualified aliens who are not subject to five-year bar can get Medicaid • Deferred Action Childhood Arrivals get DC Alliance

47. Review: Question #2 TRUE or FALSE: Applicants who attest to an eligible immigration status and are eligible for coverage based on other factors have 90 days to document immigration status if it cannot be verified electronically, but they do not receive coverage until their immigration status has been verified

48. Answer: Question #2 FALSE Immigrant applicants do have 90 days to document immigration status if documentation is needed, but they do get coverage during this time.

49. Residency Requirements

50. Medicaid Residency In general, those over age 21 not living in an institution are residents of DC if: • They live and intend to continue living in DC • People do not need to have a fixed address to be residents • No minimum length of time in DC • People entering DC with a job commitment or looking for a job are considered residents