March 2012 Prepared by Harbage Consulting for SEIU

1. THE PATIENT PROTECTION AND AFFORDABLE CARE ACT:WHAT COUNTY ELIGIBILITY WORKERS NEED TO KNOW ABOUT HEALTH REFORM March 2012 Prepared by Harbage Consulting for SEIU

2. Today’s Discussion • Federal Health Reform: What the new law does • Establishing A Statewide Eligibility & Enrollment System through California’s Health Benefit Exchange • Standardized Application • One statewide portal • Navigators: A new class of application assisters • Medi-Cal Expansion & New Eligibility Rules – What it means for county Eligibility Workers • Changing Income Rules: MAGI • Determining Family Size and Household Income • Elimination of the Asset Test • SEIU Campaign Plan for Eligibility & Enrollment

3. Patient Protection and Affordable Care Act (ACA): Remaking the U.S. Health Care System • Signed in March 2010 • Landmark moment Most significant change since the establishment of Medicare and Medicaid

4. Goals of the ACA: Expansion and Coverage for All Broad reforms to the entire health care system to: • Increase the number of people who have access to health care coverage. • Making private health insurance more affordable • Expanding public programs, including the largest Medi-Cal expansion in California history • Reduce health care cost while improving quality

5. Reforming America’s Health Care System • Majority of changes enacted between now at 2018 • Opportunity to enroll an additional4-5 Million Californians into health coverage

6. …Depends on US ! 6

7. Road to Universal Coverage • Under the ACA, low and middle income persons are offered subsidies and will then will be required to have health care coverage, either through: • Private insurance • Public program like Medi-Cal, Medicare, or Healthy Families

8. Better access to private insurance • For those who do not qualify for Medi-Cal, Medicare or Healthy Families and do not have other access to private insurance…

9. What is a Health Benefit Exchange? • A marketplace for individuals, families and small businesses to buy private health insurance • Increase competition between insurers • Can be State or federally run Most importantly, • People with incomes between 133-400% FPL ($30,657-$46,100 per year for a family of four in 2012) will be eligible for premium subsidies through the Exchange

10. California’s Exchange California is leading the nation in implementing this central piece of federal health care reform: • SB 900 (Alquist, Ch. 659, Statutes of 2010) establishes the California Health Benefits Exchange (HBEX), and • AB 1602 (Perez, Ch. 655, Statutes of 2010) outlines the duties and authority of the Exchange.

11. Protections Under State Law Most importantly, State laws specifically requires counties to determine eligibility: • Longstanding CA law states that ”A county shall determine Medi-Cal eligibility in accordance with state and federal law.” [CA Welfare and Institutions Code 14154(d)] • AB 1602 further requires the Exchange to “develop processes to coordinate with county entities that administer eligibility for the Medi-Cal program.” [CA Government Code 100503]

12. The Exchange has significant work • Create a functioning insurance market. • Develop a standardized application form, in cooperation with Medi-Cal and other state departments, • Develop one statewide electronic portal for eligibility and enrollment (CalHEERS), • Existing SAWS systems and CalHEERS must be able to share and transmit information both ways. • Develop a new class of workers: Navigators • A Navigator helps individuals, families and small business access coverage through the Exchange. …and many other tasks…

13. One standardized application for all coverage By 2014, California must implement a simplified enrollment process for Medi-Cal, Healthy Families and Exchange subsidies, including: • Establish one standardized application for all public programs and the Exchange. • This application must also be used to determine premium subsidies in the Exchange. • Be able to electronically verify some information.

14. Implications of a standardized application Having one standardized application means: • More people will have increased access to coverage – chances are they will be eligible for at least one of the coverage options. • Only one application to deal with. • Additional training will most likely be needed.

15. California’s Standardized Application • Last year’s AB 1296 implements the one standardized application in CA. • SEIU is being asked to participate in the stakeholder process to develop the standardized application which will be used for Medi-Cal, Healthy Families, and the Exchange. • This year’s SB 970 (De Leon) bill would expand the use of the standardized application developed under AB 1296 to also be used for CalFRESH and CalWORKS.

16. Health Reform Requires Simplification • Requires the state to conduct data matching to determine eligibility by matching applicant’s information with reliable, third-party data • The state cannot require applicants to submit info and documents after applying unless the info they provided conflicts with electronic data or is “otherwise insufficient to determine eligibility.” • Consumers can also authorize disclosure of personal information found in existing government databases to state agencies, such as DMV.

17. No Wrong Door: One application, multiple application venues Consumers can apply for coverage through any venue, without specifying the program they want.

18. “No wrong door” approach to all types of coverage This means that regardless where people apply for coverage: • The state eligibility framework (CalHEERS and county eligibility systems) must determine eligibility for public programs and Exchange subsidies • Enroll them into the appropriate program for which they are eligible If someone applies for Medi-Cal or Healthy Families but is eligible for Exchange subsidies (or vice versa), that person must be enrolled into the Exchange without filing another application.

19. CalHEERS: Coordinating across programs • The ACA also requires the state to develop a web portal that allows people to apply for, enroll in, and renew coverage, and get premium subsidies • This website must: • Provide info for various plans offered within the Exchange • Allow consumers to compare coverage between Exchange plans and Medi-Cal or Healthy Families • Ensure privacy and security and accept an electronic signature

20. CalHEERS: A new platform for eligibility • Currently in RFP phase SEIU and counties are at the table in discussions with the Exchange on how this new system should work.

21. Discussion: What should the standard application look like? And how should the SAWS interface work? ? ? ?

22. Application Assistance: Who does it? Before Health Reform After Health Reform Public Programs: • County Eligibility Workers • CAAs Private Insurance: • Insurance Agents/Brokers Public and Private Coverage: • County Eligibility Workers • CAAs • Insurance Agents/Brokers …and… Navigators!!!

23. Unique role of county eligibility workers While all these other classifications of workers can provide application assistance…. …only county eligibility workers may determine eligibilityfor the Medi-Cal program. 23

24. Navigators: Guiding Consumers to Coverage To promote the Exchange, Navigators are required by the ACA to: • Raise public awareness; • Distribute information on enrollment tax credits; • Help consumers and businesses enroll; • Provide referrals to enrollees for grievances or questions regarding their health plan; and, • Provide information in a manner that is culturally and linguistically appropriate.

25. Navigator Requirements The Exchange is tasked to establish rules around: • Who can be a navigator, • What a navigator must do, and • Training and continuing education requirements for navigators. These rules have not been established in California yet.

26. Discussion: How can Navigators support County Eligibility Workers? ? ? ?

27. Expansion of Medi-Cal in 2014 In 2014, Medi-Cal will be open to: • Anyone with family incomes up to 133% of the Federal Poverty Level (FPL): In 2012, 133% FPL for a family of four is $30,657. • This includes Childless adults (No more categorically eligible requirements.)

28. Changing Medi-Cal Eligibility Rules ACA changes the rules that apply in determining Medi-Cal coverage, including: • Calculating Income • Determining Household Size • Eliminating Asset Test

29. New Income Counting Rules: MAGI The ACA simplifies income-counting rules across most state Medicaid programs, creating a standardized way that income is determined across public programs nationally by: • Replacing the current welfare program income rules with Modified Adjusted Gross Income (MAGI), a tax-based system for counting individual and family income as defined by the IRS.

30. New Income Counting Rules: MAGI Before 2014 After 2014 • Each Medi-Cal program (i.e. 1931(b), PE, etc.) has different income rules. • Many different income deductions. • Anyone at 100% of the Federal Poverty Level (FPL) or below is eligible. • Most Medi-Cal programs will have the same income rules (MAGI). • Income disregard rules will be replaced with a standard five percent income disregard. • Anyone at 138% of FPL or below is eligible (133% + 5% income disregard).

31. MAGI: One Standard Across Programs • MAGI also applies to Exchange subsidies. • Consumers purchasing Exchange plans can get: • Premium subsidies for those 400% FPL and below • Reduced cost sharing for those 250% FPL and below

32. ACA also change the rules on family size and household income. Before 2014 After 2014 • Family size and household income depends on who is applying for benefits. • Generally, Medi-Cal programs count the incomes of parents and spouses in determining an individual’s eligibility. • Income of other family members is counted only if they are also applying for coverage. • Family size and household income is based on the tax filing unit (all individuals claimed as a dependent for tax purposes is included) • Income for all individuals in the tax filing unit (family) is counted regardless if they are applying for coverage or not.

33. Determining Household Size & Income Examples: • A stepmother who files taxes with her stepson currently doesn’t count in her stepson’s family size or household income. Under MAGI,the same stepmother would be included in determining family size. • If a teen-age child has an after-school job and earns income that exceeds the minimum tax filing threshold, he/she is required to a tax return even though the parents may still claim him or her as a dependent. Under MAGI,the teen-ager’s MAGI will be added to the rest of the family’s MAGI to determine household income.

34. No More Asset Tests? Before 2014 After 2014 • Requires most adults to have less than $2,000 to $4,000 in assets. • Children are not subject to asset tests. • No asset test for individuals whose income is calculated using MAGI. • Asset test still applies to elderly, disabled, medically needy, or those deemed eligible for Medi-Cal as a result of other programs (such as TANF).

35. MAGI vs. Non-MAGI populations • While MAGI rules and elimination of asset tests will apply to most Medi-Cal applicants, it will notapply to everyone, such as those in: • Medi-Cal Express Lane • Dual Eligibles’ Medicare prescription drug coverage low-income subsidies • Medi-Cal long term care services

36. Hospital can determine Presumptive Eligibility for more people. Before 2014 After 2014 Hospitals can determine presumptive eligibility for: • Children • Pregnant Women • Breast & Cervical Cancer Patients Hospitals can determine presumptive eligibility for: • All populations eligible for Medi-Cal and Healthy Families

37. A note on Immigration Rules • No changes to citizenship documentation and immigration status requirements • Exchange must also verify citizenship or lawful presence for all applicants • Undocumented immigrants are: • Not eligible for subsidies in the Exchange, • Not eligible to buy coverage in the Exchange at full cost, • Exempt from the individual mandate to have health coverage, and • Continues to be eligible for emergency and restricted-scope Medi-Cal.

38. Discussion: What do these “simplified” rules mean to County Eligibility Workers? ? ? ?

39. Preparing for 2014… …Many more changes to come.

40. Role of County Eligibility Workers Becomes Even More Important! Although many of these changes help streamline and simplify access to coverage, it still addscomplexity to eligibility determination. • Eligibility workers will play a critical role in: • Determining eligibility for MAGI and non-MAGI populations (i.e. dual eligibles), and • Case management for public programs and, likely the Exchange.

41. What SEIU is doing to Impact Health Reform Implementation in CA? ? ? ?

42. SEIU Campaign for Eligibility & Enrollment (page 1 of 2)

43. SEIU Campaign for Eligibility & Enrollment (page 2 of 2)

44. NEXT STEPS FOR THE ELIGIBILITY & ENROLLMENT CAMPAIGNTHANK YOU FOR YOUR INPUT! Prepared by Harbage Consulting for SEIU