Maintaining Health Coverage: New Rules for HIV Clients under the Affordable Care Act Presented by: Amanda Gallipeau.

Maintaining Health Coverage:

New Rules for HIV Clients under the Affordable Care Act

Presented by: Amanda Gallipeau

Today’s training

• Applying through the Marketplace – what to expect• Types of coverage

• Expanded Medicaid (MAGI)• Private health plans and help with cost sharing

• Special populations• Medicare and the Marketplace• HIV Uninsured Programs (ADAP) and the Marketplace• Questions?

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Applying Through The Marketplace

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What is the Marketplace? The Marketplace is a “one stop shop” that allows

individuals and small businesses to compare public and private insurance coverage on an “apples to apples” basis - benefits, out of pocket costs, plan performance, and customer satisfaction data.

New York State operates its own marketplace, called NY State of Health (https://nystateofhealth.ny.gov/)

2014 is the inaugural year for the Marketplace, with coverage available as early as (but not before) January 1, 2014.

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When can people apply through the Marketplace? Enrollment in private coverage is not available year-round. Open

enrollment periods are:• For 2014:

o October 1, 2013 – March 31, 2014

• For 2015:o November 15, 2014 through February 15, 2015 (HHS to release future

dates)

You can also enroll after a “qualifying life event”• Have 60 days from date of qualifying life event to access special

enrollment period

People who qualify for Medicaid and Child Health Plus are not restricted to the open enrollment period. They can apply throughout the entire calendar year.

Small businesses with fewer than 50 employees can access the Marketplace any month of the year

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Starting the processThere are several ways to apply

1) Online at https://nystateofhealth.ny.gov/

• Set up your own account and apply through the portal

2) By phone

• Call the Customer Service Center (1-855-355-5777)

3) In-person

• Through an “assistor” – navigator, certified application counselor, or certified broker

4) Via paper (least preferred method) Single application process for public and private coverage

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Household composition Now defined by IRS tax filing rules, with some exceptions:

• Individuals (other than a spouse or child) who expect to be claimed as a tax dependent by another tax payer

• Children who expect to be claimed by one parent as a tax dependent and are living with both parents who do not expect to file a joint tax return (for example, unwed parents)

• Children claimed as a tax dependent by a non-custodial parent

Household composition is determined on expected filing status; not a previous year’s return

Don’t have to be a tax filer to qualify for Medicaid or CHP.

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Household composition

Example

• A married couple - Heather and Joe

• In 2012 got married, filed 2012 return as “Married, filing jointly”

• In September 2013, had their first daughter. oWhat would their household composition be

when they went into the Exchange in October 2013?

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Household composition Example

• They would be a household of 3 because they expect to be so in 2014 (year which coverage would be effective and the advance premium tax credits would apply to their monthly premium amount)

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What kind of information is collected?

For each household member, information is collected on:• Identity (name and social security number)

• Marital Status

• Citizenship/Immigration status

• Race & Ethnicity (optional)

• Income

• Residency

• Other available insurance 10

How is information treated in the Marketplace? Information people submit will be data checked

through government databases for accuracy to

• Prove identity

• Verify household information

• Verify income information Information is kept confidential and is not used for any

purpose other than determining whether people qualify for buying insurance and getting help affording it.

Navigators and other assistors have strict privacy practices and policies 11

How long does the application process take? Most people will receive immediate eligibility

determinations• The online application process itself generally takes 45

minutes to 2 hours (average time).

• Some individuals may have to submit additional information for verification, like proof of identity or income. This may delay the eligibility determination.

• Marketplace technically has up to 30 days to decide for pregnant women and children, 45 days for everyone else.o Medicaid legal processing timeframes haven’t changed

under the ACA. 12

Appeals process

New appeals process to contest eligibility determinations• Marketplace appeal instead of fair hearing

No change to appeals process for service denials• Plan appeals/fair hearings for Medicaid consumers

• Plan appeals for CHP and private insurance consumers

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Who is available to help? Navigators and In-person assistors

http://info.nystateofhealth.ny.gov/IPANavigatorSiteLocations • Provide face to face assistance• Compensation from DOH grant program• Training and certification required• Serve Individuals and Small Business Marketplace

Insurance Brokers/Agents• Face to face and phone assistance• Commission-based compensation from insurance plans• Training and certification required• Choose to certify in Small Business Marketplace, Individual, or both

Certified Application Counselors• Can be care providers, local social service districts, community based organizations• Face to face and phone assistance• No compensation from the state or insurance plans • Training and certification required

Customer Service Center/Maximus • Phone assistance only

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How should people prepare for a meeting with a navigator or other assistor?

People should call first to make an appointment – there may be a wait

People should create an email address in advance (if they don’t already have

one)

People will need to bring certain information to the appointment:

• Social Security Numbers and birthdates for all family members

• Employer and income information for everyone in the household. It is a good

idea to bring wage statements like W-2 forms or letters from employers, as well

as tax statements like last year’s tax return

• If any family members have other health insurance available, people will need to

provide information about the premiums, cost-sharing and benefits. 15

Expanded Medicaid coverage (MAGI)

through the Marketplace

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New Medicaid Eligibility Categories

• Pregnant Women• Children • Parents/Caretaker Relatives• Childless Adults ages 19 to 64 without Medicare

MAGI* (through

Marketplace)

• 65+ (age as a condition of eligibility)• Disability (as a condition of eligibility)• TANF, SSI, Foster Care• Spend down, MBI, MSP• Cancer Programs, Former Foster Care• Residents in adult homes, treatment centers,

OMH facilities

Non-MAGI (through LDSS)

*MAGI = Modified Adjusted Gross Income from tax return17

MAGI Medicaid coverage Higher income level - up to 138% FPL. No asset test.

• Levels already over 138% FPL have been adjusted upward. o Pregnant women and infants – 233% FPL; children – 165% FPL

Under IRS rules for adjusted gross income (AGI), VA income, Worker’s Compensation and child support are disregarded

Cannot spenddown to MAGI income level.

• Federal subsidies are available to help pay for private health insurance, if household income is at/below 400% FPL

• Children over income for Medicaid can get Child Health Plus. MAGI Medicaid provides 12 months of continuous coverage People can get up to 3 months of retroactive coverage Managed care plan enrollment is prospective (following month)

• Fee for service Medicaid will cover in the interim

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MAGI Medicaid benefit package

Benefit package in New York State is the same for MAGI and non-MAGI Medicaid categories, with one exception (outlined below). Both MAGI and non-MAGI include:• Community coverage (non-long term care)

• Community-based long term care

• Institutional (nursing home) coverageo Must be MAGI recipient before needing nursing home care to

be covered under MAGI (medically frail) category

o MAGI applicants who are already in nursing home when they apply for Medicaid will be treated as non-MAGI.

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Private insurance options through the

Marketplace and help with cost sharing

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Qualified health plans (QHPs)

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The Marketplace offers Qualified Health Plans (QHPs). QHPs are required to have these essential health benefits:

1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services, including behavioral health treatment6. Prescription drugs7. Rehabilitative and habilitative services and devices8. Laboratory services9. Preventive and wellness services and chronic disease management10. Pediatric services, including oral and vision care

Qualified health plans (QHP)network requirements

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QHPs must have adequate network of providers, including essential community providers (ECPs)

ECPs have with experience caring for medically underserved populations or low-income populations, including

• Providers who qualify for 340B drug purchase prices

• Ryan White HIV/AIDS providers

• Federally Qualified Health Centers (FQHCs) and FQHC “Look-Alikes”

• Family Planning Providers (Title X Family Planning Clinics)

• Safety-net hospitals

• STD Clinics

• TB Clinics, Hemophilia Treatment Centers, and Black Lung Clinics

• other entities that serve predominantly low-income, medically-underserved individuals

Different levels of QHP coverage – metal tiers

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Platinum – typically the more expensive plan, but offers most comprehensive benefits and lower out of pocket costs

Gold Silver Bronze – the least expensive premiums, but pay more

out of pocket

Help with QHP cost sharing

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Two types of subsidies for Qualified Health Plan enrollees• Advance Premium Tax Credits (APTC) – helps reduce the

monthly premium of the plan

• Cost Sharing Reductions (CSR) –A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan. If you're a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits

• Some households can get both subsidies

APTC - Who is eligible? Those with income between 138% FPL and 400% FPL

• US citizen or lawfully present

• Must not be eligible for other minimum essential coverage

Immigrants with incomes below 100% FPL can get APTC if their immigration status makes them ineligible for Medicaid

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APTC Is applied to your monthly premium amount

• Amount of credit is based on the expected income you report when applying

• Can receive it “up-front” to reduce the monthly amount you pay

• Or can pay full premium amount each month and receive it as a credit when you file taxes

If income increases• It is important to report to the Marketplace – since tax

credit is based on a lower projected amount, you may have to pay difference when filing next year’s taxes 26

Offers of employer coverage An offer of employer coverage will make a person

ineligible for Advance Premium Tax Credits – EVEN IF THE OFFER OF COVERAGE IS NOT TAKEN

The exception is if the coverage does not meet the minimum health benefits, or is more than 9.5% of the employee’s income for a single plan• The affordability rule is only considered for the SINGLE plan,

even if the whole family is offered a plan

• If the SINGLE plan is less than 9.5% of the employee’s income, it is considered affordable under these rules, and if there is an offer of coverage for the family, they are INELIGIBLE for tax credits

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Cost Sharing Reductions (CSR) Reduces the out-of-pocket charges a person must pay for

medical care covered by the plan • Deductibles, co-pays, co-insurance

Income up to 250% Federal Poverty Level (FPL) Must choose Silver Level Plan 3 levels of CSR based on income

• Up to 150%

• 150-200%

• 200-250%28

How is CSR provided? Federal government pays the health insurer upfront Enrollee cost sharing charges are automatically reduced

when an eligible person or family enrolls in a silver plan People do not have to keep track of their spending or get

reimbursed Not provided as a tax credit Not “reconciled” at the end of the year

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2014 Federal Poverty LevelsPersons in

family/household

100% Poverty Guideline

138% Poverty Guideline

200% Poverty Guideline

250% Poverty Guideline

400% Poverty Guideline

1 $11,670 $16,104 

$23,340 

$29,175 

$46,680

2 $15,730 $21,707

 $31,460

 $39,325

 $62,920

3 $19,790 $27,310

 $39,580

 $49,475

 $79,160

4 $23,850 $32,913 

$47,700 

$59,625 

$95,400

5 $27,910 $38,515 

$55,820 

$69,775 

$111,640

6 $31,970 $44,118 

$63,940 

$79,925 

$127,880

7 $36,060 $49,762 

$72,120 

$90,150 

$144,240

8 $40,090 $55,324 

$80,180 

$100,225 

$160,360

8+add $4,060 for each additional

personadd $5,602

 add $8,120

 add $10,150

 add $16,240

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What if my income has changed? If I made a lot more last year than I am making now, will they

count the higher income on my tax return?• No – the portal will ask for what you expect to make this year.

Will I have to prove that my salary went down?• No - the portal will check what you estimate against last year’s return

and then come back and ask you to explain why it has changed. If you have a reasonable explanation, your information should be accepted.

What if my income goes up again later?• You will need to enter the new information into your account as soon

as you get a raise or new job that pays more.

• This is important so that the amount of your tax credit can be adjusted.

• Remember that Medicaid provides 12 months of continuous coverage, even if income increases. 31

Penalties (Individual mandate) The penalty for not getting insurance will not take effect if people

enroll by March 31, 2014 The penalty is fairly low in 2014 (higher of $95 or 1% of income per

adult), but increases every year. In 2016 it is the higher of $695 or 2.5% per adult. • The fee for children is half of the adult amount

• Is assessed at tax filing

The amount is assessed per person in the household without insurance

Exemptions from the penalty:• individuals who cannot afford coverage

• members of Federally Recognized Tribes

• members of recognized religions with an objection to health insurance

• individuals who are not required to file tax returns

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This might be the hardest part … choosing a QHP planEach consumer will have different needs What medical services do you anticipate needing?

• Dental, vision, possible surgeries

• Provider networks

• Prescription needs – check formularies How much can you afford to pay?

• Metal tiers of coverageo Platinum, Gold, Silver, Bronze – varying levels of cost-sharing

o Only the silver plan will provide cost sharing benefits for individuals and families up to 250% FPL

QHP coverage isn’t activated until you pick a plan AND pay your initial premium

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LGBT in ACA

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LGBT Population Concerns Same sex spouse/partner health insurance status

• NY is a marriage-equality state and married same-sex couples are entitled to apply for family health plans

• Special rules might apply for couples with children

LGBT knowledgeable health care providers• Consumers should seek out a provider who offers a

welcoming environment o Directory of LGBT trained providers:

[email protected]

• AIDS Institute supports training centers to build LGBT cultural competency o http://hivtrainingny.org

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Privacy Concerns The Explanation of Benefits (EOB) is mailed to the

residence listed as the primary policyholder. EOB identifies who received care, what care was provided,

and includes testing and procedures performed. Clients can request that the plan sends the EOB to an

alternate address to protect privacy.

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Transgender Populations The Marketplace relies on Social Security Administration

records to confirm name and gender. Transgender applicants should list their name and gender

exactly as they appear in Social Security’s records – even if it does not match the name or gender they are currently using.

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Immigrant Populations

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All family members are protected

By law, information about applicants and nonapplicants may only be used to determine eligibility for health insurance.

This requirement extends to all involved in the application, eligibility, and enrollment process.

Information obtained about applicants or members of their household used to determine eligibility for insurance will not be used by U.S. Immigration and Customs Enforcement for civil immigration enforcement purposes. (www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf )

The federal subsidies, tax credits, and cost sharing reductions will not be considered in the “public charge” decision if and when a person adjusts status to LPR. https://www.healthcare.gov/what-do-immigrant-families-need-to know/

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Undocumented Individuals Definition: individuals born in another county who lost permission

to remain in the U.S., or entered the U.S. without permission

They CANNOT access regular Medicaid or QHP through the Individual Marketplace

They CAN use the Marketplace to obtain:

• Emergency Medicaid for themselves

• CHP for their undocumented children

• Regular Medicaid or QHP for eligible family members (children and/or spouse)

They CAN purchase “off exchange” QHPs for themselves (NYS rule)

They are EXEMPT from the individual mandate

They CAN continue to access HIV Uninsured Care Programs, including ADAP

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Households with Undocumented Members For APTC, count a portion of the undocumented person’s

income … do NOT include the person in the household count

For Medicaid purposes, income is counted and the undocumented person is counted (legally responsible relatives only)

Other household members could all qualify for different programs, while some may not qualify for any at all

By law, applications may not request the citizenship or immigration status of an individual who is not seeking coverage for himself or herself.

Undocumented person can get emergency Medicaid.

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Medicare and the Marketplace

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Will the Marketplace helppeople with Medicare ?

No – they already have insurance (Medicare)

People with Medicare cannot use qualified health plans or get APTC or cost sharing reductions (unless they have to pay for Part A)

Also, most people with Medicare can’t get Medicaid through the Marketplace – they have to go to their local social services district instead, because they are non-MAGI

But those who are in the two year waiting period for Medicare CAN use the Marketplace, and so can their MAGI-related caretakers

Consumers who already have Medicaid

– transition to MAGI44

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How does Marketplace affect people already getting Medicaid? Non-MAGI only:

No change. LDSS/HRA will continue to process changes and renewals.

MAGI only (had obtained under pre-MAGI rules) Should be evaluated under MAGI

budgeting at renewals and when changes are reported.

Fit into both MAGI and non-MAGI category: Ditto. Can apply through Marketplace now

to eliminate spenddown.

Relationship between HIV Uninsured

Programs (ADAP) and the Marketplace 46

HIV Uninsured Care Programs (HUCPs) ADAP/HUCP participants may transition to Medicaid, enroll in

comprehensive private insurance via NYS of Health marketplace, or remain in ADAP/ HUCP program based upon their eligibility status.

HIV Uninsured Care Programs assist with the costs of premiums for a variety of insurance products as a way to maximize available funds.

HIV Uninsured Care program is coordinating enrollments with the NY State of Health Marketplace and facilitating a streamlined process for cost sharing and premium payments for eligible clients.

HIV Uninsured Care assistance will continue to help clients with cost sharing and premium coverage of Exchange coverage when those costs are a barrier to care. 47

HIV Uninsured Care Programs (HUCPs) ACA Advice to Participants and Applicants

When choosing a plan, current program clients can make sure: Your doctor accepts the Marketplace health plan.

Your pharmacy participates in the plan and is enrolled with ADAP. If an applicant is eligible for an Advanced Premium Tax Credit

(APTC), the credit is applied directly to the monthly premiums.

Generally speaking, Silver, Gold and Platinum plans are cost effective and have lower up-front costs for services not covered by APIC

For additional information: www.nyhealth.gov/diseases/aids/resources/adap/index.htm or call 800.542.2437 8:00am - 5:00pm, Monday through Friday. 48

ADAP continues to play a critical role

ADAP can provide wrap-around coverage for out-of-pocket costs of QHP coverage.

ADAP will continue to assist undocumented immigrants who can’t access Medicaid or QHP.

For non-MAGI Medicaid, ADAP can still be used to meet Medicaid spenddown.

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New York State of Health For more information of the Affordable Care Act or New

York’s Marketplace• NY State of Health

nystateofhealth.ny.gov1-855-355-5777

For help finding an assistor• http://info.nystateofhealth.ny.gov/resource/find-ny-state-h

ealth-certified-broker

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Questions? Contact Empire Justice Center

• (800) 724-0490 x 5822

Amanda Gallipeau, Health Law Paralegal• (585) 295-5731

• [email protected]

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