OCTOBER 2015 JILL HANKEN VIRGINIA POVERTY LAW CENTER ENROLL VIRGINIA! Medicaid – FAMIS Overview for Virginia Navigators & Other Assistors 919 E Main St. Suite 610, Richmond, VA T: F:

ACA Marketplace Coverage Household Size  Apply tax code rules  Tax Dependents are in household (children, relatives, non- relatives Household Income  Modified Adjusted Gross Income (MAGI)  Apply tax code rules  “Adjusted Gross Income” PLUS non-taxable Social Security (unless it’s received by a dependent child), tax exempt interest, excluded foreign income If between 100% and 400% FPL, tax credits available  But can still buy full-priced insurance if not in this range

Marketplace “Assesses” Eligibility for Medicaid & FAMIS If assessed eligible for Medicaid/FAMIS, Marketplace will forward application to Virginia Department of Social Services (DSS) Case transfers still slow Best Practice - Anyone who appears to be eligible for Medicaid / FAMIS should apply directly for state benefits   Apply online at  Call Cover Virginia at to apply by phone  Print out and complete a paper application (Spanish version available) and mail it to your local DSS orpaper applicationDSS  Apply in person at your local DSS in the city/county where you liveDSS

Medicaid & FAMIS Divided into Categories  Families & Children  Aged, Blind and Disabled  Non-long term care  Long term care (nursing home, community based care)  Miscellaneous Each category has its own rules! Medicaid Policy Manual – al.cgi al.cgi Dept. of Medical Assistance Services –

Families & Children Use MAGI rules (with some differences for families that don’t file taxes) Important disregards / deductions  Child Support Received  Soc. Sec. received by dependent children who don’t have to file taxes  Pre-tax set asides for healthcare, child care, etc.  Self employment expenses/depreciation Main Family & Children Categories  Children under age 19  Pregnant Women  Low Income Parents  Foster Care and Adoption Assistance Children up to 21  Plan First (family planning only for men & women)  Breast & Cervical Cancer Treatment  Former Foster Care Youth (up to age 26)

Families and Children Income Levels Children under 19  143% FPL + 5% disregard  FAMIS to 200% FPL + 5% disregard Pregnant Women  143% FPL +5% disregard  FAMIS Moms 200% FPL + 5% disregard Parents  Ranges from 33% FPL – 51% FPL + 5% disregard, depending on locality

Families & Children, cont’d Plan First – family planning services only  200% + 5% disregard Breast & Cervical Cancer  200% FPL (Not MAGI) Former Foster Care Youth up to age 26  No income test

5% Disregard is Significant Apply 5% disregard if HH income is higher than the limit. (100% FPL for family size x.05 = Disregard)  Family of 1 - $50/mo.  Family of 2 - $67/mo.  Family of 3 - $84/mo.  Family of 4 - $102/mo.  Family of 5 - $119/mo.

Aged, Blind & Disabled (ABD) Aged (over age 65), Blind, Disabled (ABD)  80% FPL  Medically Needy – “Spend-down” where higher income  Long term care (nursing home and community-based waiver programs) – 300% SSI and Spend-down  Medicare Savings Programs (QMBs, SLMBs etc) – 100%-135% FPL – can pay Medicare premiums & other out-of-pocket costs  Resources rules apply  Bank accounts, property, other assets  Usually $2000 countable resources (single); $3000 countable resources (couple)  MAGI rule do NOT apply

What’s Missing? Other adults (non-parents, not pregnant, not ABD)  NOT COVERED – even if $0 income Medicaid GAP – state option to cover other adults up to 138% FPL  30 states (including D.C.) have adopted  This will be considered again in 2016 legislative session Be prepared to explain to applicants.  Names of health clinics, other assistance in area  Possible application for Plan First  Necessity of Medicaid denial for tax penalty exception  Availability of Special Enrollment if income increases to over 100% FPL

Governor’s Access Program (GAP) Adults with “serious mental illness” Non-Financial Requirements:  Uninsured  Age  US Citizen or “lawfully residing” immigrant  Seriously Mentally Ill (Form P-603): major depression, bipolar disorder, schizophrenia, PTSD, panic disorder (substance abuse can be secondary) Income below 60% FPL ($7062/year) Services: medical, mental health, prescriptions. But no ER, inpatient, or transportation.

No Medicaid Expansion = Coverage Gap

Important Medicaid Procedures Applications must be processed within  10 days pregnant women  90 day applicant alleging disability  45 days all others Three months retroactive coverage available if eligible in those months

Important Rules for Pregnant Women Household size includes unborn child(ren) Once eligible / enrolled, changes in income don’t matter throughout duration of pregnancy Also eligible for 60-days post partum Dental services added in 2015 Newborn is “deemed” eligible & automatically enrolled in Medicaid/FAMIS for 1 year

Important Rules in FAMIS Child must be uninsured No “waiting period” required if insurance dropped Can now get FAMIS/FAMIS Moms even tho there is access to subsidized state-employee health coverage “FAMIS-Select” option - $100/FAMIS eligible child to help pay for employer based coverage

Important Rules for Immigrants Medicaid Manual Chapter M Very complicated – eligibility usually depends on date of entry to U.S. and specific immigrant status Special rules for “Legally Residing” immigrants who are children under age 19 or pregnant  Eligible for Medicaid when they meet financial requirements and they are “residents” of Virginia.  Must be given opportunity to state “intent” to remain in Virginia to show residency  “Legally residing” means they are documented, even if it’s with a Visa

Important Rules for Immigrants, cont’d Most other legal immigrants must be in U.S. for at least 5 years before obtaining Medicaid coverage.  Virginia also has restrictive rules that require a work history or military connection.  This can create a permanent bar for some legal immigrants All immigrants – including undocumented immigrants can get Medicaid for “emergency services” if  They are in a Medicaid category and meet financial and non- financial requirements (e.g. income, resources, Virginia residence)

Important Rules for Immigrants, cont’d Because of these limitations in Virginia’s Medicaid eligibility, some legal immigrants can get tax credit subsidies from the Marketplace, even if their income is under 100% FPL.

Other Recommended Training Center on Budget and Policy Priorities – webinar series “Health Reform Beyond the Basics” National Health Law Program – – Advocates Guide to the Medicaid Programwww.healthlaw.org Enroll America – toolkits, webinars

ENROLL Virginia! is a nonprofit, nonpartisan project that helps individuals and small businesses (1) obtain health insurance, including private health coverage through the federal health insurance marketplace; (2) qualify for applicable tax subsidies; and (3) comply with the Patient Protection and Affordable Care Act to avoid penalties for failure to do so. The project is supported by a federal grant (Funding Opportunity Number CA-NAV from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services) and administered by the Virginia Poverty Law Center. The contents provided here are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.