The Basics of the ACA, Medicaid & FAMIS in Virginia 2018-2019 ACA NAVIGATOR NAME HEALTHCARE NAVIGATOR E-MAIL ENROLL VA: 1-888-392-5132 T: XXX-XXX-XXXX

The Affordable Care Act or “OBAMACARE” Goals: Health Insurance at Lower Cost Private Insurance Reform Better Health Delivery System Changes in coverage since January 1, 2014: State option to expand Medicaid, effective January 1, 2019 in VA New Health Insurance Marketplace People required to have Minimum Essential Coverage (no penalty after 2018) Qualified Health Plans required to cover a fixed set of benefits called Essential Health Benefits

Minimum Essential Coverage Minimum Essential Coverage Includes: Medicare, at least Part A Medicaid Most employer plans or COBRA Any Marketplace plan Certain individual plans bought outside the Marketplace Tricare Most Veterans Healthcare programs What does NOT count as minimum essential coverage? Coverage for only vision/dental Workers’ Compensation Coverage only for specific disease or condition Plans that only offer discounts on medical service Limited benefit Medicaid (Plan First or GAP) Short-term policies

What is the Marketplace? The Federally Facilitated Marketplace (FFM) where individuals can shop for qualified health plans. Allows for “apples-to-apples” comparisons of qualified health plans Uses plain language to explain coverage options After submitting an application, there is no obligation to enroll in a health plan Financial assistance only available with FFM plans! Virginia has a federally facilitated marketplace that allows you to shop and compare different qualified health insurance plans under one website. It is important to note that you should make sure you visit healthcare.gov because there are many other fraudulent websites. This is also important because this is the only website with premium tax credits available On healthcare.gov you simply create an account, fill out an application and you will get an instant eligibility decision. From there, you can choose a plan, but there is no obligation.

Essential Health Benefits Patient Ambulatory Services Emergency Services Hospitalization Maternity and Newborn Care Mental Health and Substance Abuse Disorders Prescription Drugs Rehabilitative and Habilitative Services Laboratory Services Free Preventative and Wellness Services Pediatric Services including Dental and Vision

Basic Eligibility To purchase a plan on the Marketplace, you must: Be a US citizen or national, or non-citizen who is lawfully present in the US for the entire time coverage is sought Live in service area Not be incarcerated Not have access to affordable and adequate insurance Adequate = actuarial value of the plan is >60% Affordable means the plan costs < 9.56% of the household income Have income between 100% FPL and 400% FPL to receive financial assistance Exception for legally residing immigrants with income below 100% “Reconciliation” will occur when taxes are filed Some immigrants who are not eligible for Medicaid due to immigration status may qualify for the financial assistance through marketplace despite having income below 100% FPL, however most will fall into the coverage gap.

Household Size Household is defined using IRS rules for who is included in your tax household Methodology used by both the Marketplace and some Medicaid categories Exceptions for Medicaid in certain situations Married individuals must file jointly to receive financial assistance through the Marketplace Those who file as “Married Filing Separately” are not eligible to received financial assistance though the Marketplace.

Modified Adjusted Gross Income (MAGI) Count: Taxable wages/salary Profit from self-employment Social Security benefits (SSDI, retirement) Unemployment benefits Alimony received* Most retirement benefits (including VA pensions) Interest (including tax-exempt interest) Rental income Do not count: Child support received Supplemental Security Income (SSI) Workers’ compensation payments Veteran’s benefits (service- related disability) Gifts/Inheritances Pre-tax deductions (IRAs, childcare, health) Alimony paid* Social Security of dependents who aren’t required to file taxes *For divorce agreements made after December 31, 2018, alimony will not be taxable for the recipient or deductible for the payee

Eligibility for Financial Help Premium tax credits reduce the amount you pay for your premium. You may be eligible if you are between 100-400% of the FPL. Cost sharing reductions (CSRs) lower deductibles, co-pays and other out-of-pocket costs if under 250% of FPL and you pick a Silver level plan.

Household/ Family Size Premium Tax Credit Eligibility Household/ Family Size 100% 138% 150% 200% 250% 300% 400% 1 $12,140 16,753 18,210 24,280 30,350 36,420 48,560 2 $16,460 22,715 24,690 32,920 41,150 49,380 65,840 3 $20,780 28,676 31,170 41,560 51,950 62,340 83,120 4 $25,100 34,638 37,650 50,200 62,750 75,300 100,400 5 $29,420 40,600 44,130 58,840 73,550 88,260 117,680 6 $33,740 46,561 50,610 67,480 84,350 101,220 134,960 7 $38,060 52,523 57,090 76,120 95,150 114,180 152,240 8 $42,380 58,484 63,570 84,760 105,950 127,140 169,520

Example: Calculating the PTC Teresa, Antonio, Gaby & Michael Income: $50,200/year (200% FPL) Expected contribution 6.34% of income ($3,183/year, $265/month) 3 Silver plans available to family $10,000/year, $833/month $10,542/year, $879/month $10,800/year, $900/month BENCHMARK PLAN PTC Calculation Cost of Benchmark $10,542 Expected Contribution $3,183 Premium Tax Credit Amount $7,359/year $613/month

Plan Selection Level of Coverage Actuarial Value Bronze 60% Silver 70% Gold 80% Platinum 90% Catastrophic <60% Lower AV = lower premiums, but higher deductibles and other out-of-pocket costs Catastrophic plans are only available to those under 30 and those eligible for an affordability exemption. Premium tax credits cannot be used to purchase these plans. CSRs increase the AV of the Silver plans only! Compare premiums, cost-sharing amounts, networks and formularies before choosing a plan!

Open Enrollment for Coverage for 2019 Open enrollment is November 1, 2018- December 15, 2018 You can enroll outside of Open Enrollment with a Special Enrollment Period (must enroll within 60 days of the qualifying event). Note: Medicaid/FAMIS applications accepted & processed all year

Special Enrollment Periods I lost my existing coverage because A family member passed away I turned 26 I changed jobs I was fired My COBRA, CHIP or Medicaid benefits expired or I lost my eligibility I became divorced My employer insurance is no longer affordable or adequate This does not include voluntary termination or termination for non-payment. I experienced a life change: I got married I moved to a new state Birth of a child I gained eligible immigration status I am no longer incarcerated Other situations Marketplace error Bad conduct of an entity outside of the Marketplace (ex: Navigator, CAC, Insurance Company) Native American or Alaskan Native Most of these now require the consumer to have had insurance within the previous 60 days and will require proof of the qualifying life event.

Medicaid and FAMIS in VA

Many complexities and rules often change, this is just an overview! Medicaid and FAMIS Many complexities and rules often change, this is just an overview! Eligibility is limited to people in certain categories Financial eligibility varies depending on category Some categories also have a resources test Annual renewal must be completed to maintain coverage If eligible for full benefits Medicaid, cannot get financial assistance on the Marketplace

Coverage Categories Medicaid Newly Eligible (Medicaid Expansion!) Families and Children Children under age 19 (FAMIS Plus)* Pregnant Women* Low Income Families and Children (LIFC)* Foster Care and Adoption Assistance & Children up to 21 Former Foster Care Youth (up to age 26) Aged, Blind and Disabled* Limited Benefits Plan First, Family planning services only Breast & Cervical Cancer Treatment Governor’s Access Plan (GAP), for those with Serious Mental Illness Spend-down Medicare Savings Programs CHIP (CHILDREN’S HEALTH INSURANCE PROGRAM) Children (FAMIS)* Pregnant women (FAMIS MOMS)* * Will be discussed in more detail

Medicaid Expansion!!! Legislature adopted May 30, 2018! “Newly eligible” adults: Aged 19 through 64, Not eligible for an current full- benefit Medicaid category or Medicare MAGI income up to 138% FPL No resource test About 300,000+ will get coverage New coverage begins January 1, 2019

New Income Limit- 138% FPL

These groups may be shifted to new category quickly and simply! The Newly Eligible Enrolled in another Medicaid category (Limited Benefits): Plan First GAP Program Breast & Cervical Cancer Treatment enrollees Blind/Disabled with a spend- down Children aging out of Medicaid at age 19 Parents of most Medicaid- enrolled children These groups may be shifted to new category quickly and simply! Others who are not currently enrolled: Childless adults Low income parents Blind/Disabled with income above 80% FPL and/or excess resources Adults applying for SSI/SSDI SSDI recipients waiting 24 months for Medicare Marketplace enrollees with income 100%-138% FPL Incarcerated adults (for some hospital care) and upon release

Income Limits for FAMIS- Up to 200%

Emergency Medicaid Services Available to all “otherwise eligible” non-citizens Must meet a category and financial requirements for that category More will be eligible through Medicaid Expansion Legal or undocumented Emergency includes Labor & Delivery Other hospital ER Dialysis

Applications Application Time limits 10 days pregnant women 90 days when disability determination 45 days all others 3 months retroactive coverage available if eligible, Medicaid only (not FAMIS or FAMIS MOMS) Retroactivity cannot go past January 1, 2019 for “newly eligible”

Application Doors for All Types of Health Insurance Online Marketplace: www.healthcare.gov Medicaid/FAMIS Information: www.coverVA.org Application: www.commonhelp.virginia.gov Phone Marketplace: 1-800-318-2596 Cover VA: 1-855-242-8282 Local Help Enroll Virginia: www.enrollva.org or 1-888-392-5132

Twitter-@EnrollVirginia Questions? xxx-xxx-xxxx name@enroll-virginia.com www.enroll-virginia.com Facebook-www.facebook.com/enrollva Twitter-@EnrollVirginia Thank you! ENROLL Virginia! is a nonprofit, nonpartisan entity that assists individuals and small businesses to obtain health insurance including commercial health coverage through the federally facilitated health insurance marketplace, to qualify for applicable tax subsidies, and to comply with the U.S. Patient Protection and Affordable Care Act and avoid penalties for failure to do so. The program is paid for by a federal grant (Funding Opportunity Number CA-NAV-13-001 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.