Nebraska Medicaid and the Impact of the Affordable Care Act on Eligibility Nebraska Association of Health Underwriters February 18,

Introduction and Agenda Ruth Vineyard, Deputy Director Nebraska Department of Health and Human Services, Division of Medicaid and Long Term Care (MLTC) Our focus today will be on Medicaid Eligibility and the impact of the Affordable Care Act 2

Introduction and Agenda Agenda Overview Medicaid Program Medicaid Eligibility Overview ACA Impact on Medicaid Eligibility Current Status of Medicaid and the Marketplace Questions 3

Medicaid and CHIP (Children’s Health Insurance Program) Home and Community Based Services State Unit on Aging Division of Medicaid and Long- Term Care

Administered by the Department of Health and Human Services Provides health care services to eligible elderly and disabled individuals and eligible low-income pregnant women, children and parents Pays for covered services for those persons who cannot afford to pay for medically necessary services and who meet certain eligibility requirements Medicaid Program

Jointly funded with Federal Government and State dollars Federal Government sets rules in statute and regulations that give states some flexibility to administer the program Federal Government has oversight responsibilities to ensure federal dollars are spent consistent with federal regulations State Medicaid programs are responsible for administration/operations of Medicaid Medicaid is always the payer of last resort No open enrollment period 6

Medicaid Eligibility Overview Medicaid is a means tested program however, individuals must first qualify for a category of eligibility. People Served and Eligibility Groups Pre-ACA Aged and disabled Low-income pregnant women Children Parents Individuals who meet a category of eligibility must meet income and for some populations, resource tests. 7

Medicaid Eligibility Overview 8

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Pre-ACA Eligibility Process 10 Consumer fills out NE application, submits to NE Medicaid Does documentation support eligibility criteria? Screen application for eligibility criteria such as income or disability Contact applicant for documents to support eligibility criteria Enroll in Medicaid Transfer Yes No Deny Medicaid eligibility

ACA Impact -Medicaid Eligibility Insurance Marketplace for Each State Single Streamlined Application “No Wrong Door” New Standard Method of Calculating Income Modified Adjusted Gross Income (MAGI) No Resource Tests Real-Time Eligibility Determination Medicaid Eligible People not Eligible for APTC/CSR with Exchange Plans Interaction with Insurance Marketplace Consumer Support What About the ABD Population? 11

ACA Impact -Medicaid Eligibility Mandatory Insurance Marketplace All states must implement an insurance Marketplace and offer Qualified Health Plans (QHPs) as defined in the ACA State option for Marketplace model State Based Exchange (SBE) Federal Partnership Marketplace Federally Facilitated Marketplace (FFM) Nebraska chose an FFM Significant interaction/coordination required between Nebraska’s Medicaid program and the Federally Facilitated Marketplace 12

Medicaid and the Marketplace will use the same application Single Application, created and approved by the Secretary of DHHS Applications may be completed on-line, on paper, in person or over the phone ACA Impact-Medicaid Eligibility Single Streamlined Application

ACA Impact -Medicaid Eligibility “No Wrong Door” Individuals can apply at the Marketplace or Medicaid and be routed to the most appropriate coverage for their circumstance Significant coordination between the Marketplace and Medicaid are required to support eligibility determination, appeals and to answer consumer questions “Better Door” approach by the Center for Medicare and Medicaid Services (CMS) 14

ACA Impact -Medicaid Eligibility Modified Adjusted Gross Income (MAGI) MAGI is a federally defined, mandated way to calculate income for eligibility determinations All states and the FFM must calculate income using MAGI Although minor, there are some differences in the way the FFM and Medicaid programs must calculate income No resource test required for eligibility. Only current income counts. Switch to MAGI necessitated significant changes to computer systems and eligibility determination business processes MAGI only applies to certain eligibility groups (Children, Parent Caretakers, Pregnant Women) 15

ACA Impact -Medicaid Eligibility Eligibility Groups ACA as written by congress mandated Medicaid coverage for all adults 0 – 133% FPL Supreme Court ruling made this coverage optional, at State discretion (Funding could not be withheld) Nebraska has opted to not cover this population The ACA added Former Foster Children as a mandatory eligibility group 16

ACA Impact -Medicaid Eligibility Real-Time Eligibility Determination ACA requires, where possible, real-time eligibility determination Key pieces of information, such as income, is electronically verified against a federal data hub to increase speed of eligibility determination. Previously, paper documentation was used to verify application information This shift to real-time determination causes a significant impact to Medicaid systems and workflow 17

ACA Impact -Medicaid Eligibility APTC/CSR ACA provides Advance Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR) to help individuals with income at or below 400% FPL pay for health costs If an individual is eligible for Medicaid, (s)he cannot be eligible for APTC/CSR. This requires all individuals applying for a Marketplace plan, that requests APTC/CSR to undergo a Medicaid eligibility assessment or determination Significant coordination required between Marketplace and Medicaid 18

“No Wrong Door” – Simple Case 19 Federal Marketplace State Medicaid Consumer fills out application, submits to Marketplace Consumer fills out application, submits to Medicaid OR Medicaid determination : Medicaid eligible? Notify consumer and enroll in Medicaid. Notify consumer, transfer application to marketplace Consumer covered by Medicaid Assess for Medicaid: Potentially eligible? Yes No Notify consumer, transfer application to Medicaid Notify consumer and enroll in QHP on Marketplace. Consumer covered by Marketplace TransferTransfer Transfer No Yes TransferTransfer

“No Wrong Door” – Complex Case 20 Federal Marketplace State Medicaid Family fills out one application, submits to Marketplace Family fills out one application, submits to Medicaid OR Medicaid determination, each member: Medicaid eligible? Notify family, enroll only Medicaid eligible members. Notify family, transfer only non- Medicaid eligible members to marketplace Some members covered by Medicaid Assess each member: Potentially Medicaid eligible? Yes No Notify family, transfer only potential Medicaid members Notify family, enroll non- Medicaid members in QHP. Some members covered by Marketplace TransferTransfer Transfer No Yes TransferTransfer

ACA Impact -Medicaid Eligibility Consumer Support No wrong door allows consumers to contact Marketplace or state Medicaid agency to obtain information about eligibility Necessitates cross-training on Marketplace eligibility and Medicaid eligibility Requires coordinated tracking of issues to ensure consumers are not bounced between Marketplace help desk and Medicaid help desk 21

ACA Impact -Medicaid Eligibility Aid to the Aged, Blind and Disabled (AABD)Population Eligibility rules unchanged under ACA AABD population are MAGI exempt Still requires a qualifying medical condition for eligibility However, due to ACA mandated single streamline application, AABD applicants must fill out a different form than other Medicaid applicants 22

ACA Impact -Nebraska New application New eligibility rules Changes to business processes Changes to systems Training for staff Significant interaction with Marketplace 23

ACA Timeline -Nebraska 24 ACA Becomes Law NE Begins Planning NE Goes FFM Implement FFM Integration Go Live Begin Eligibility Replacement System New Eligibility System Live Mar 2010 April 2010 Nov 2012 Oct 2013Jan 2016 Nov 2012 – Oct 2013 Oct 2013

ACA Impact -Nebraska Issues to Watch Moving Forward FFM Not Ready for Account Transfers Causing significant additional work for Medicaid eligibility workers Causing consumer confusion Causing delays getting people covered Work-arounds New “check-box” on application Medicaid Eligibility Check 25

“Better Door”, Current Status 26 Federal Marketplace State Medicaid Consumer fills out application, submits to Marketplace Consumer fills out application, submits to Medicaid OR Medicaid determination : Medicaid eligible? Notify consumer and enroll in Medicaid. Notify consumer, transfer application to marketplace Consumer covered by Medicaid Assess for Medicaid: Potentially eligible? Yes No Notify consumer, transfer application to Medicaid Notify consumer and enroll in QHP on Marketplace. Consumer covered by Marketplace TransferTransfer Transfer No Yes TransferTransfer X

Questions? 27