Medicaid Changes in Maryland under the Affordable Care Act Lorie Mayorga Deputy Director, Eligibility Policy Department of Health and Mental Hygiene

Changes to Medicaid Medicaid expansion: new eligibility for non-disabled, non-elderly, childless adults up to 138% of the Federal Poverty Level Certain populations transition to simplified eligibility rules based on income only Primary Adult Care population automatically transitioning to full Medicaid effective January 1st Former foster youth eligible for Medical Assistance up to age 26, regardless of income effective January 1st

Medicaid Regulations Medical Assistance Fair Hearing Appeals, COMAR 10.01.04 Approved effective October 1, 2013 by the Joint Committee on Administrative, Executive & Legislative Review Committee (AELR) Emergency Regulations same as proposed Proposed regulations published October 18, 2013 Medical Assistance Eligibility, COMAR 10.09.24 MCHP, COMAR 10.09.11 MCHP Premium, COMAR 10.09.43

Medicaid/MCHP Premium Eligibility Individuals must still meet Medicaid/MCHP Premium’s non-financial eligibility criteria Citizenship/immigration status Residency MHBE will make determinations on income-based Medicaid only for the following groups: children pregnant women parents and caretaker relatives of dependent children non-elderly, non-disabled childless adults Generally, the tax definitions of household size and MAGI-based income apply

Medicaid: Household Size, COMAR 10.09.24.06-1B Household size must be calculated for each household member, as it can vary even within the household Example: Lee and Amanda are married. Amanda is pregnant with twins. Amanda’s household size: 4 (Amanda + the twins + Lee) Lee’s household size: 2 (Lee and Amanda; the twins are not included in Lee’s household)

Household Size: Medicaid Exceptions The tax rules for household size do not apply for Medicaid/MCHP Premium when: the applicant is not planning to file taxes (i.e., income below filing threshold) the individual (child or adult) lives with a grandparent or other caretaker relative, regardless of who claims the individual as a tax dependent a child under age 21 lives with both parents, but only one parent will claim the child as a tax dependent a child, under age 21, lives with a custodial parent but will be claimed as a tax dependent by the non-custodial parent

Household Size—Exceptions cont’d In those situations, the (traditional) relationship-based household rules apply: For adults, a household consists of: adult applying for coverage applicant’s spouse, if living with the applicant applicant’s natural, adopted, and stepchildren under age 21, if living with the applicant For children under age 21, a household consists of: the child applying for coverage any of the child’s parents, stepparents, or adoptive parents living with the child for households headed by a non-parent caretaker adult, the caretaker adult any of the child’s siblings, step-siblings, or adoptive siblings under age 21 living with the child

MAGI-Based Income for Medicaid/MCHP Medicaid looks at monthly income A pro-rated portion of reasonably predictable changes in income may be considered if there is a basis for anticipating the changes e.g., such as a signed contract for employment, a clear history of predictable fluctuations in income, or other indications of future changes in income For Medicaid eligibility, MHBE uses the most recently published FPL level in effect for the month when an applicant applies

2013 Monthly Federal Poverty Level Guidelines (DC + all states except for Alaska and Hawaii)

MAGI-Based Income Limits for Medicaid and MCHP Premium Household Income To be eligible for MAGI Medicaid, applicant’s current monthly household income must meet specified standards Coverage Groups FPL Adults 138% Medicaid for children under age 1 199% Medicaid for children ages 1-21 MCHP 211% MCHP Premium 322% Parents and Caretaker Relatives Pregnant Women 264%

MAGI Income Rules Whose income is counted? In general, MAGI income of all individuals in an applicant’s household is counted toward household income, with two exceptions: Income of children (even over age 21) in household with parent if they are dependents and not expected to be required to file a tax return Income of most other dependents (not children or spouses) if not expected to be required to file a tax return A spouse’s MAGI income is always counted even if claimed as a tax dependent

Medicaid/MCHP Premium MAGI Income Special rules for Medicaid/MCHP Premium MAGI Lump sum payments are counted only in month received Taxable educational scholarships, awards—continue to be excluded from Medicaid income Certain types of income for American Indian/Alaska Natives are excluded

Changes to MCHP Premium No exclusionary period for voluntarily dropping employment-based health coverage Maximum 90 day “lockout” for nonpayment of premium Enrollment still requires payment of first month’s premium, but now children will receive a period of fee-for-service coverage during the MCO processing period

Medicaid/MCHP Premium Eligibility Determinations Maryland Health Connection determines eligibility only on the basis of MAGI income If application shows that applicant may be eligible for Medicaid on a different basis, or if the applicant requests a determination for non- MAGI groups, application will be referred to DHMH Some individuals who would otherwise have required a disability evaluation may now qualify for Medicaid in the adult expansion group

Retroactive Coverage Retroactive coverage rules remain the same: Medicaid will pay providers for services during any of the 3 months before application for individuals who are found eligible for such months Maryland Health Connection cannot determine eligibility for services furnished before 1/1/14 The single streamlined application allows Medicaid-eligible individuals to indicate that they have bills from the last 3 months Current eligibility is determined first—no application will be referred for “retro” processing unless applicant is eligible in application month

Former Foster Care Individuals: Proposed COMAR 10.09.24.03 Former foster care individuals may be determined eligible under MAGI coverage rules if they are: (a) Are younger than 26 years old; (b) Are not eligible and enrolled for coverage under a mandatory Medicaid group other than childless adult; and (c) Were in a Maryland out-of-home placement, including categorical Medicaid: (i) On attaining age 18 and leaving out-of-home placement, or (ii) On attaining age 19-21 during extended out-of-home placement under COMAR 07.02.11.04B.

Advance Premium Tax Credit vs. Medicaid APTC/Cost Sharing Reduction Medicaid/MCHP Premium Definition of MAGI-based income IRS definition IRS definition, except that the following is excluded: income of dependents as long as they are not expected to be required to file a tax return; certain American Indian/Alaska Native income; and educational scholarships and grants. Also, lump sum payments are counted only in the month received. Data sources used FTI is checked first; if the FTI is not reasonably compatible, then State data sources are checked automatically State data sources

APTC/CSR vs. Medicaid/MCHP Premium Applicable FPL FPL in effect as of the first day of Open Enrollment (always in October) FPL in effect for the month that coverage is sought Percentage of FPL Determined using annual income Determined using monthly income Definition of household IRS definition IRS definition except when: an applicant does not plan to file taxes; an individual lives with a grandparent or other caretaker relative; a child who lives with both parents is claimed by only one parent; or a child is claimed by non-custodial parent

Eligibility Scenarios

Scenario One Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren makes $38,000 per year. What coverage is each member of the household eligible for?

STEP 1: Determine Medicaid/MCHP Premium eligibility Scenario One Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren is a salaried employee making $38,000 per year. STEP 1: Determine Medicaid/MCHP Premium eligibility There are 3 people in the household; the fact that Lauren does not claim Mitchell as a dependent does not affect the Medicaid household size. The applicable monthly FPL is $1,627.50, so the monthly household income of $3,166.67 is at 195% of the poverty line, making both Mitchell and Patrick eligible for MCHP. Lauren, is not eligible for Medicaid because the income is higher than 138%

Scenario Two Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. Before that he was unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters. HIX calculates that Kurt’s annual income is $28,000 per year. Given that the difference between Kurt’s attested income and the annualized income from MABS is greater than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee. What coverage is Kurt eligible for?

Scenario Two STEP 1: Determine Medicaid eligibility Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. Before that he was unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters. HIX calculates that Kurt’s annual income is $28,000 per year. Given that the difference between Kurt’s attested income and the annualized income from MABS is greater than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee. STEP 1: Determine Medicaid eligibility Because Kurt’s employment is seasonal, HIX’s calculations were not correct. The income is corrected during the Inconsistency Period and Kurt is determined eligible for Medicaid.

Contact Information Lorie Mayorga lorie.mayorga@maryland.gov 410-767-1464 Maryland Health Connection: marylandhealthconnection.gov Customer Service Center: 1-855-642-8572