Jeannine Peterson MPA Hamilton Health Center October 26, 2015

 Identify what types of health care insurance coverage is available  Identify who is eligible for health care coverage  Where to go for help in applying for coverage  Where to go to access medical and dental services

Public and Privately Funded Programs

 Provides free health insurance for low income adults and children  Have incomes at or below 138% of the federal poverty level  Are lawfully present, or, in an eligible qualified immigration status.

 Lawful Permanent Residents (“LPRs” or “green card holders”)  Refugees  Aslyees  Cuban/Haitian entrants  Conditional entrants  Individuals paroled into the US for more than one year  Certain domestic violence and trafficking survivors and their children  Persons granted withholding of deportation/removal

 Pregnant women  Children under age 21  Refugees  Asylees  Cuban and Haitian Entrants  Plus others  Refer to the Pennsylvania Medical Assistance Handbook for a full listing of those considered to be “Lawfully Present”

 Provides health coverage for individuals over age 65 or who have been receiving Social Security Disability Income for over 2 years.  Only available to U.S. Citizens and Legal Permanent Residents (LPRs or “Green Card Holders”) who have been in the United States for at least 5 years.  Individuals without the requisite work credits may have to pay for Medicare, even if eligible based on immigration status.

 Provides free or low-cost health insurance to children up to age 19 whose families are lawfully present and earn too much to qualify for MA  No family makes too much money to get CHIP. Depending on income some coverage is free others pay premium  Comprehensive and includes both physical, behavioral, dental, vision, and hearing services, as well as prescription drugs, emergency care and in-patient services

 Marketplace – Obamacare ◦ Health insurance plans that provide comprehensive coverage at an affordable price for many low- income consumers ◦ An immigrant must be lawfully present to enroll in a Marketplace plan and to receive financial help paying for the plan ◦ Undocumented immigrants are excluded from enrolling in the marketplace, even from buying a plan at full cost.

Medicaid or MA

 Must be living in PA and planning to be here indefinitely  No time requirement, can travel in and out of the state as long as you plan on returning (example: migrant or seasonal workers)  No permanent address required but you must be able to check their mail regularly

 Important because income and resource limits vary by category  Each category covers a specific population: children, pregnant women, parents, healthy adults, disabled adults, disabled children, the elderly – and there are more  Now every Pennsylvanian fits into an MA category as long as they meet the residency requirements, are low income, and have the eligible immigration status

 Each MA category has its own income and resources limits, which vary based on the applicant’s household size  “Income” - the money an individual receives every month, from sources such as employment, pensions, government benefits, etc  “Resources” - generally the 5 things an individual owns, such as savings and checking accounts, retirement accounts, the cash value of life insurance policies, etc .

 “ Qualified” Immigrants  Adults  Must wait five year before being eligible for MA unless you meet certain criteria

 Pregnant women (through the 60-day post-partum period)  Children under age 21  Refugees and asylees (even if they now have a green card)  Cuban/Haitian entrants;  Survivors of trafficking  Immigrants whose deportation is being withheld;  Certain veterans and their families  Certain people who have lived in the U.S. continuously since before 8/22/1996 who are now legal immigrants  Refer to the Pennsylvania Medical Assistance Handbook for a full listing of those without a waiting period

 Lawfully Present (residing) Children under 21& Pregnant Women  State option: PA Chose to expend Medicaid to this group  This group does not need to meet the more stringent standard of “qualified” immigration status that applies to adults  No 5 year bar: can get MA coverage as soon as they enter US as long as they meet other eligibility requirements (residency and income) There are other categories of Lawfully Present listed in the MA handbook

 Called HealthChoices  State is divided into regions with each region having certain insurance companies under contract to the PA Department of Human Services  Recipient must select a MA insurance company i.e. UPMC, Gateway, Health Partners, United, etc  Recipient must select a Primary Care Provider (PCP)  If an insurance company or PCP isn’t selected one will be chosen for you  Mental Health and Substance Abuse Services are “carved out”, that is, they are managed separately

For People with Medical Conditions

 Health care coverage for any immigrant regardless of their immigrant status as long as they meet EMA requirements. This includes undocumented immigrants and those “qualified” immigrants who fall within the five year bar  Temporary MA coverage to treat a specific medical condition known as an Emergency Medical Condition (EMC); usually an acute problem  After the treatment of the condition, the MA coverage ends

 A medical condition with acute symptoms including severe pain, that without immediate attention, could result in: o Health being in serious jeopardy o Serious impairment to bodily functions o Serious dysfunction of any body organ or part  Does not necessarily require ER visit  Does not include any services related to organ transplants

 Eligible for EMA if experiencing a high risk pregnancy  Labor and Delivery automatically covered  Pre natal and post natal covered up to 60 days post delivery

 Doctors letter required to accompany application  Use the standard MA application form (PA- 600HC)  Apply online using the COMPASS system, or via telephone by calling  Write on the form “Application for EMA only”  Immigrant does not have to indicate their immigrant status (documented vs undocumented)

 Doctor determines if condition meets EMC definition and be willing to write the letter ◦ Letter must identify what the EMC is ◦ Identify what specific criteria the condition satisfies ◦ What types of medical services will be required for to treat the condition ◦ Identify how long treatment will be required. Recommendation is no longer than 6 months and then condition can be reassessed, unless the doctor knows it will take longer. Longer time frame brings greater scrutiny ◦ Explain what will happen if patient doesn’t get the care that’s needed

 Residency  Income and Resource  Work with doctor and County Assistance Office  Include Medical Records

 EMC is usually for short term conditions, but chronic conditions can be covered, but substantiating this will be more difficult  We have resource materials available to you today that may help you with this

CHIP

 Provides free or low-cost health insurance to uninsured children up to age 19 whose families earn too much to qualify for MA  Includes both physical and behavioral services, including prescription drugs, vision, hearing and dental services as well as emergency care and in- patient services  Uses the same “lawful presence” immigration status utilized for pregnant women and children applying for MA  No income too high for CHIP but may have to pay premium for coverage

 Use online system – COMPASS same as for MA  If unsure if child is MA or CHIP eligible, apply for MA. The county assistance office will transfer the application to CHIP if family income is too high for CHIP  Apply directly to CHIP if you know the income is too high for MA and child doesn’t have a disability

Obamacare Coverage

 Must be “lawfully present” to enroll in a plan and receive financial help paying for the plan  Lawful presence includes: ◦ Lawful Permanent Residents (LPRs or “green-card holders”) ◦ Humanitarian statuses like asylum ◦ Non-immigrant visa holders, including those on work or student visas  “Qualified” immigrants who do not meet the Five Year Bar should also consider the Marketplace  Undocumented immigrants are excluded from enrolling in the marketplace, even from buying a plan at full cost

 Premium Tax Credits (PTC) help lower an individual’s monthly health insurance premium (money paid each month to be enrolled in the plan)  Cost Sharing Reductions (CSR) help with out- of-pocket costs (money spent on things like doctor’s visits, lab tests, and prescription drugs.) CSRs are only available to people enrolled in “Silver” level Marketplace plans

 Only people with household incomes between 138% FPL and 400% FPL can get help paying for Marketplace coverage using PTCs and CSRs exception  Immigrants who are ineligible for MA because of their immigration status can get PTCs and CSRs even if their income is below the traditional 138% FPL floor. This includes immigrants who are ineligible for MA because of the Five Year Bar

 Apply online at Healthcare.gov or by calling  Only during open enrollment periods: ◦ Open Enrollment for 2016 coverage will be October 15, 2015 through December 15, 2016 ◦ Can only enroll outside this period if you have a major life event, such as marriage, divorce or child birth  Must document citizenship or immigrant status

 Certified Application Organizations have received designation by the Federal Government  Individuals called Certified Application Counselors are able to assist with enrollment into Medicaid, CHIP and the Marketplace  Who are designated: Federally Qualified Health Centers, hospitals, and social service agencies

 Identify health care providers that accept your insurance  If uninsured, i.e. do not qualify for Medicaid, CHIP, EMA, or the Marketplace, seek out free clinics or Federally Qualified Health Centers who have sliding fee scale and other types of free services  Do not use the Emergency Room for non- emergency care  You will need to find a doctor within the health care network willing to assist with EMA paperwork

 Need routine primary care for children and adults (well child check ups, immunizations, sick care for adults and children)  Need work physical exams, driver physical exams  Women’s annual exams, prenatal care, birth control

 Dental care  Mental health  Substance Abuse

 Language ◦ Must comply with Title VI of 1964 Civil Rights Act ◦ Any organization that receives federal funding - health care provider, insurance company, the County Assistance Office, must provide interpreting services free of charge ◦ Can be live interpreters or telephone service  Social Security Number ◦ Should not be required to receive services at publically funded clinics, for EMA or for CHIP; Do not use false number, just indicate no number ◦ It is required for MA and the CAO can help with this  Immigration Status ◦ “Qualified Immigrants must prove their status ◦ Health clinics do not require proof

 PA Health Law Project’s 2015 ◦ MA Eligibility Manual ◦ Health Care for Immigrants: A Manual for Advocates in Pennsylvania  PA Department of Human Services ◦ MA Manual

QUESTIONS