1. The Basics of the ACA, Medicaid & FAMIS in Virginia
ACA
NAVIGATOR NAME
HEALTHCARE NAVIGATOR
ENROLL VA:
T: XXX-XXX-XXXX

2. 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

3. 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

4. New Consumer Protections
After ACA
Children covered on parent’s plan through age 26
Coverage of pre-existing conditions
FREE preventative services
Harder for insurers to cancel coverage
10 Essential Health Benefits covered at all plan levels
Medical loss ratio – requiring insurers to spend at least 80% of premiums on medical services or rebate to consumers
No annual or lifetime caps on services
Limits on annual consumer costs, out-of-pocket maximums
Reduced risk of bankruptcy
Financial assistance for some consumers to purchase insurance
Phasing out Medicare Part D donut hole
Rates can only be adjusted by age, geography and smoking status, not gender or medical conditions

5. 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

6. Examples of Free Preventative Services
Regular check-ups and well visits
Mammograms
Cervical cancer, colon cancer and osteoporosis screenings
High blood pressure and cholesterol screenings
Bone density measurements
Flu shot
Developmental screenings, including autism
Multiple health screenings for newborns
Vaccinations
Behavioral health assessments for children

7. 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.

8. 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 % 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.

9. 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.

10. 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

11. Eligibility for Financial Help
Premium tax credits
reduce the amount you pay for your premium. You may be eligible if you are between % 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.

12. 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

13. 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

14. 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!

15. Open Enrollment for Coverage for 2019
Open enrollment is November 1, 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

16. 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.

17. Medicaid and FAMIS in VA

18. 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

19. 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

20. 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

21. New Income Limit- 138% FPL

22. 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

23. Medicaid Expansion: Early and Future Initiatives
The 2018 Appropriations Act directs Virginia Medicaid to implement new coverage for adults and transform coverage
Beginning January 1, 2019:
Implement New Adult Coverage And Other Policy Initiatives
Beginning January 1, 2019 –
New coverage for adults with incomes up to 138% FPL
Key initiatives include:
Health and Wellness Incentives
Referrals to Workforce Resources
Appropriate Utilization of ER Services
Future initiatives in development for certain individuals:
Health and Wellness Accounts
Cost-sharing including copayments
Training, Enrollment, Education, Employment and Opportunity Program (TEEOP)
Supportive Employment and Housing Benefit
Future Initiatives in Development:
(These initiatives require federal approval of a § 1115 Demonstration Waiver)
The state budget creates a framework for expanding adult coverage as well as making additional changes to our Medicaid program. It’s important to understand the timing of these changes.
New coverage will be available to adults with incomes up to 138 percent of the federal poverty level beginning January 1, 2019
Several new initiatives will also begin January 1, 2019, such as:
Health and Wellness Incentives that will be offered as a benefit through the health plans;
Referrals by health plans to the Career Works Centers (One Stops) to help with job training, education, and job placement assistance; and
Outreach and care coordination to frequent emergency room visitors.
In the future, there will be other initiatives for certain individuals, but the details for those changes are still in development and will require federal approval through a Section 1115 Demonstration Waiver, which gives a state flexibility to test innovations within the Medicaid program.
I want you to know that you will have an opportunity to submit public comments on these future initiatives before they are final. Virginia Medicaid encourages you to monitor the Cover Virginia website for updates and participate in this process when the public comment period begins.
As an advocate, you may work with an individual who is interested in applying for the new adult coverage when enrollment begins, but that person may have some questions about the future initiatives. Please encourage people to go ahead and apply when enrollment begins so they can have coverage beginning on January 1, You can let them know that any additional benefits or requirements will happen later, and they will get information in plenty of time to ask questions and understand how they might be affected.
New adult coverage begins January 1, 2019, while future initiatives are still in development

24. Children under 19 Medicaid (FAMIS Plus) CHIP (FAMIS)
MAGI under 143% FPL + 5% disregard
No resource test
CHIP (FAMIS)
MAGI under 200% FPL + 5% disregard
Child must be uninsured when the application is completed (same for FAMIS Moms)

25. Pregnant Women Medicaid for pregnant women
MAGI under 143% FPL + 5% disregard
FAMIS Moms for pregnant women
MAGI under 200% FPL + 5% disregard
A pregnant woman counts as 2 people (or more if carrying multiples) in assistance unit
Coverage continues until 60 days post-partum (Even if income goes up)
No resource test
Newborn “deemed” eligible for 1 year
Also applies to babies of Emergency Service aliens

27. Low Income Families and Children (LIFC)
Very low income parents, caretaker relatives
MAGI income, no resource test
Income limit varies based on localities, 3 groups
E.g. Income limit for a family of 3 (no disregard)
$475/month in Group I
$588/month in Group II
$700/month in Group III
“Transitional” coverage when income goes up
All parents with household income below 138% FPL will be newly eligible under LIFC or Medicaid Expansion!

28. Aged, Blind, and Disabled (ABD)
Aged (over 65 years), Blind, & Disabled (ABD)
Income under 80% FPL
Non-MAGI category
Resource Rules apply
Bank Accounts/property/other assets
If they have “excess resources”, may be “newly eligible” under Medicaid Expansion category
Limits on ”countable” resources ($2,000 individual, $3,000 couple)
Covers most SSI recipients

29. Important Rules for Immigrants
Very complicated! Eeligibility usually depends on date of entry to U.S. and specific immigrant status.
“Qualified Aliens” who arrived before/after 8/22/96.
Ex. LPRs, Refugees/Asylees, Parolee, Cuban or Haitian Entrant, Battered Alien, Afghan or Iraqi Special Immigrant, Victims of Trafficking)
If after 8/22/96 most barred for at least 5 years, except:
“Legally Residing” immigrants under 19 years old and pregnant women, includes Visa holders
Certain veteran/active duty immigrants & their family members
Also better rules on social security numbers
“Any non-citizen who is only eligible to receive an SSN for a valid non-work reason is not required to provide or apply for an SSN.”
-Virginia Medical Assistance Eligibility Manual, M (A)(2)

30. Important Rules for Immigrants, cont’d
Virginia uses restrictive rules even after the 5-year bar
Requires 40 quarters of work (counting spouse, dependents).
Can result in a permanent bar!
Special 7 year coverage for certain groups
Refugees & Asylees
Deportation is being withheld under Section 243(h) of the INA.
Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980
Victims of a Severe Form of Trafficking
Afghan or Iraqi Immigrant Admitted to the U.S. on a Special Immigrant Visa
Note: legally residing immigrants ineligible for Medicaid can qualify for subsidized Marketplace coverage even if income is under 100% FPL.

31. 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

32. 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”

33. Application Doors for All Types of Health Insurance
Online
Marketplace:
Medicaid/FAMIS
Information:
Application:
Phone
Marketplace:
Cover VA:
Local Help
Enroll Virginia: or

34. Twitter-@EnrollVirginia
Questions?
xxx-xxx-xxxx
Facebook-
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 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.