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The Basics of the ACA, Medicaid & FAMIS in Virginia

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Presentation on theme: "The Basics of the ACA, Medicaid & FAMIS in Virginia"— Presentation transcript:

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

26

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.


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