1. THE ACA, ELIGIBILITY & ENROLLMENT Shanna Hanson, FHFMA

2. 100 Years Ago (1906)  Life expectancy 47  Bathtub 14%  Telephone 8%  Cars 8,000  Paved roads 144 miles  Speed limit 10 mph  CA 21 st most populated state  Births at home 95%  Avg worker $200-$400 per year  Drs 90% no college  Women washed hair once a month  Las Vegas pop. 30  High school grads 6%  Marijuana, heroin, morphine all legal

3. Health Coverage Memory Lane  19 th Century: Little or no money  1930’s: Insurance  1962: Medicare  1965: Medicaid – Low-Income Families; ABD – 1986: Pregnant Women and Infants (State Option) – 1989: Pregnant Women and Children (Mandated) – 1990: Children 6-18 (Phased In) – 1997: SCHIP  2010: PPACA  2014: TOMORROW!!!

4. Objectives  Review areas of eligibility and enrollment process impacted by the ACA, regardless of expansion  Examine what changes and how  Help you prepare your staff and facilities for changes Today’s Agenda

5. Language is Important  States May vs. States Must  State Option vs. Required by States  Proposed vs. Final (Rules)  MAGI – Modified Adjusted Gross Income  Medicaid, Marketplace or both?  Marketplace (a.k.a., Exchange) – FFM – Federally Facilitated Marketplace – FSP – Federal State Partnership Marketplace – State-Based Marketplace

6. Language is Important  QHP – Qualified Health Plan. Insurance coverage sold through the Marketplace, subsidized or not.  APTC – Advanced Payment of Tax Credits. Subsidies received for QHP coverage in the Marketplace.  IAP – Insurance Affordability Programs. Medicaid, CHIP, APTC Subsidized QHP.  IPA – In-Person Assister. State program, separate from the Navigator program.  CAC – Certified Application Counselor Unfunded assister.

7. Expansion vs. Non-Expansion Overview  Supreme Court Decision – Can’t penalize a state that does not expand Medicaid to 133% of Federal Poverty Level.  No other provisions of the law affected. – Example: coordination with the Marketplace, including use of standard income eligibility methods, apply.

8. Expansion vs. Non-Expansion “So What?” Impact on Medicaid Program Administration  State policies and procedures will change  Materials published  Training provided  Culture shifts  State Medicaid systems must communicate electronically with the Marketplace  Coverage gap in states that choose not to expand  Other expansion models being considered

9. Impact of ACA on Eligibility and Enrollment  Application  Assistance  Presumptive Eligibility  Eligibility  Verifications  Technology

10. Process designed to be more consumer friendly  Forms: single streamlined, multi-benefit or supplemental  Interview: no face-to-face for MAGI  Reconsideration: 90 days without new application  Signatures: electronic, phone, fax, other  Submission: online, phone, in person, mail or IAP agency (no “wrong door”) Application No Wrong Door!

11. Application “So What?” Path to eligibility will be easier, less burdensome, and take less processing time.  Federal government published three applications  Additional supplemental forms may be needed  Other application options exist  Application assistance is a necessity – Massachusetts: less than 1 in 18 finish online Approved !

12. How Many Assisters Do We Need?  2.25 hours estimated per consumer  211,000 consumers  475,445 total hours of assistance  Assuming assisters are using 85% of their time over six months of open enrollment to help consumers  884 hours per assister  475,445 / 884 = 538 assisters needed Arkansas New Hampshire  $73,000 per assister estimated, plus overhead costs  $600,000 grant  8 or less navigators Georgetown University Health Policy Institute Center for Children and Families

13. Assister by Marketplace Type Federally FacilitatedState-federal PartnershipState-based Navigator: program development Federal government State Navigator: program management Federal government Federal government with state participation State Navigator: funding Federal government awards grants to a minimum of two entities in the state, one of which must be a community- based organization State can use federal exchange establishment grants for planning, but cannot use that funding for operations In-person assister: program development Will not have themRequiredOptional In-person assister: program funding Not applicable State can use federal exchange establishment grants to establish and operate the program Certified Application Counselor: program development Required for marketplace, optional for Medicaid Certified Application Counselor: funding None

14. Navigator and IPA Duties 1.Maintain expertise 2.Maintain a fair, accurate and impartial manner 3.Facilitate selection of a QHP 4.Provide referrals for enrollees 5.Provide information in a culturally and linguistically appropriate manner 6.Perform outreach and education

15. CAC Duties Marketplace (All) Provide information. Assist individuals to apply for coverage. Help to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs. Medicaid/CHIP (Some or All) Provide information. Help individuals complete an application or renewal. Work with the individual to: – Provide documentation – Submit to the agency – Interact with the agency – Respond to agency requests – Manage their case

16. Marketplace CAC Certification Requirements 1.Registers 2.Is trained prior to providing application assistance 3.Complies with applicable authentication and data security standards, and with the privacy and security standards 4.Provides application assistance in the best interest of applicants 5.Complies with any applicable state law(s) 6.Provides information with reasonable accommodations 7.Enters into an agreement

17. Authorized Representatives  Designated by the applicant/beneficiary  Has the legal authority to interact on behalf of the applicant/beneficiary  Can sign the application  Receives notices  Individual or organization  Must be allowed by the state

18. Hospital Enrollment “So What?” 1.Possibility of larger staff focused on assistance 2.Staff space allocations 3.Centralized or decentralized 4.Privacy for applicants 5.Performing tasks outside of your core business 6.Initial and ongoing training 7.Staff certification 8.Staying current with program and policy changes 9.Employing the most efficient and effective processes

19. Presumptive Eligibility  Presumptive Eligibility (PE) Enrollment by “Qualified Hospitals” –Participate as a Medicaid provider; –Notify state Medicaid agency of its decision to make PE determinations; –Agree to make determinations consistent with state policies and procedures; –At state option, assist individuals in completing and submitting the full application and in understanding any documentation requirements; and –Not be disqualified by the state Medicaid agency.  PE Expansion Groups

20. Presumptive Eligibility “So What?”  Provider payment during temporary eligibility period – Payment stands even if person found ineligible  State rules will vary, which may make PE more or less attractive to hospitals  Risk of becoming uninsured after PE period  Staffing, logistics, privacy, training and certification

21. Eligibility  MAGI-Based Medicaid: Collapse into 4 groups  MAGI-Excepted Medicaid: Aged, disabled, etc.  Optional Groups: BCCT, working disabled (exempt from MAGI)  Emergency Medicaid: No changes  Retroactive Coverage: Up to three months  Spend down in 209(b) States not Medically Needy: Aged, blind, disabled

22. Eligibility  Maintenance of Effort: 9/30/19 for children  Children – Highest level for age group – 185% Federal Poverty Level for infants  Enrollment While Pending (e.g., disability): – MAGI-based or QHP enrollment while pending for MAGI-excepted coverage – Medicaid is retroactive, QHP coverage is not – MAGI-excepted Medicaid would be a secondary payer for overlapping eligibility

23. Eligibility CriteriaMAGI-Based Medicaid/CHIPQualified Health Plan HouseholdTax household with exceptionsTax household IncomeTax rules with exceptionsTax rules Disregard5%Not applicable Budget PeriodPoint in time (current month) Annual based on last tax return Start DateUp to 3 months retroactiveProspective

24. Eligibility “So What?”  States may drop and/or change Medicaid programs when the Maintenance of Effort expires 12/31/13, except for children  Program options will impact: – Process the applicant goes through – Cycle time – Payment to the provider

25. Verifications  What –Age, DOB, Household Size: States “may” verify –Income: Process and sequence could vary –Pregnancy: Self-attestation  How –Data-driven Process: Electronic sources –Documentation Submission: Online, phone, in person, or via mail –Electronic Data Matches: States decide usefulness, frequency and time-frame (could be after enrollment)

26. Verifications  How Cont’d – Self-Attestation: Permitted, except as required by law, or not permitted by law – When Documentation is Permitted: Not reasonably compatible – When State Law Does Not Permit Self Attestation: State option to accept self-attestation unless ACA does not permit  Reasonably Compatible: Both attestation and electronic information are either above or below the eligibility level  Reasonable Opportunity Period: 90 days for Marketplace; differs for Medicaid

27. Verification “So What?”  Verifications plans will be state specific  State policy decisions will be based on their verification plan  Transparency

28. Technology Open enrollment: 10/1/2013 - 3/31/2014  Online application system must support single streamlined application  Electronically Pass Accounts: Medicaid and the Marketplace  FFM Medicaid “Determination” or “Assessment” – Medicaid eligibility determination or – Medicaid eligibility assessment (at the state’s option)  Implement state access to “The Hub”  Systems must support new renewal process

29. Technology “So What?”  Open enrollment without the technology to support it will create backlogs and frustration.  State rules dictate the type of Medicaid decisions that can be made by the FFM.  A lot to do. Will states be ready?

30.  Reviewed six areas of the eligibility process impacted by ACA, regardless of expansion.  Examined what changes and how.  Gave you points to ponder as you begin to prepare your staff and facilities for the changes ahead. ̶Application ̶Assistance ̶Presumptive Eligibility ̶Eligibility ̶Verifications ̶Technology Wrap-Up

31. Human Arc Health Care Reform Resources humanarc.com Additional Questions? shanson@humanarc.com Industry Blog LinkedIn @HumanArc_ HumanArc Scoop.it!