1. Medicaid & Marketplace Updates Kyle Fisher Kfisher@phlp.org October 2015

2. Session Topics Medicaid Traditional Medicaid Expansion  Transition from Healthy PA to HealthChoices New Expansion Category Immigrant Coverage Options Marketplace Cost-Sharing Reductions 2

3. TRADITIONAL MEDICAID EXPANSION Medicaid 3

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5. Phase Out of Healthy PA Gov. Corbett’s alternative Medicaid expansion created new managed care delivery system  Effective January 1 st, 2015  Called the Healthy PA Private Coverage Option (PCO) Gov. Wolf moved to a simpler, traditional expansion under the “HealthChoices” managed care system: Two phases: PCO -> MCO  June 1 st - 121,000 enrollees transferred  Sept. 1 st – 79,000 enrollees transferred 5

6. Medicaid Expansion PCO to MCO transition completed September 1 st Private Coverage Option now defunct “Adult” benefit package implemented 4/27/15 DHS intends to withdraw the Healthy PA 1115 waiver by Sept. 30  Notice given to CMS on March 10, 2015 (6 months req.)  None of the other Healthy PA reforms, such as premiums or work incentives, go into effect 6

7. Delivery Systems What is HealthChoices? Long established Medicaid managed care program Expanded statewide  “New West” in fall 2012; “New East” in spring 2013 Separate physical health & behavioral health systems  Known as behavioral health “carve-out”  Single BH MCO in each county Covers most adults, not dual-eligibles (on PH side)  Until, at least, MLTSS proposal implemented 7

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9. NEW ADULT/EXPANSION CATEGORY Medicaid Eligibility 9

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11. Newly Eligible Adults Adults age 19-64 Income under 138% FPL Cannot qualify for Medicare No asset test 11 Household of 1 Household of 2 Household of 3 Household of 4 138% FPL (2015) monthly $1,354$1,832$2,311$2,789

12. Monthly vs Annual Income Medicaid uses “point-in-time” eligibility  Essentially monthly  Unlike HealthCare.gov, which uses annual income But, if monthly income is over 138% FPL, and  Expected annual income is less than 138%  Because income expected to decrease or end  Such as unemployment comp. & seasonal employment Then CAO should use expected annual income  See policy clarification PMA17446312 (2/2015) 12

13. Medicaid Eligibility Basics 3-step analysis for each person 1) What category does the person fit in? 2) What is the person’s household size? 3) Is the person under the monthly income limit for that category and household size? 4 th step for immigrants 1) What is the person’s immigration status and does it meet the relevant Medicaid standard? 13

14. MAWD Medical Assistance for Workers with Disabilities Underused category  High income & resource limits  Minimal work requirement  Many who do not consider themselves “disabled” meet the MAWD disability standard Age 16-64; requires 5% premium  Based on recipient’s income only, after disregards see manual on PHLP website 14

15. IMMIGRANT COVERAGE OPTIONS Medicaid Eligibility 15

16. Immigration Status Overview “Lawfully Present”  Medicaid standard for:  Children  Pregnant women “Qualified”  Plus five year waiting period, for most immigrants  More narrow than “lawfully present”  Medicaid standard for:  Adults 16

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18. The 5 year bar Waiting period runs from date the person obtains “qualified” status Does not apply to certain immigration categories (generally humanitarian): Refugees & Asylees (even if later become LPR) Persons granted withholding of deportation Cuban/Haitian entrants Iraqi or Afghan special immigration status U.S. veterans or active duty military, spouses, or children 18

19. GA-related Medical Assistance For very low-income immigrants subject to the ‘5 year bar’ and still in waiting period. This is state-funded MA that covers about 4,000 immigrants. GA/MA has no 5 year bar. Category: 1. Temporary Disability  Employability Assessment Form– Box 3 2. Health-Sustaining Medications form, or 3. Age 59+ 19

20. GA/MA Income Limits GA-related MA (if disability/need for Rx) Income limits vary slightly by region, see MAEH 368 Appendix A GA-related MA (if age 59+) 20 HouseholdIncome Limit (monthly) Resource Limit HH of 1 $205$250 HH of 2 $316$1000 Household SizeIncome Limit (6 months) Resource Limit HH of 1$2,550$2,400 HH of 2$2,650$3,200

21. HealthCare.gov Special rule for immigrants who do not qualify for Medicaid because of immigration status  No income floor for PTC - Income: 0 - 400% FPL To qualify for premium tax credits Normally an income “floor”:  Income: 138 - 400% FPL 21 1 person2 people3 people Adults 138% poverty $16,248$21,984$27,310

22. Emergency Medical Assistance What options exist for someone who doesn’t meet the “qualified” or “lawfully present” standards? Emergency Medical Assistance  no immigration status required  must be otherwise eligible (meet category & income req.)  Limited to time period of emergency condition 22

23. Emergency Medical Assistance  An emergency medical condition is a medical condition with acute symptoms of such severity including severe pain, that without immediate attention, the result may be:  The patient’s health is in serious jeopardy.  Serious impairment to bodily functions.  Serious dysfunction of any body organ or part.(see MAEH 322) Detailed letter from physician is key 23

24. COST-SHARING REDUCTIONS Marketplace 24

25. Cost-Sharing Reductions 2.2 million 2015 Marketplace enrollees (under 250% FPL) failed to take advantage of Cost-Sharing Reductions 25 *Avalere Health Analysis

26. Marketplace Basics - Subsidies Who qualifies?  Premium Tax Credits  Income between 100-400% FPL  Cannot be eligible for other “minimum essential coverage”  Cannot be offered “affordable” (<9.5%) employer-based coverage  Cost-Sharing Reductions  Income between 100-250% FPL  Eligible for premium tax credits  Enroll in Silver-level plan 26

27. Cost-Sharing Reductions Why would someone forego CSRs? Lower premiums! Essential that they understand the trade-off:  Premiums vs Cost-sharing CSR harder to understand than APTC  PTC are a concrete number  CSR vary by plan, operate in the background 27

28. Types of Plans – “Metal Levels” Highest Premiums & Lowest Cost Sharing Lowest Premiums & Highest Cost-Sharing *before CSR 28 Actuarial Value. The percentage of total average costs that a plan will cover.

29. Cost Sharing Reductions How do Cost Sharing Reductions work?  Three levels of CSR based on income  Paid directly to the Silver plan  Seamlessly reduces enrollee’s out-of-pocket charges 29 Standard Silver – no CSR 100-150% FPL 151-200% FPL 201-250% FPL Actuarial Value 70% AV94% AV87% AV73% AV

30. Cost Sharing Reductions Average cost-sharing at each CSR tier: 30 Kaiser Family Foundation

31. Types of Plans – “Metal Levels” 31

32. Resources DHS Medicaid Expansion Website  www.HealthChoicesPA.com www.HealthChoicesPA.com Medical Assistance Eligibility Handbook  http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm Avalere Health Analysis  http://avalere.com/expertise/managed-care/insights/more-than-2-million-exchange- enrollees-forgo-cost-sharing-assistance http://avalere.com/expertise/managed-care/insights/more-than-2-million-exchange- enrollees-forgo-cost-sharing-assistance PHLP Helpline: 1-800-274-3258  KFisher@phlp.org KFisher@phlp.org PHLP Medicaid Eligibility Manual  http://www.phlp.org/wp-content/uploads/2015/02/Eligibility-Manual-2015.pdf http://www.phlp.org/wp-content/uploads/2015/02/Eligibility-Manual-2015.pdf 32