Prepared by Families USA for use in the District of Columbia

About These MaterialsFamilies USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for a training program for DC eligibility workers. These workers determine eligibility for Medicaid and other benefit programs (including SNAP and TANF). They will help consumers apply for coverage and financial assistance, report changes, renew coverage, and verify the information that is needed to determine eligibility. These workers will not be responsible for helping consumers select health plans.

These training materials are posted here as an example that can be adapted for other training programs. They contain information that is specific to the District of Columbia, which would have to be changed if used in another state. Contact Families USA at stateinfo@familiesusa.org for assistance with adapting these materials.

ESA Policy Training Day 2

MAGI, Non-MAGI, and Eligibility Categories

Prepared by Families USA for use in the District of Columbia

Prepared by Families USA for use in the District of Columbia

What is MAGI?

• The Affordable Care Act defines how eligibility will be determined for:• Most Medicaid beneficiaries• All people who get premium tax credits and

cost-sharing reductions

• Modified Adjusted Gross Income (MAGI) is the new way of looking at household composition and income

• MAGI won’t be used for certain populations

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Who are the MAGI groups?• Four groups:

• Parents and caretaker relatives• Children • Pregnant women• Adults aged 21-64 without dependent

children

• About 158,000 beneficiaries

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Parents and Caretaker Relatives

• Includes parents and caretaker relatives and, if living with them, their spouses

• One group called 1931 Low-Income Families

• Eligible for Medicaid with incomes up to 221% of poverty

• Those over age 65 can receive MAGI Medicaid as parents/caretaker relatives

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Who is a caretaker relative?

• Relative (based on blood, adoption, or marriage) with whom dependent child is living who assumes primary responsibility for child’s care

• The spouse of a parent or caretaker relative

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Children

• Children under age 19 are eligible with incomes up to 324% of poverty

• Children age 19 and 20 are eligible with incomes up to 221% of poverty

• System will automatically identify:• Medicaid kids• Targeted Low-Income Children

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Continuous Eligibility for Children

• All children get a full year of Medicaid coverage even if eligibility changes

• Children who are hospitalized and turn 21 while hospitalized continue to be eligible for Medicaid until the end of hospital stay

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Example: Continuous Eligibility

Marika and her nine-year-old daughter Chloe have an income at 275% of poverty. Marika has a DC Health Link plan with a premium tax credit, and Chloe has Medicaid.

Marika’s hours increase over the summer and her income rises to 350% of poverty. Marika reports the change.

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Example: Continuous Eligibility (cont’d)

DC Health Link updates Marika’s premium tax credit amount to reflect the change. Chloe stays in Medicaid even though she is above 324% of poverty.

Marika’s hours return to normal at the end of the summer. She reports the change, and DC Health Link adjusts her premium tax credit amount. Again, Chloe stays in Medicaid.

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Pregnant Women

• Eligible for Medicaid with incomes up to 324% of poverty

• Eligibility as pregnant woman ends the month that includes the 60th day postpartum

• System will automatically identify:• Medicaid pregnant women• Targeted Low-Income Pregnant Women

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Continuous Eligibility for Pregnant Women

Eligibility continues to the end of the post-partum period even if a pregnant woman’s income goes above 324% of poverty.

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Adults Ages 21-64 withoutDependent Children

• Eligible for Medicaid with incomes up to 215% of poverty

• DC expanded Medicaid early

• System will automatically identify:• CAM group• Program Code 775 group

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Presumptive Eligibility for Pregnant Women

• Certain Medicaid providers can determine a pregnant woman presumptively eligible for Medicaid without a full application

• Presumptive eligibility is for a maximum of 60 days

• Beneficiary must also file a full Medicaid application within 60 days

• Eligible only for outpatient services

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Hospital Presumptive Eligibility

• Under new rules, all Medicaid hospitals can make presumptive eligibility determinations for MAGI populations

• Eligible for all services

• Anyone determined presumptively eligible has 60 days to complete an application

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Non-MAGI Populations• SSI recipients

• Deemed newborns

• Foster care youth

• Project Wish beneficiaries

• Former foster care youth up to age 26

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Non-MAGI Populations (cont’d)• Those who are aged, blind, or disabled

• Those seeking long-term services and supports (nursing home and home- and community-based services)

• Medicare Savings Program beneficiaries

• Dual eligibles

• Medically needy/spend-down beneficiaries

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Former Foster Care Youth

New eligibility category• Young adults who:• Are under age 26• Were in foster care in DC • Were receiving Medicaid when they

turned 18 (or were emancipated) or left foster care (after age 18)

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Why is the distinction between MAGI and non-MAGI important?

• In some cases, non-MAGI populations can get additional benefits

• Helps determine whether a person is placed in fee-for-service or managed care Medicaid

• Determining eligibility for non-MAGI populations sometimes has extra requirements

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How will you know if someone is in a non-MAGI category?

• Answers to screening questions in application or renewal form

• Request for a full determination

• Submission of supplemental non-MAGI application forms

• Agency has information about the person’s non-MAGI eligibility

What happens to non-MAGI applications?

Goal: Get applicant covered as quickly as possible

• If possible, make non-MAGI eligibility determination promptly

• If non-MAGI determination will take longer, enroll applicant in either MAGI Medicaid or a DC Health Link plan with tax credits until non-MAGI determination is done

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Example: Ron

Ron is 49 years old and works part-time earning $15,000 per year. He has some medical conditions that make it difficult for him to do certain daily tasks. When he fills out the application, he answers “yes” to the non-MAGI screening questions.

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Ron’s Application

Ron may be eligible for non-MAGI Medicaid based on having a disability

Because disability determinations take time, determine Ron’s MAGI eligibility

Ron is eligible for MAGI Medicaid until his non-MAGI eligibility determination is complete

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Prepared by Families USA for use in the District of Columbia

Review: Question #1

Martin is 21 years old. His income was at 175% of poverty when he applied and got Medicaid. Three months later, he got a second job and his income went up to 230% of poverty.

TRUE OR FALSE: Since this change happened during the year, Martin can keep his Medicaid because of continuous eligibility.

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Answer: Question #1

FALSEOnly children and pregnant women have continuous eligibility.

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Review: Question #2

ESA will determine eligibility for which of the following groups in 2014?

a. Childless adults aged 21-64b. People with disabilitiesc. Pregnant womend. Dual eligiblese. The medically needy/spend-down

beneficiaries

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Answer: Question #2

ANSWER: B, D, and EESA will still determine eligibility for non-MAGI populations, which includes those who are disabled, dual eligibles, and those who are medically needy/spend-down beneficiaries in 2014.

Pregnant women and childless adults aged 21-64 are MAGI populations and will use the new system.

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Review: Question #3

TRUE or FALSE: If an applicant might be eligible for Medicaid on a non-MAGI basis, she must wait until her non-MAGI eligibility has been determined to get coverage.

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Answer: Question #3

FALSEApplicants who are waiting for a non-MAGI determination should be enrolled in Medicaid or a DC Health Link plan based on their income.

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Recap of Eligibility Categories

• What you will do:• Enter applicant’s information into DC

Health Link• Enter changes into DC Health Link

• What the system will do for you:• Determine eligibility category for each

applicant automatically

Overview ofEligibility Factors

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Prepared by Families USA for use in the District of Columbia

Eligibility Factors at a GlanceEligibility Factors Medicaid DC Health Link with

Premium Tax CreditDC Health Link

without Premium Tax Credit

Household Income Household income up to Medicaid eligibility level for MAGI group

Household income above 100% and below 400% of poverty

Citizenship/Immigration Status

Citizen or qualified alien (pregnant women and children under 21 also eligible if lawfully present)

Citizen or lawfully present Citizen or lawfully present

Residency Resident of DC Resident of DC Resident of DC

Incarceration Status Not incarcerated Not incarcerated

Tax Filing Status Agrees to file taxes (jointly if married)

Job-Based Coverage No offer of coverage through employer, family member’s employer, or government

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Household Composition

• New rules are based on tax household

• Special rules for certain family situations and families that do not file taxes

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Income

• New rules are based on tax income

• Changes to income disregards and no more deductions

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Citizenship and Immigration Status

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Immigration Status and Medicaid• Citizens are eligible for full Medicaid, as are

individuals who have an immigration status that makes them a “qualified alien”• Depending their type of immigration status, some

people who are “qualified aliens” are subject to the five year bar

• Pregnant women and children who are “lawfully present” are also eligible for full Medicaid• Pregnant women and children are exempt from the

five year bar

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Immigration Status and DC Health Link

• Must be a citizen or “lawfully present”

• More types of immigration status are included in the “lawfully present” category, than in the “qualified alien” category

• No five year bar for DC Health Link plans, premium tax credits and cost sharing reductions

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DC Alliance• For people under 200% of poverty not

eligible for Medicaid, including• People subject to five-year Medicaid bar• Some other immigrants, such as DACA

• No premiums, but limited benefits

• Is not minimum essential coverage

• Separate application and face-to-face interview required• Eligibility will still be determined by ESA in

2014

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Immigrants Have a Choice during the Five-Year Bar Period

Immigrants can get:• DC Alliance• DC Health Link plan with premium tax credits

and cost-sharing reductions

DC Alliance DC Health Link

No premiums Level of premiums depends on premium tax credit amount

No copayments Copayments

Limited benefits Full benefits

Very limited network of providers

Regular private insurance provider network

Not minimum essential coverage

Minimum essential coverage

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Including Non-Applicants

• People should list all household members when they apply for DC Health Link coverage and Medicaid

• They should note which members are seeking coverage and list other members as non-applicants

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Verifying Citizenship and Immigration Status

• DC Health Link will automatically attempt to confirm information through electronic data sources

• If DC Health Link can’t confirm:• Applicant has 90 days to provide documentation• Applicant receives coverage during that time, if

eligible based on the information they provide

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Documenting Citizenship and Immigration Status

• Documentation requirements for citizenship• One form of primary documentation, or• Two forms of secondary documentation:

1. ID with photo or other identifying information2. Other documentation from list

• See handout for documentation types• An official government document will be

needed to verify immigration status • See handout for list of acceptable documentation

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Working with Immigrant Applicants

• Applying for health coverage is not a “public charge”

• Be clear on how information will and will not be used

• Be sure that applicants understand what information is required for non-applicants

• If citizenship or immigration status cannot be verified right away:• Applicant has 90 days to provide documentation• Applicant receives coverage during that time, if

eligible based on other information (eligibility based on other factors must be verified for Medicaid)

Things to consider:

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Review: Question #1

Which of the following groups with incomes below 200% of poverty have a choice between DC Alliance and DC Health Link:

a. Lawfully present childrenb. Lawfully present adults subject to five-

year barc. U.S. citizensd. Deferred Action Childhood Arrivals

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Answer: Question #1

ANSWER: BLawfully present adults subject to the five-year bar• Lawfully present children get Medicaid• U.S. adult citizens get Medicaid• Qualified aliens who are not subject to five-year

bar can get Medicaid• Deferred Action Childhood Arrivals get DC

Alliance

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Review: Question #2

TRUE or FALSE: Applicants who attest to an eligible immigration status and are eligible for coverage based on other factors have 90 days to document immigration status if it cannot be verified electronically, but they do not receive coverage until their immigration status has been verified

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Answer: Question #2

FALSEImmigrant applicants do have 90 days to document immigration status if documentation is needed, but they do get coverage during this time.

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Residency Requirements

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Medicaid Residency

In general, those over age 21 not living in an institution are residents of DC if:• They live and intend to continue living in DC

• People do not need to have a fixed address to be residents

• No minimum length of time in DC• People entering DC with a job commitment or

looking for a job are considered residents

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Medicaid Residency for People under Age 21

In general, those under age 21 are considered DC residents if:• They live in the District (even without a

fixed address) or

• Their parent or caretaker relative lives in the District

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Special Situations for Residency

Situation Residency

In an institution Resident of state that made the placement

In an institution, but not placed by the state

Resident where person lives and intends to reside

Getting SSI supplement Resident of state that pays it

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Residency Requirements for DC Health Link

In general, people over age 21 are considered DC residents if:• They live in and intend to continue living in DC,

including:• Those with no fixed address who intend to live in

DC• People who have a job commitment or are

seeking employment and living in DCThose under age 21 can be considered residents:

• Where they live, or • Where their parent/caretaker lives (if the child

claims the same residence)

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What if a household includes someone who lives in a different state?

• Some tax households will include members who do not live in DC

• Include their information on the application• Application needs this information to

determine eligibility of the DC residents in the household

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Example

Jim (26) and Liz (28) are married and have a child, Sam (5). Jim and Sam live in the District. This year, Liz will live in North Carolina for a job. Jim has a DC Health Link plan, and Sam qualifies for Medicaid.

Liz is in a separate plan in North Carolina.

Their income is just under 250% of poverty, so Liz and Jim are eligible for premium tax credits and cost-sharing reductions, and Sam is eligible for Medicaid. Liz gets a premium tax credit and cost-sharing reductions in her plan, and Jim gets a premium tax credit and cost-sharing reductions in his plan.

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Verifying Residency• DC Health Link will automatically attempt to confirm

residency• If it can’t, use one of the following current

documents:• Driver’s license• Lease (signed within one year)• Rent receipt• Utility bill• Letter from landlord

• Homeless applicants need to indicate an intent to reside in DC, no documentation needed

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Incarceration

• Medicaid: • Eligible if incarcerated• Coverage is suspended during incarceration

• DC Health Link and premium tax credits:• Ineligible if incarcerated• Does not include those who are incarcerated

“pending disposition of charges” (those who have been charged but not convicted or acquitted)

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Pregnancy

• It is important to include pregnancy on application because:• Pregnant women are eligible for

Medicaid at higher levels of income• Pregnancy can affect household size

• Application will accept self-attestation for pregnancy

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Job-Based Coverage

Why does job-based coverage matter?

Job-based coverage must be:1. Minimum value: plan covers at least 60% of

health care expenses on average2. Affordable: premiums cost no more than 9.5%

of household income

If an offer of job-based coverage is not minimum value and affordable, applicant could still be eligible for premium tax credits.

DC Health Link figures this out, but consumers may have questions.

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Prepared by Families USA for use in the District of Columbia

How to Get Insurance Information from Employers

• DC Health Link website will have a form that people can print and ask their employer to fill out with insurance information

• Handout materials include an example of what this form will likely look like: “Employer Coverage Tool”

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What is “minimum value”?

• Plan covers, on average, at least 60% of enrollees’ health care expenses

• Based on deductible, co-pays, and co-insurance

• Employer must calculate this information and include it on:1. Summary of Benefits of Coverage2. Employer Coverage Tool

Individuals never should have to calculateminimum value.

What is “affordable” coverage?

The premium for employee-only coverage in the least expensive comprehensive plan costs no more than 9.5% of household income.

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Prepared by Families USA for use in the District of Columbia

Affordability: Family Members

• Affordability for family members with offer through employer still based on employee-only coverage• Does not matter if family coverage costs more

than 9.5% of household income

• Family members with unaffordable family coverage offer will not be able to get premium tax credits

Family Example: The Rodriguez Family

Joe and Rita Rodriguez are married with two kids. They make about $55,000/year. Joe’s employer offers coverage to Joe and the rest of his family. Rita works part-time and can’t get health coverage through her employer. They want to know if they could be eligible for premium tax credits:

Premium to cover just Joe: $250/month 5.4% of income

Premium to cover entire family: $500/month 10.9% of income

Who in the Rodriguez family may be eligible for premium tax credits?

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Prepared by Families USA for use in the District of Columbia

Rodriguez Family: Answer

No one in the Rodriguez family is eligible for premium tax credits.

REASON: The premium they must pay for employee-only coverage costs less than 9.5% of their household income.

Family Example 2: The Rodriguez Family

The next year, Joe’s employer decides to stop offering family coverage and offers coverage only to employees. The cost to cover Joe is still $250/month. The family still estimates their annual household income to be $55,000 and Rita’s employer still does not offer coverage.

Who in the Rodriguez family may be eligible for premium tax credits now?

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Prepared by Families USA for use in the District of Columbia

Rodriguez Family: Answer• Joe is still not eligible for premium tax credits.• Rita and the kids might be eligible for

premium tax credits.

REASON: Joe’s offer of coverage through his employer still makes him ineligible because it costs less than 9.5% of his household income. Since Rita and the kids no longer have an offer of coverage through Joe’s employer, they may be eligible for premium tax credits.

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How long does an affordability determination last?

Once DC Health Link finds job-based coverage unaffordable, it’s considered unaffordable for the entire employer plan year

• Protects consumers regardless of increases in income

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Maintaining Eligibility for Premium Tax Credits

If the employer plan year spans two calendar years, DC Health Link will ask a person to confirm income in the new calendar year.

• The person must respond to this request to protect eligibility for premium tax credits for full employer plan year

• If the person does not respond and his or her income increases, he or she could lose premium tax credit eligibility for the second calendar year

Example: GloriaGloria is single and makes $25,000/year. Her employer’s offer of coverage would cost her $250/month. This is more than 9.5% of her expected household income. Her employer’s plan year is September 2014-August 2015. • September 2014: Gloria starts receiving premium tax credits• January 2015: DC Health Link asks her to verify her income for

2015; Gloria responds to the request• July 2015: Gloria gets a raise; her new annual income for 2015

is $30,000/year (making $250/month premiums affordable)

Gloria is still eligible for premium tax credits for her employer’s full plan year, including January-August 2015, because she responded to the DC Health Link request.

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When does an employee need to reassess affordability or minimum value?

Re-determine employee eligibility at the start of every new employer plan year.

• If cost or value of employer plan changes in new plan year, employee might lose eligibility for premium tax credits.

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Example

Employer plan year:October 2013-September 2014

DC Health Link plan year:January 2014-December 2014

Even though it is the middle of the DC Health Link plan year, employees need to re-determine whether they qualify for premium tax credits before the start of October 2014, based on their employer’s new plan.

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Prepared by Families USA for use in the District of Columbia

Review: Question #1

A family of four has an offer of job-based coverage through the father’s employer that meets minimum value requirements. The premium for employee-only coverage would cost 6% of their household income. The premium for family coverage costs 10% of their household income.

Does this offer of coverage make the family ineligible for premium tax credits?

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Answer: Question #1

Yes, this offer of coverage does make the family ineligible for premium tax credits.

REASON: The coverage is of minimum value, and the premium for employee-only coverage costs less than 9.5% of their household income.

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Recap of Eligibility Factors

• What you will do:• Enter applicant information into DC Health Link• Explain eligibility determination to applicants• Examine documentation as needed

• What the system will do for you:• Check data sources• Determine eligibility• Tell you where additional verification is needed