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Affordable Care ActOverview
Session 1
Presented by Tokie Moriel & John Tvedt
1DHS/DFO/IMTA/2013-07-15
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What is ACA?
• The Affordable Care Act (ACA)
• Comprehensive reforms that:
– Improve access to affordable health
– Protect consumers
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ACA Key Facts
• Stronger Consumer Rights and Protections
• More Affordable Coverage
• Better Access To Care
• Stronger Medicare
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Consumer Rights & Protections
• End to Pre-Existing Condition Discrimination
• End to Limits on Care
• End to Coverage Cancellations
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More Affordable Coverage
• Value for Your Premium Dollar
• Stopping Unreasonable Rate Increases
• Small Business Tax Credits
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Better Access to Care
• Free Prevention Benefits
• Coverage for Young Adults
• Coverage for Americans with Pre-Existing Conditions
• Affordable Insurance
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Strengthening Medicare
• Lower Cost Prescription Drugs
• Free Preventive Services
• Fighting Fraud
• Providing Choices while Lowering Costs
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Federal Rules
• The Department of Health and Human Services (HHS) and the Internal Revenue Service (IRS) issued federal rules that included changes and alignment to eligibility:
– Requirements
– Methods and processes
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Eligibility Requirement Changes
• Modified Adjusted Gross Income (MAGI) based income standards
– Medicaid uses current monthly income
– Cost Sharing Reductions (CSR) and Advanced Premium Tax Credits (APTC) use projected annual income
• Redefines household composition
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Eligibility Requirement Changes
• Income Changes.
– Non-recurring Lump sums
– Scholarships and grants
– Income of American Indians and Alaska Natives
– Child Support
– Worker Compensation
– Veteran’s Benefits
– Depreciation of business expenses
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Eligibility Requirement Changes
• Federal Poverty Level (FPL)
• Determining proper coverage
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Seamless, Streamlined System of Eligibility and Enrollment
Submit single, streamlined application to the FFM or the State
Eligibility is verified and determined
Enroll in affordable coverage
• Online • Phone • Mail • In Person• Other electronic
means
• Supported, in part, by the Federally-managed data services hub
• Eligibility for: • Medicaid and CHIP • Enrollment in a QHP • Advance payments
of the premium tax credit and cost-sharing reductions
• Online plan comparison tool available to inform QHP selection
• Advance payment of the premium tax credit is transferred to the QHP
• Enrollment in Medicaid/CHIP or QHP
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A Seamless System of Coverage
400%
CHIP/Medicaid for Children
FPL Varies by State (average
241% FPL)
FPL
250%
FPL
133%FPL
100%FPL
Qualified Health Plans without Financial Assistance
Qualified Health Plan w/ Premium Tax Credits
250%-400% FPL Medicaid/CHIPChildren
Qualified Health Plan w/ Premium Tax Credits and
Cost-sharing reductions between 100% - 250% FPL
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Iowa Health and Wellness Plan
101% - 133% FPL
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FFM Plan Levels of Coverage
Levels of Coverage
• Bronze• Silver• Gold• Platinum
Plan Pays On Average
• 60 %• 70%• 80%• 90%
Enrollees Pay On Average*(In addition to monthly premium)
• 40%• 30%• 20%• 10%
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A Seamless Path to Affordable Coverage
• The Affordable Care Act:
– Expands access to affordable coverage
– Simplifies Medicaid & CHIP
– Ensures a seamless system of coverage
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Expanding Access to Coverage
• Enrollment in the new income-based category without having to first screen for other eligibility groups
• Enables people with disabilities and those needing long-term care services & supports to enroll in the group that best meets their needs
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Expanding Access to Coverage
• Creates new coverage group for former foster care children
• Expansion of Presumptive Medicaid increases the number of providers allowed to make presumptive determinations for more populations.
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Simplifying Medicaid & CHIP
• Switch to MAGI methodology
• Modernize verification process
• Federal data matches
• Renewals at least every 12 months
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Coordination: A Seamless System of Coverage
• Single, streamlined application for all insurance affordability programs
• Website that provides program information and facilitates enrollment in all insurance affordability programs
• Coordinated verification policies across Medicaid, CHIP and the FFM
• Standards and guidelines for eligibility determinations and information transfers
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Coordination: Key Provisions of ACA
• The Medicaid/CHIP agency:
– Determines eligibility for individuals transferred from another insurance affordability program
– Evaluates an individual for potential eligibility for other insurance affordability programs
– Certifies for the FFM/other programs the criteria applied in determining Medicaid eligibility
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Coordination: Key Provisions of ACA
• Medicaid/CHIP agencies have established agreements with the FFM that clearly delineate the responsibility of each program to:
– Minimize burden on individuals
– Ensure compliance with the other eligibility coordination requirements of the provision (i.e., MAGI screen)
– Ensure prompt determinations of eligibility and enrollment consistent with timeliness standards
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State Responsibilities: Potential Eligibility for Other Programs
• For individuals determined as not eligible for Medicaid/CHIP, the agency:
– Evaluates the individual for potential eligibility for other insurance affordability programs
– Transfers the individual’s electronic account to the FFM for CSR/APTC determinations for insurance plan enrollment
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Coordinated Eligibility Determinations with FFM
• The Federally Facilitated Marketplace makes initial assessment of Medicaid/CHIP eligibility; State make the final eligibility determination
• Assessments made using the applicable Medicaid/CHIP income standards, citizenship and immigration status, using verification rules and procedures consistent with Medicaid and CHIP regulations
• The FFM and Iowa have entered into an agreement outlining each entities responsibilities ensuring a seamless and coordinated process
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Coordinated Eligibility Determinations with FFM
• When the FFM makes an initial assessment, Iowa:
– Accepts the electronic account
– Does not request duplicative information/documentation
– Promptly determines Medicaid/CHIP eligibility without requiring a new application
– Accepts any findings made by another program, no further verification
– Notifies the other program of the receipt of the electronic account and Medicaid’s final eligibility determination if the individual is receiving coverage through another program
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Non-MAGI Populations Applying through FFM
• The FFM will transfer applications to Iowa for a determination of Medicaid on a basis other than MAGI
• Iowa will:
– Notify the FFM of the final determination of eligibility for those individuals who are participating in an insurance affordability program
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Non-MAGI Populations Applying through Iowa
• Evaluating eligibility for other insurance affordability programs for individuals undergoing a Medicaid determination on a basis other than MAGI
• Iowa:
– Determines potential eligibility other insurance affordability programs
– Transfers the individual’s account to the FFM
– Provides timely notice to the FFM
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Continuation of Coverage
• Coverage renewal
– FFM
– State
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A New Approach
• Shifts verification responsibilities
• Less reliance on paper
• “Which coverage is right for you?”
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Time Frames
• October 1, 2013
– Open enrollment for insurance affordability programs
– Must accept single streamlined applications and apply new rules
– Must be able to transmit information to Marketplace
– Evaluate under current rules for eligibility prior to 1/1/14
• January 1, 2014
– Coverage under insurance affordability programs can begin
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Conclusion
• Additional ACA webinars
• Session review – Income Maintenance Workers ONLY