Nebraska Medicaid and the Impact of the Affordable Care Act on Eligibility

Nebraska Association of Health UnderwritersFebruary 18, 2014

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Introduction and Agenda• Ruth Vineyard, Deputy Director

• Nebraska Department of Health and Human Services, • Division of Medicaid and Long Term Care (MLTC)

• Our focus today will be on Medicaid Eligibility and the impact of the Affordable Care Act

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Introduction and Agenda• Agenda Overview• Medicaid Program• Medicaid Eligibility Overview• ACA Impact on Medicaid Eligibility• Current Status of Medicaid and the Marketplace• Questions

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• Medicaid and CHIP (Children’s Health Insurance Program)• Home and Community Based Services• State Unit on Aging

Division of Medicaid and Long-Term Care

• Administered by the Department of Health and Human Services

• Provides health care services to eligible elderly and disabled individuals and eligible low-income pregnant women, children and parents

• Pays for covered services for those persons who cannot afford to pay for medically necessary services and who meet certain eligibility requirements

Medicaid Program

Medicaid Program• Jointly funded with Federal Government and State dollars• Federal Government sets rules in statute and regulations that

give states some flexibility to administer the program• Federal Government has oversight responsibilities to ensure

federal dollars are spent consistent with federal regulations• State Medicaid programs are responsible for

administration/operations of Medicaid• Medicaid is always the payer of last resort• No open enrollment period

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Medicaid Eligibility Overview• Medicaid is a means tested program however, individuals

must first qualify for a category of eligibility.• People Served and Eligibility Groups Pre-ACA• Aged and disabled • Low-income pregnant women• Children • Parents

Individuals who meet a category of eligibility must meet income and for some populations, resource tests.

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Medicaid Eligibility Overview

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7.5%13.2%

15.3%

64.0%

Medicaid Enrollees by PopulationRoughly 240,000 Total

AgedAdultsBlind/DisabledChildren

Medicaid Eligibility Overview

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20.7%

7.5%

44.7%

27.1%

Medicaid Expenditures by PopulationRoughly $1.8B

AgedAdultsBlind/DisabledChildren

Pre-ACA Eligibility Process

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Consumer fills out NE

application, submits to NE

Medicaid

Does documentation

support eligibility criteria?

Screen application

for eligibility criteria such as income

or disability

Contact applicant

for documents to support eligibility criteria

Enroll in MedicaidTransfer

Yes

NoDeny

Medicaid eligibility

ACA Impact -Medicaid Eligibility• Insurance Marketplace for Each State• Single Streamlined Application• “No Wrong Door”• New Standard Method of Calculating Income• Modified Adjusted Gross Income (MAGI)• No Resource Tests• Real-Time Eligibility Determination• Medicaid Eligible People not Eligible for APTC/CSR with

Exchange Plans• Interaction with Insurance Marketplace• Consumer Support• What About the ABD Population?

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ACA Impact -Medicaid EligibilityMandatory Insurance Marketplace

• All states must implement an insurance Marketplace and offer Qualified Health Plans (QHPs) as defined in the ACA

• State option for Marketplace model• State Based Exchange (SBE)• Federal Partnership Marketplace• Federally Facilitated Marketplace (FFM)

• Nebraska chose an FFM• Significant interaction/coordination required between

Nebraska’s Medicaid program and the Federally Facilitated Marketplace

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• Medicaid and the Marketplace will use the same application• Single Application, created and approved by the Secretary

of DHHS• Applications may be completed on-line, on paper, in person

or over the phone

ACA Impact-Medicaid EligibilitySingle Streamlined Application

ACA Impact -Medicaid Eligibility“No Wrong Door”

• Individuals can apply at the Marketplace or Medicaid and be routed to the most appropriate coverage for their circumstance

• Significant coordination between the Marketplace and Medicaid are required to support eligibility determination, appeals and to answer consumer questions

• “Better Door” approach by the Center for Medicare and Medicaid Services (CMS)

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ACA Impact -Medicaid EligibilityModified Adjusted Gross Income (MAGI)

• MAGI is a federally defined, mandated way to calculate income for eligibility determinations

• All states and the FFM must calculate income using MAGI• Although minor, there are some differences in the way the

FFM and Medicaid programs must calculate income• No resource test required for eligibility. Only current income

counts.• Switch to MAGI necessitated significant changes to computer

systems and eligibility determination business processes • MAGI only applies to certain eligibility groups (Children, Parent

Caretakers, Pregnant Women)

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ACA Impact -Medicaid EligibilityEligibility Groups

• ACA as written by congress mandated Medicaid coverage for all adults 0 – 133% FPL

• Supreme Court ruling made this coverage optional, at State discretion (Funding could not be withheld)

• Nebraska has opted to not cover this population

• The ACA added Former Foster Children as a mandatory eligibility group

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ACA Impact -Medicaid EligibilityReal-Time Eligibility Determination

• ACA requires, where possible, real-time eligibility determination

• Key pieces of information, such as income, is electronically verified against a federal data hub to increase speed of eligibility determination.

• Previously, paper documentation was used to verify application information

• This shift to real-time determination causes a significant impact to Medicaid systems and workflow

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ACA Impact -Medicaid EligibilityAPTC/CSR

• ACA provides Advance Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR) to help individuals with income at or below 400% FPL pay for health costs

• If an individual is eligible for Medicaid, (s)he cannot be eligible for APTC/CSR.

• This requires all individuals applying for a Marketplace plan, that requests APTC/CSR to undergo a Medicaid eligibility assessment or determination

• Significant coordination required between Marketplace and Medicaid

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“No Wrong Door” – Simple Case

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Federal Marketplace

State Medicaid

Consumer fills out

application, submits to

Marketplace

Consumer fills out

application, submits to Medicaid

OR

Medicaid determination :

Medicaid eligible?

Notify consumer and enroll in

Medicaid.

Notify consumer, transfer

application to marketplace

Consumer covered by Medicaid

Assess for Medicaid: Potentially

eligible?Yes

No

Notify consumer, transfer

application to Medicaid

Notify consumer and enroll in QHP on Marketplace.

Consumer covered by

Marketplace

Transfer

Transfer

No

Yes

Transfer

“No Wrong Door” – Complex Case

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Federal Marketplace

State Medicaid

Family fills out one

application, submits to

Marketplace

Family fills out one

application, submits to Medicaid

OR

Medicaid determination, each member:

Medicaid eligible? Notify family,

enroll only Medicaid eligible

members.

Notify family, transfer only non-Medicaid eligible

members to marketplace

Some members

covered by Medicaid

Assess each member: Potentially Medicaid eligible? Yes

No

Notify family, transfer only

potential Medicaid members

Notify family, enroll non-Medicaid

members in QHP.

Some members

covered by Marketplace

Transfer

Transfer

No

Yes

Transfer

ACA Impact -Medicaid EligibilityConsumer Support

• No wrong door allows consumers to contact Marketplace or state Medicaid agency to obtain information about eligibility

• Necessitates cross-training on Marketplace eligibility and Medicaid eligibility

• Requires coordinated tracking of issues to ensure consumers are not bounced between Marketplace help desk and Medicaid help desk

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ACA Impact -Medicaid EligibilityAid to the Aged, Blind and Disabled (AABD)Population

• Eligibility rules unchanged under ACA• AABD population are MAGI exempt• Still requires a qualifying medical condition for eligibility

• However, due to ACA mandated single streamline application, AABD applicants must fill out a different form than other Medicaid applicants

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ACA Impact -Nebraska• New application• New eligibility rules• Changes to business processes• Changes to systems• Training for staff• Significant interaction with Marketplace

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ACA Timeline -Nebraska

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ACA Becomes

Law

NE Begins Planning

NE Goes FFM

Implement FFM

Integration

Go Live

Begin Eligibility Replacement

SystemNew

Eligibility System

Live

Mar 2010

April 2010

Nov 2012 Oct 2013 Jan 2016

Nov 2012 – Oct 2013 Oct 2013

ACA Impact -Nebraska• Issues to Watch Moving Forward• FFM Not Ready for Account Transfers• Causing significant additional work for Medicaid eligibility

workers• Causing consumer confusion• Causing delays getting people covered

• Work-arounds• New “check-box” on application• Medicaid Eligibility Check

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“Better Door”, Current Status

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Federal Marketplace

State Medicaid

Consumer fills out

application, submits to

Marketplace

Consumer fills out

application, submits to Medicaid

OR

Medicaid determination :

Medicaid eligible?

Notify consumer and enroll in

Medicaid.

Notify consumer, transfer

application to marketplace

Consumer covered by Medicaid

Assess for Medicaid: Potentially

eligible?Yes

No

Notify consumer, transfer

application to Medicaid

Notify consumer and enroll in QHP on Marketplace.

Consumer covered by

Marketplace

Transfer

Transfer

No

Yes

Transfer

X

Questions?

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