the affordable care act part 2: eligibility and enrollment
TRANSCRIPT
THE AFFORDABLE CARE ACT:
ELIGIBILITY & ENROLLMENT
PAGE 2
OVERVIEW
• Eligibility Requirements
• Exchange Enrollment
• Eligibility & Enrollment Verification
• Penalties
• Appeal Process
• Key Dates
PAGE 3
EXCHANGE ELIGIBILITY
PAGE 4
ELIGIBILITY: REQUIREMENTS
• For an individual to qualify for the Exchange they need to:
o Be a U.S. citizen, national, or legal resident
o Must reside in the same state that they are applying for coverage
o For programs that require an income eligibility, income will be based off Modified Adjusted Gross Income
• An individual is not eligible for coverage through the Exchange if incarcerated, unless charges are pending
• For CHIP, Medicaid, and Medicare, individual must meet that program’s specific eligibility requirements
PAGE 5
ELIGIBILITY: EXEMPTIONS
• Individuals must have the minimum level of healthcare coverage provided or face a penalty
• The following categories provide exemptions for individuals from this coverage requirement:
o Religious Exemptions
o Undocumented Immigrants
o American Indians
o Financial Hardships
o Incarceration
PAGE 6
ELIGIBILITY: PROHIBITED FACTORS
• Issuers can no longer deny coverage to individuals with pre-existing conditions
• Issuers are no longer able to drop individuals due to the diagnosis of serious illnesses
• Issuers are no longer allowed to set annual and/or lifetime limits
PAGE 7
ELIGIBILITY: GOVERNMENT BASED
HEALTHCARE
Medicaid• A state-based healthcare program that provides coverage to low-
income households and individuals with disabilities
CHIP• CHIP is the Children’s Health Insurance Program
Medicare• A government health insurance program administered by the
Centers for Medicare and Medicaid Services
PAGE 8
ELIGIBILITY: MEDICAID
Medicaid Eligibility Before ACA Medicaid Eligibility After ACA- Pregnant women and children (<6 years)
whose family income is ≤ 133% of the Federal Poverty Level
- Children under 19 whose families are at or below the FPL
- Families with children that meet the Aid to Families with Dependent Children
- Most Supplemental Security Income recipients
- Recipients of adoption or foster care individuals
- Special protected groups- Certain Medicare beneficiaries - Certain optional groups
Source: CMS.gov - Brief Summaries of Medicare and Medicaid and Kaiser Family - Medicaid A Primer
- Eligibility groups streamlined to - children - pregnant women - parents and caretaker relatives- adults (ages 19-64)
- Income eligibility will be based off modified adjusted gross income and household income
- Eligibility based off monthly income at time of application
- Minimum income eligibility for adults is 133% of FPL
Source: Federal Register - Medicaid Program Eligibility Changes under the ACA and Kaiser Family - Medicaid and the uninsured
PAGE 9
ELIGIBILITY: CHIP
• CHIP covers children whose family income is too high for Medicaid
• The ACA will keep the same eligibility standards in place through 2019
• The ACA has expanded eligibility beyond the original requirements of children under 19 and household incomes of 200%
PAGE 10
ELIGIBILITY: MEDICARE
• Overall eligibility for Medicare does not change with the enactment of the ACA
• Medicare eligibility requirements include:o Being a U.S. citizen or legal immigranto Being age 65 or older
Source: SocialSecurity.gov Medicare and Proof of Citizenship
PAGE 11
ELIGIBILITY: MEDICARE
Medicare Part Eligibility Requirements
Part A
Individual is eligible if under age 65 and:- Receives Social Security Disability Insurance for minimum of 24 months,- Receives disability from Railroad Retirement Board,- Receives disability due to Lou Gehrig’s disease,- Has worked 10 years in a governmental job where Medicare taxes were paid and
meet requirements for Social Security Disability; or be the child/widower of someone who has met those requirements, or
- Has permanent kidney failure or has received a kidney transplant
Individual is eligible if age 65 or older and:- Receives benefits from Social Security or Railroad Retirement,- Has an eligible spouse, - Has worked (either individual or spouse) in a government job where Medicare
taxes were paid, or- A dependent parent of a fully insured deceased child
Part B - Anyone eligible for Part A can enroll in Part B- Monthly premium is based off income
Part C - Anyone who is eligible for Parts A and B can enroll in Part C
Part D - Anyone who is enrolled in Parts A, B, or C is eligible for the prescription drug coverage
- Monthly premium is based off income
Source: SocialSecurity.gov Medicare
PAGE 12
ENROLLMENT PROCESS
PAGE 13
ENROLLMENT PROCESS: APPLICANT
• Applicants can enroll in an Exchange through the Exchange website, in person at a designated assistance center, via toll-free telephone number, or by mail
• The following information will be needed when completing an Exchange application:o Nameo Addresso Date of birtho SSNo Proof of U.S. citizenship/immigration status
PAGE 14
ENROLLMENT PROCESS: APPLICANT
• Notifications of eligibility are sent out once the determination is complete
• Notifications letters should explaino the applicant’s eligibility determinationo the steps taken and any remaining steps needed to complete
enrollment processo the appeal process available to the applicant
PAGE 15
ENROLLMENT PROCESS: APPLICANT
• Through enrollment process, if applicant is found eligible for government-based healthcare (e.g., Medicare, CHIP, or Medicaid) the Exchange will automatically enroll applicant into program
• Applicants can shop through Exchange to find the best coverage option for their situation
• The Exchange will provide notification to the chosen insurance issuer
PAGE 16
ENROLLMENT PROCESS: EMPLOYER
• Employers can submit an application to the Small Business Health Options Program (SHOP) Exchanges to determine eligibility*
• Once employer’s application is approved, the SHOP will help the employer both enroll and select health plan options for their employees
PAGE 17
*UPDATES TO SHOP PROGRAM
• The requirement that a SHOP must allow employers the option to offer employees a choice among all qualified health plans (QHPs) at the metal level (i.e., bronze, silver, gold, or platinum) chosen by the employer has been delayed for one year.
• For plan years beginning before January 1, 2015 federally facilitated-SHOPs will not offer an employee-choice option but will instead allow employers to offer their employees a single QHP from the SHOP's available choices. State-operated SHOPs may, but are not required to, offer an employee-choice option.
• SHOP special enrollment period has been changed from 60 days to 30 days after a qualifying event.
• HHS has posted an application for SHOP eligibility for employers that are not able to apply online or are not working with a broker and an application for employees to submit to check their eligibility for SHOP coverage from their employer.
As of
6/2013,
HHS has
issued final
regulations
around the
SHOP
program
PAGE 18
ENROLLMENT PROCESS: EMPLOYER/SHOP
• The SHOP will provide notification to:
o employers regarding eligibility to participate in the Exchange
o employees regarding the plan options and how to enroll
o the insurer containing the employees’ enrollment information
• The SHOP is also required to notify HHS that the employer is providing insurance and the eligible employees have enrolled in a QHP
PAGE 19
ENROLLMENT VERIFICATION
PAGE 20
ENROLLMENT VERIFICATION:
APPLICANT
• U.S. citizenship and incarceration status will be verified by:
o Comparing records at the Social Security Administration
o If the information cannot be confirmed, HHS will go to the Department of Homeland Security for confirmation
• Other application criteria will be verified against the respective federal agencies
PAGE 21
ENROLLMENT VERIFICATION:
APPLICANT
• HHS will conduct annual redeterminations to determine eligibility for upcoming plan yearo If applicants are approved, they will receive notification showing
data used to make the decision and their eligibility status o If applicants are not approved, they will receive coverage for one
month after notification and can no longer claim tax benefits
• Applicants will need to supply any information that has changed
• Applicants will need to sign and return the notification
• After the signed notification is received, applicants can re-enroll/terminate/change health plans
PAGE 22
ENROLLMENT VERIFICATION:
EMPLOYER
• To verify employer submitted information, the SHOP will cross reference the employer’s information with government agencies
• The SHOP will redetermine employer eligibility through review of the annual report submitted to it by the employer
PAGE 23
PENALTIES
PAGE 24
PENALTIES: INDIVIDUALS AND
EMPLOYERS
Individuals• Penalties will be imposed for failure to maintain the
minimum level of individual coverageo Penalties will either be a flat rate or a percentage of income,
whichever is highero Penalty rates will be adjusted annuallyo IRS will administer and collect the penalty
Employers (50+ employees)• If coverage is inadequate or not provided, a penalty will be
assessed based on the annual applicable dollar amount and number of full-time employees
PAGE 25
APPEAL PROCESS
PAGE 26
APPEAL PROCESS: APPLICANT
• Each state will be responsible for creating their own appeal process
• The Exchange will notify applicants if they are ineligible for government-based healthcare and provide alternative options for affordable healthcare
• Applicants can appeal adverse eligibility decisions and cost reimbursement denials from insurance companies through an internal or external appeal process
PAGE 27
APPEAL PROCESS: EMPLOYER
• An employer will be able to appeal an adverse eligibility determination made by a SHOP
• The SHOP must give the employer 30 days notice to respond to an eligibility denial and submit the necessary documentation to the SHOP
• If the SHOP still denies eligibility after receiving documentation from the employer, the employer may request an external appeal review by a third party arbitrator
PAGE 28
KEY DATES
PAGE 29
KEY DATES: EXCHANGE ENROLLMENT
DATE EVENTJanuary 1, 2013 For 2012 tax year, employers need to include on the employee’s W-2
the cost of employer-sponsored health coverage. o They must include both employer and employee portions of the cost
of health benefits. The tax deduction will be eliminated for employers who receive
Medicare Part D retiree drug subsidy payments. o These payments are a federal subsidy paid to employers who offer
retirement benefits for prescription drugs. o Employers who receive this payment will have to include the amount
as taxable income.
March 1, 2013 • Employers must provide all employees with a written notice detailing:- the availability of the healthcare Exchange, - a description of the services provided, - contact information for assistance, - possible tax credit eligibility, and- information regarding loss of employer sponsored coverage if they
purchase individual coverage in a QHP through the Exchange.
PAGE 30
KEY DATES: EXCHANGE ENROLLMENT
DATE EVENT
October 1, 2013 • Open enrollment period begins for the Exchanges
January 1, 2014 ACA Exchanges are in effect Any U.S. citizen/legal resident who does not have health insurance and
is not exempt will be liable for a tax penalty Employers that do not provide health insurance coverage will be fined
PAGE 31
REED & ASSOCIATES, CPAS
For more information on Reed & Associates, CPAs please contact us at:
Phone: 860-395-1996
Or visit our website:
reedassociatescpas.com
Quality. Integrity. Experience.