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About These Materials

About These Materials

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About These Materials

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  1. About These Materials Families 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 for assistance with adapting these materials.

  2. ESA Policy Training Day 1

  3. Overview • Why is the Affordable Care Act changing Medicaid and private insurance? • How is Medicaid changing in DC? • What is DC Health Link? • How do premium tax credits and cost-sharing reductions work? • What happens if income changes?

  4. Background on the Affordable Care Act

  5. Why is the Affordable Care Act changing Medicaid and private insurance? • Many people are currently uninsured • Antiquated eligibility systems are hard for workers and consumers to use • Private insurance is expensive • Consumer protections are limited • Pre-existing conditions lead to denials of coverage Families USA 2013

  6. The District of Columbia DC is a leader in coverage, but nearly 7%are still uninsured. DC covers adults up to 200% of poverty and kids up to 300% Unlike most states, DC already covers childless adults But there is still work to do . . . Total Uninsured Population:U.S. - 15.1% DC - 6.9% Number of UninsuredPeople in DC, 2011: 42,007 Source:  CBPP analysis of Census Bureau data from the American Community Survey 2011

  7. New Affordable Care Act Protections: 2014 • Those who do not qualify for Medicaid (due to income or five-year bar) can get new premium tax credits • Low-income adults will newly qualify for Medicaid in many states (but they are already covered in DC) • People can apply online and verify information electronically • Private insurers cannot deny people coverage or charge them more because they are sick

  8. DC Medicaid and the Affordable Care Act

  9. Medicaid Will Stay the Same for Most People • DC is preserving its good coverage levels • DC is modernizing applications, eligibility determinations, and renewals

  10. Modernizing Eligibility Determinations • Most applications can be done online • Numerous eligibility categories not necessary • Electronic verification will be used when possible • New application will determine eligibility for Medicaid and premium tax credits

  11. MAGI and Non-MAGI Eligibility Eligibility for most Medicaid recipients will be determined using new system • New MAGI (Modified Adjusted Gross Income) rules • Used for parents/caretaker relatives, children, pregnant women, and childless adults aged 21-64

  12. MAGI and Non-MAGI Eligibility (cont’d) • Eligibility for some will still be done by ESA for now • Used for those who are aged, blind, disabled, or need long-term care services • We call this the “Non-MAGI” population

  13. MAGI Income • Based on how IRS calculates tax income • Example: Instead of subtracting income disregards and deductions from income like we do today, take away adjustments to income • New system will calculate all of this for you

  14. MAGI Household Composition • New way of defining household based on who is on the same tax return (if family files taxes) • Some exceptions in Medicaid • Different rules for families that do not file taxes • New system will determine household composition for you

  15. Introduction to DC Health Link

  16. How DC Health Link Works New marketplace for private insurance for individuals, families, and small businesses • Provides clear, comparative information about plans from different insurance companies • Some will get help paying premiums for these plans • Includes only plans that meet quality standards

  17. What is your role in DC Health Link? • ESA workers will help DC residents apply for coverage • New system uses one application for: • Medicaid • Premium tax credits for DC Health Link plans

  18. Overview • What are DC Health Link plans like, and how will DC residents be able to compare plans? • What type of assistance is available to people buying DC Health Link plans?

  19. What will DC Health Link plans cover? • Coverage similar to that offered by most employers • All plans must cover a minimum benefits package, called Essential Health Benefits (EHB)

  20. Medicaid Benefits Differ from DC Health Link Benefits Medicaid covers more than the Essential Health Benefits and does not charge enrollees premiums, so it is important to help people who qualify get Medicaid instead. All applicants to DC Health Link will be assessed for Medicaid eligibility.

  21. Plans offered in four metal levels: Different Levels of DC Health Link Plans Note: Measured based on total cost of covered benefits for a typical population

  22. Platinum plan: Premiums cost the most, but plan pays more (and patient pays less) for health care services Bronze plan: Premiums cost the least, but plan pays less (and patient pays more) for health care services Silver and gold plans: Somewhere in between Understanding Metal Levels

  23. Hypothetical Plans

  24. Why are we talking about these costs? We’ll come back to these plan levels when we talk about premium tax credits and cost-sharing reductions. People who get premium tax credits will also have to choose a metal level plan.

  25. Premium Tax Credits

  26. Premium Tax Credits: The Basics • Premium tax credits help people pay for health insurance if they do not have job-based coverage, Medicaid, or Medicare • Premium tax credits pay a certain amount of monthly premiums, based on income • Through DC Health Link, people can get tax credits monthly based on expected annual income • At tax time, premium tax credits are adjusted based on actual annual income

  27. Example: Lower Monthly Premiums Latisha, age 55, has a small catering business. A health plan charges her $420/month in premiums, which is a huge portion of her income of $34,000/year. She applies to DC Health Link and is found eligible to enroll in a plan with premium tax credits. With the tax credits, she pays $265/month for a silver plan.

  28. Lower Incomes, More Help The less income someone has, the less he or she has to pay. Example: With income at 100% of the poverty level ($11,490 for an individual), a person pays 2% of income for a silver plan’s premiums. With income at three times the poverty level ($34,470), a person pays 9.5% of income for the same silver plan’s premiums.

  29. The Amount People Pay Depends on the Plan They Choose • Premium tax credit amounts are based on the cost of a silver plan. If a person or family wants more comprehensive coverage, they can buy a gold or platinum plan and pay the difference. • Those who want lower premiums can buy a bronze plan, but they would face higher costs for medical care.

  30. Example • A silver plan costs $400. Keisha’s tax credit is: $400 (full cost) - $120 (expected contribution) = $280 credit. • A bronze plan costs $300. Keisha can use her tax credit for this, and her monthly premium would be only $20 ($300 - $280 = $20), but she’ll have higher copayments or a higher deductible in this plan.

  31. People can report their income changes to get premium tax credits and cost-sharingreductions adjusted If someone’s annual income is higher than projected, he or she may have to pay back excess premium tax credits up to a cap (this is called “reconciliation”) If someone’s income is lower than projected, he or she will get more in premium tax credits at the end of the year Cost-sharing reductions do not need to be paid back Income Changes

  32. Review: Question #1 TRUE or FALSE: If a person receiving premium tax credits has an increase in income and does not report it, she may end up owing some of her premium tax credit back at the end of the year.

  33. Answer: Question #1 TRUE Not reporting an increase in income could mean that a person needs to pay back some of her premium tax credit. Prepared by Families USA for use in the District of Columbia

  34. Review: Question #2 QUESTION: A person has found out she is eligible for a $100 premium tax credit. Will she pay more in premiums for a gold plan or a silver plan offered by the same company?

  35. Answer: Question #2 ANSWER: The gold plan The gold plan will cost the person more in premiums because it is a more expensive plan. The government pays the same premium tax credit no matter which plan the person picks.

  36. DC Coverage Assistance Options in 2014 Approximate Income Levels as a Percent of Poverty

  37. Cost-Sharing Reductions

  38. People with incomes below 250% of poverty will get extra help paying for medical services in certain plans This willreduce the maximum amount that a sick person would pay out of pocket It could reduce the deductible, co-insurance, or copayments in a silver plan, making it more like a gold or platinum plan Cost-Sharing Reductions: The Basics

  39. What is cost-sharing?

  40. Cost-Sharing Reductions (Individual) In DC, most people in these income brackets will be getting Medicaid. A small population may be in private DC Health Link plans with cost-sharing reductions.

  41. Maria is very sick, and she is not eligible for Medicaid because she is under a five-year bar. Maria’s income is about 180% of poverty. She pays all of her medical expenses until she reaches her plan’s deductible, and then she pays copayments for drugs and doctors. QUESTION: At what point will her plan stop charging her copayments? Cost-Sharing Reductions: Question #1

  42. Cost-Sharing Reductions: Answer #1 ANSWER:When her medical out-of-pocket medical expenses for the year reach $2,250, excluding premiums

  43. Cost-Sharing Reductions: Question #2 QUESTION: Richard does not qualify for Medicaid because his income is 220% of poverty. At what point will his plan stop charging copayments?

  44. Cost-Sharing Reductions: Answer #2 ANSWER: When his out-of-pocket medical expenses for the year reach $5,200

  45. You will play an important role in helping people apply for help with their coverage The new system will do much of the work for you This training is designed to help you understand why the new system works the way it does You will be able to refer applicants to additional sources of help Things to Remember

  46. Applications Prepared by Families USA for use in the District of Columbia

  47. What’s changing? • New application for MAGI-based Medicaid and premium tax credits • Many ways to apply • Easier eligibility determination

  48. New Applications • Two online applications: • Full application for financial assistance • MAGI Medicaid • Premium tax credits and cost-sharing reductions • Shortened application to buy a full-cost DC Health Link plan • You can help encourage people to fill out the full application, since new help is available

  49. Which groups use other applications? • Medicare assistance programs (SLMB, QMB, Low-Income Subsidy) • “Non-MAGI” Medicaid for elderly, blind, disabled, people who need long-term care, medically needy • DC Alliance • Other benefits, such as SNAP and TANF

  50. Ways to Apply • Online • By phone • In person • By mail In-person interviews are not required!