The ACA and MAGI:
The Impact on NC Medicaid
WSS Leadership Summit
March 2014
Carolyn McClanahan
Rhonda Dalton
Elizabeth O’Dell
1
ACA in Review
• ACA – Insurance Affordability Programs
–
–
–
–
Medicaid
NCHC
Tax Credits (including Advance Payment)
Cost-sharing
• Open Enrollment – through 3/31/14
• To qualify for APTC or cost-sharing must
be ineligible for Medicaid/NCHC
2
Overview of Changes
• Pregnant Women Coverage
– Client’s statement must be accepted as
verification of pregnancy and due date unless
there is a discrepancy
– If an applicant is unsure of the due date, the
County DSS must request information
– Certification period for MPW is still the first
month of eligibility through post-partum
3
Overview of Changes
• Post-Eligibility for MAGI
– Do not request verification of information on a noncustodial parent for IV-D prior to approving an
application
– Do not request third party insurance information prior
to approving a Medicaid application
– Do not require applicants to apply for all benefits to
which they might be entitled, such as unemployment
benefits or RSDI prior to approving an application
• For UIB, if the applicant has not applied timely, do not count
any phantom benefits. MAGI rules do not allow counting
income that is not received
4
Overview of Changes
• Former Foster Care Children (MFC) and Expanded
Foster Care Program (EFCP)
– The eligibility requirements for EFCP have not changed.
– For EFCP, it does not matter what state he was in foster care at
age 18.
– For MFC, the child must have aged out of foster care in NC and
been enrolled in NC Medicaid when he turned 18.
– If a child is receiving EFCP and turns age 21, evaluate for MFC if
all eligibility requirements are met. If not eligible for MFC,
evaluate for all other Medicaid programs.
5
Overview of Changes
• Electronic Verification
– At application and review
• Verification from an electronic source must be
used first before requesting information from the
client.
• If the client provides an unsolicited verification of
income that is more current, use that verification.
• If a more current verification is in an active agency
case file, use that verification.
6
FFM Applications
• Date applicant applied at the FFM is the
date of the Medicaid application
– Will determine base period
– Retro months
– Ongoing months
7
FFM Applications
• Submission date is the date the 45/90 day
processing begins
– Application processing rules have not
changed
• Applications must pend 45/90 days
• If past 45/90 days must pend 2 DMA-5097’s 12
days apart. Can deny on the day following the
expiration of the 2nd DMA-5097.
8
Example
• DOA is Nov.15, 2013. DOS is Jan. 22,
2014. Received in the county March 2,
2014.
– Retro = August, Sept. and Oct.
– Ongoing = Nov.
– Application has pended 45 days so the county
will need to send 2 DMA-5097’s and deny on
the 13th day after the second request
9
Example
• DOA is March 12, 2014. DOS March 18, 2014.
Received in the county March 20, 2014.
–
–
–
–
Retro = Dec, Jan and Feb
Ongoing = March
45th day = April 26, 2014
County will send 2 DMA-5097’s requesting needed
information but case cannot be denied until due date
of April 26.
10
FFM Applications
• All applications prior to Jan.1, must be
evaluated for traditional coverage
– If evaluation results in ineligibility for any
traditional program, it is not necessary to key a
traditional application.
– County should clearly document the MAGI
streamlined application as if they were
completing an inquiry and authorize to go to the
FFM
11
Applications – April 1 and later
• What happens on April 1?
– Can still apply at FFM
– If potentially eligible for Medicaid, application
sent to NC
– If ineligible, transfer back to FFM and will be
evaluated for tax credits/subsidy, but cannot
enroll in plan until open-enrollment in October
12
Applications April 1 and later
• If client applies for Medicaid and is denied,
account is sent to the FFM to determine
eligibility for credit/cost-sharing, but cannot
enroll in plan until open enrollment.
• If an active beneficiary is terminated,
account is sent back to the FFM for
immediate evaluation
13
Applications April 1 and later
• Certain situations allow for special
enrollment period outside open enrollment
– Loss of coverage, including ineligibility for
continuing Medicaid/NCHC
– Birth/death/marriage
14
MAGI
• Modified Adjusted Gross Income Methodology
• This is used to determine how income is
counted and how household composition and
a family size is constructed when determining
eligibility for Medicaid/NCHC.
• For Medicaid/NCHC purposes, the applicant’s
countable income will be the “MAGI-based
income.
15
MAGI Terms
• Parent - Natural, adoptive, or step
• Caretaker - Must have a child under age 18 in
the household
• Medicaid Aged Child - Natural, adopted, or
stepchild under the age of 19
Note: Medicaid still covers under age 21, but they
are not considered a Medicaid child in the
household of a non-filer
• Sibling - Natural, adoptive, or step
• Family Size - Number in the MAGI household
16
MAGI Terms
• Tax Filer
• An individual who expects to file a tax return for the taxable year
in which a determination is made for Medicaid/NCHC.
• Tax Dependent
• An individual expected to be claimed as a dependent by
someone else
• May also be a tax filer
• Non-filer
• An individual who is not expected to file a tax return or expected
to be claimed as a tax dependent by someone else
17
MAGI Household
• Each household member will have their own
MAGI household
• Individuals who live in a household may have a
different family size
• The family size will determine the income limit
18
MAGI Household
• Under traditional budgeting the following individuals are
not included in the needs unit but the MAGI household
may include:
•
•
•
•
•
SSI Recipient
CAP Recipient
IAS
WFFA
Individuals under age 19 who:
• Are or have been legally married
• Are serving or have served in the military
• Have been legally emancipated
19
MAGI ~ Household Composition
1
2
3
4
5
6
Will applicant/
beneficiary file Taxes?
Yes
Will applicant/
beneficiary file Taxes?
No
Will applicant/
beneficiary be a tax
dependent for anyone
else?
Yes
Does the applicant/
beneficiary meet any of
the exceptions*?
No
Will applicant/
beneficiary file Taxes?
Yes
Will applicant/
beneficiary be a tax
dependent for anyone
else?
Yes
Does the applicant/
beneficiary meet any of
the exceptions*?
No
Will applicant/
beneficiary file Taxes?
No
Will applicant/
beneficiary be a tax
dependent for anyone
else?
No
Will applicant/
beneficiary file Taxes?
No
Will applicant/
beneficiary be a tax
dependent for anyone
else?
Yes
Does the applicant/
beneficiary meet any of
the exceptions*?
Yes
Will applicant/
beneficiary file Taxes?
Yes
Will applicant/
Beneficiary be a tax
dependent for anyone
else?
Yes
Does the applicant/
beneficiary meet any of
the exceptions*?
Yes
Will applicant/
beneficiary be a tax
dependent for anyone
else?
No
Tax HH: HH is
applicant, co-filer
spouse and a/b’s
tax dependents.
Include live in
spouse if not
included in tax HH.
Tax HH: HH is tax filer’s household
claiming a/b as a dependent. Include a/b’s
live-in spouse if not included in tax HH
HH is applicant/beneficiary, spouse in the home, and their children in home
under age 19.
If applicant/beneficiary is under age 19: Also includes: live-in parent(s) and
live-in siblings under age 19
20
*EXCEPTIONS: Is the Applicant:
1. A tax dependent of someone other than spouse or parent?
2. Under age 19 and living with both parents who will not file jointly?
3. Under age 19 and will be claimed by a non-custodial parent?
Types of Medicaid/NCHC Households
Tax Household – Used as Medicaid/NCHC when applicant is tax filer or tax dependent and not exceptions apply. The
household includes:
Tax Filer(s) Tax Dependents of Tax Filer(s)
Spouse of applicant/recipient, if in the home and not in the tax household
Non-filer household – Used when applicant/recipient is not tax filer or tax dependent or meets one of the exceptions. The
household includes:
Individual, and if living in the home:
Individual’s spouse
Individual’s natural, adoptive and step children under age 19
If individual is under age 19, includes same as above AND
Individual’s natural, adoptive and step parent(s) in the home
Individual’s natural, adoptive and step siblings in the home
Pregnant Women
NOTE: Under either type of household (tax or non-filer), when a pregnant woman is the applicant/beneficiary, always include
the unborn(s) in her household when determining her eligibility for any MAGI program. When the pregnant woman is a
household member of another applicant/beneficiary, include only the PW – do not add the unborn(s).
21
Clarifications
•
•
•
•
Used for both applicants and beneficiaries
Added “their” children under columns 4, 5 and 6
A spouse is a co-filer not a dependent
When determining the hh of a pregnant women you
include the number of unborn(s)
• Spouse’s have to file jointly or separately
• Under columns 2 and 3 the applicant’s hh is the same as
the taxpayers. The taxpayer’s hh consists of the
taxpayer, co-tax payer spouse and their dependents.
Include live in spouse if not already included in tax HH.
Include applicant’s live in spouse if not already in tax hh.
22
Counting Income Chart
Counting Income Tax Household
Tax
Household
Tax Filer(s)
Tax Dependent – child of tax filer – does not
meet an exception
Count income of tax filer
and co-filer spouse.
Include live in spouse’s
income if not already
included in tax HH
Only count income of tax
dependents who expect
to file a tax return.
Count income of tax filer(s)
Count income of the tax dependent applicant
and other tax dependents who expect to file
a tax return. Count the income of the tax
dependent’s spouse if not included in the tax
household.
23
Counting Income Chart
Counting Income Non Filer
Non-filer
rules
Tax Dependent – not child
of tax filer
(non-filer rules)
Adult –
age 19 or
older
Medicaid age child – under
age 19
Count income for own
household regardless of
whether they expect to file
taxes and count income of
live-in spouse.
If the tax dependent has
children under age 19 in
the household, count
income of children under
age 19 if they expect to
file return.
If the tax dependent is
under age 19 ( see last
column for Medicaid age
child-under age 19)
Count
income of
applicant
and
spouse, if
in home.
Count
income of
children in
household
under 19
only if
expect to
file return
If parent(s) is not in the
household count income for
own household regardless
of whether they expect to
file taxes and count income
of live in spouse and live in
siblings under age 19.
If the Medicaid age child
has children under age 19,
count income of children
under age 19 if expect to
file return. If parent(s) is in
the household, count the
income of the parent(s). Do
not count income of the
child and siblings under age
19 unless they expect to file
a tax return.
24
Clarifications
• Medicaid aged child under age 19
– If parent(s) is in the household, count the income of
the parent(s).
• Do not count income of the child and siblings under age 19
unless the child/siblings expect to file a tax return
– Tax Dependent – child of tax filer – does not meet an
exception
• Only count the income of the tax dependent applicant if they
expect to file a tax return
25
Example 1
• Caroline, age 19, is pregnant and has applied
for Medicaid. She lives with her Mother, Teresa,
who is divorced from Caroline’s father, and her
15 year old sister, Lucinda. There are no other
siblings in the home. Caroline does not have any
income and does not expect to file taxes herself,
but expects to be claimed as tax dependent by
her father, Carl, who also claims Lucinda.
Lucinda does not expect to file taxes either.
26
Example 1
Caroline’s MAGI H/H: Caroline expects to be claimed as a tax dependent, but she does not meet any tax dependent exceptions.
Column 2 corresponds to her situation. This means that her H/H will be the household of the tax payer who is claiming her – it will
be her father, Caroline, her unborn child, plus any other dependents – Lucinda. Her family size will be 4.
Caroline’s Countable Income: The counting income chart indicates that for the tax dependent who does not meet an exception,
we will count the income of the tax filer – Carl.
Lucinda’s MAGI- HH: Lucinda expects to be claimed as a tax dependent and she meets a tax dependent exception. Column 5
corresponds to her situation. This means that her H/H will be Lucinda, the applicant, and her mother, Teresa. Her family size will
be 2. Caroline is over 19 and is not in her hh.
Lucinda’s Countable income: Count the income of her live in parent Teresa.
A
P
P
L
I
C
A
N
T
Medicaid
Household
Caroline
Lucinda
Carl
Caroline
X+1
X
X
Lucinda
X
Teresa
Family Size
4
X
2
27
Example 2
• Doreen is 16 years old and has applied for
Medicaid along with her mother, Thelma, her
father, George, and her 10 year old brother,
Kevin. George and Thelma do not expect to file
taxes nor be claimed as dependents. Doreen
works and expects to file taxes, but does not
expect to be claimed as a dependent. Kevin
does not expect to file nor be claimed as a
dependent.
28
Example 2
Doreen’s MAGI H/H: Doreen expects to file taxes and does not expect to be a tax dependent for anyone else. Column 1
corresponds to her situation. This means her household will consist of herself only. She is a family size of 1.
Countable Income: The counting income chart indicates that for Doreen, a tax filer, we will count only her income when
determining her eligibility.
Kevin’s MAGI H/H: Kevin does not expect to file taxes nor expects to be claimed as a tax dependent. Column 4
corresponds to his situation. This means his household will consist of himself, his live in parents, Thelma and George, and
his live in sibling under age 19, Doreen.
Countable Income: His countable income will be Thelma, George, and Doreen’s countable income. Doreen is under 19
and expects to file a tax return.
Thelma and George’s MAGI H/H: They do not expect to file taxes nor be claimed as a tax dependent. Column 4
corresponds to their situation. This means their hh will consist of Thelma, George, Doreen and Kevin. Family size of 4.
Countable Income: Income of Thelma, George and Doreen because she is under 19 and expects to file a tax return.
A
P
P
L
I
C
A
N
T
Medicaid Household
Doreen
Kevin
Thelma
George
Family Size
Doreen
X
Kevin
X
X
X
X
4
Thelma
X
X
X
X
4
George
X
X
X
X
4
1
29
Example 3
• Rebecca is a single, age 22, and lives with her
son, Jason, age 3. She does not expect to file
taxes, but does expect that she and her son will
be claimed as dependents by her mother and
father, Claire and Clarence. There are no other
dependents.
30
Example 3
Rebecca’s MAGI H/H: Rebecca expects to be claimed as a tax dependent and she does not meet
any exceptions, therefore, column 2 corresponds to her situation. Her household will be the
household of the taxpayer claiming her. This means it will include her mother and father (the tax
payers), herself, and her son – a family size of 4.
Countable Income: Rebecca is a tax dependent who does not meet an exception. The counting
income chart indicates that we will count the income of the tax filers, Claire and Clarence.
Jason’s MAGI H/H: Jason expects to be claimed as a tax dependent and meets an exception - he will
be claimed by someone other than a spouse or parent. Column 5 corresponds with his situation. His
hh will be Jason and his mother, Rebecca.
Countable Income: Jason’s countable income will be his mother’s income only.
A
P
P
L
I
C
A
N
T
Medicaid
Household
Rebecca
Jason
Claire
Clarence
Family Size
Rebecca
X
X
X
x
4
Jason
X
X
2
31
Example 4
• Cynthia, age 40, is applying for herself. She and
her three children, Joseph 5, Mary 7, and Jacob
9, all live together in the home. She and the
children’s father, Adam, are separated. Cynthia
states to the caseworker “she does not expect to
file a tax return but she expects that her
husband will claim her and the children as
dependents.” The children do not expect to file
taxes.
32
Example 4
Cynthia’s H/H: Cynthia and her husband are still married. Spouses cannot claim a spouse as a dependent – they are
co-filers which makes Cynthia a tax filer. Column 1 corresponds to her situation. Her household will be herself, her
spouse/co-filer, Adam, and their three children whom they claim as dependents. A family size of 5.
Countable Income: Since she is a tax filer, we will count the income of the tax filers which includes the co-filer, Adam’s
income. It does not matter that he is not in the home since he is included in the tax household.
Joseph’s H/H: Joseph does not expect to file taxes but will be claimed as a tax dependent by his father who does not live
in the home. Joseph will meet a tax dependent exception - he will be claimed by a non-custodial parent. Column 5
corresponds to his situation. His hh will be himself, his mother, Cynthia, and his siblings Mary and Jacob. A family size
of 4.
Countable Income: His countable income will be the income of his live in mother, Cynthia.
Mary and Jacobs’ MAGI HH and Countable income will be the same as Joseph’s.
A
P
P
L
I
C
A
N
T
Medicaid
Household
Cynthia
Joseph
Mary
Jacob
Adam
Family
Size
Cynthia
X
X
X
X
X
5
Joseph
X
X
X
X
4
Mary
X
X
X
X
4
Jacob
X
X
X
x
4
33
Recertifications
• Recertifications – MAGI-based programs
– Use traditional rules for recerts in 2014
– Keying:
• Pilot counties – continue in P 2/6
• Non-pilot counties – continue in EIS
– Complete recert application in P7 only if
ineligible under traditional rules
34
Recertifications
• EIS/NC FAST will automatically extend cert
periods by one month if not terminated or
assigned new cp (each month)
• Oldest recerts worked first – EIS will create
report monthly
• Working with NC FAST
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Questions?
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