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 stateinfo@familiesusa.org for assistance with
adapting these materials.
ESA Policy Training
Day 1
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?
Prepared by Families USA for use in the District of Columbia
Background on the
Affordable Care Act
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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 Uninsured
People in DC, 2011: 42,007
Source: CBPP analysis of Census Bureau data from the American Community Survey 2011
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
DC Medicaid and the
Affordable Care Act
Prepared by Families USA for use in the District of Columbia
Medicaid Will Stay
the Same for Most People
• DC is preserving its good coverage levels
• DC is modernizing applications, eligibility
determinations, and renewals
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
Introduction to
DC Health Link
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
Overview
1. What are DC Health Link plans like, and
how will DC residents be able to
compare plans?
2. What type of assistance is available to
people buying DC Health Link plans?
Prepared by Families USA for use in the District of Columbia
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)
Essential Health Benefits (EHB)
1. Outpatient services
6. Prescription drugs
2. Emergency services
7. Rehabilitative and habilitative services
3. Hospitalizations
8. Laboratory services
4. Maternity and newborn care
9. Preventive services
5. Mental health and substance use
disorder services (no day or visit limits
in DC)
10. Pediatric services (includes oral and
vision care)
Prepared by Families USA for use in the District of Columbia
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.
Medicaid covers the 10 Essential Health Benefits, PLUS:
EPSDT (Early and Periodic Screening,
Diagnostic, and Treatment) services to
children under 21
Access to federally qualified
health centers
Family planning services
Emergency and non-emergency
transportation to medical care
Prepared by Families USA for use in the District of Columbia
Different Levels of DC Health Link Plans
Plans offered in four metal levels:
Metal Level
Generosity
Platinum (highest monthly
premiums)
Covers about 90% of medical
care costs
Gold
Covers about 80% of medical
care costs
Silver
Covers about 70% of
medical care costs
Bronze (lowest monthly
premiums)
Covers about 60% of medical
care costs
Note: Measured based on total cost of covered benefits
for a typical population
Prepared by Families USA for use in the District of Columbia
Understanding Metal Levels
• 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
Prepared by Families USA for use in the District of Columbia
Hypothetical Plans
Metal Level
Full Premium
Price at Age 40
Deductible
Patient Co-Pay
for Sick Care
Doctor Visit
Platinum
$460
$0
$20/primary
$40/specialty
Gold
$370
$0
$30/primary
$50/specialty
Silver
$295
$2000
$45/primary
$65/specialty
Bronze
$230
$5000
$60/primary
$70/specialty
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
Premium Tax Credits
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
Income Changes
• People can report their income changes to get
premium tax credits and cost-sharing reductions
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
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
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
Prepared
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?
Prepared by Families USA for use in the District of Columbia
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.
Prepared by Families USA for use in the District of Columbia
DC Coverage Assistance Options in 2014
Approximate
Income
Levels as a
Percent of
Poverty
Prepared by Families USA for use in the District of Columbia
Cost-Sharing Reductions
Prepared by Families USA for use in the District of Columbia
Cost-Sharing Reductions: The Basics
People with incomes below 250% of poverty will
get extra help paying for medical services in
certain plans
• This will reduce 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
Prepared by Families USA for use in the District of Columbia
What is cost-sharing?
Prepared by Families USA for use in the District of Columbia
Cost-Sharing Reductions (Individual)
Income as % of
Poverty Level
(Shown for a Family
of One)
Out-of-Pocket Maximum
Cost-Sharing
for an Individual
(Double for a Family)
Co-Pays/
Co-Insurance/
Deductibles Are Similar
to This Metal Level Plan
100-150%
$2,250
Platinum
150-200%
$2,250
Gold
200-250%
$5,200
Silver
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.
Prepared by Families USA for use in the District of Columbia
Cost-Sharing Reductions: Question #1
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?
Prepared by Families USA for use in the District of Columbia
Cost-Sharing Reductions: Answer #1
ANSWER:
When her medical out-of-pocket medical
expenses for the year reach $2,250,
excluding premiums
Prepared by Families USA for use in the District of Columbia
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?
Prepared by Families USA for use in the District of Columbia
Cost-Sharing Reductions: Answer #2
ANSWER:
When his out-of-pocket medical expenses
for the year reach $5,200
Prepared by Families USA for use in the District of Columbia
Things to Remember
• 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
Prepared by Families USA for use in the District of Columbia
Applications
Prepared by Families USA for use in the District of Columbia
What’s changing?
• New application for MAGI-based Medicaid
and premium tax credits
• Many ways to apply
• Easier eligibility determination
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
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
Prepared by Families USA for use in the District of Columbia
Ways to Apply
•
•
•
•
Online
By phone
In person
By mail
In-person interviews are not required!
Prepared by Families USA for use in the District of Columbia
The Advantages of Using
the Online Application
• Application is easy to read
• Help by phone available 24/7
• Some information will be pre-populated
• Allows for real-time verification
• Application is dynamic
• Applicant gets information on whether or not
eligibility has been determined at the end
Prepared by Families USA for use in the District of Columbia
People Will Still Want In-Person Help
• Trusted government agencies
• In-Person Assisters (IPAs)/Navigators (new)
• Other groups, like community clinics and
hospitals
Prepared by Families USA for use in the District of Columbia
In-Person Assisters
• Funded by DC Health Benefit Authority
• Conduct outreach and education in the
community
• Trained to help with application and plan
selection
• Provide help in other languages and assistance
for people with disabilities
• Give impartial information
Prepared by Families USA for use in the District of Columbia
Certified Application Counselors
• Another type of assister trained to help with
application and plan selection
• May be staff in community health clinics,
hospitals, schools, or other community
organizations
• Registered with DC Health Link, but not funded
• Focused on helping people who come through
their doors, rather than conducting active
outreach
Prepared by Families USA for use in the District of Columbia
Accessibility
• Applications and forms must be
accessible for people with limited English
proficiency and people with disabilities
• Application will be available in English,
Spanish, and, later in 2014, Amharic
Prepared by Families USA for use in the District of Columbia
What does the application ask about?
• Household
• Income
• Citizenship and immigration status
• Residency
• Pregnancy
• Other coverage
Prepared by Families USA for use in the District of Columbia
Applicants and Non-Applicants
• Some household members may be non-applicants
• Important to list all household members to get
full benefits
• For instance, a large household with income of
$45,000 may be entitled to more benefits than
a smaller household with the same income
• People DO NOT have to list Social Security
numbers or immigration status for non-applicants
Prepared by Families USA for use in the District of Columbia
Example: Tania
Tania is applying for health coverage. She and
her husband have children. Her husband does
not want health coverage, but he agrees that
the rest of the family should apply.
What can you tell Tania?
Prepared by Families USA for use in the District of Columbia
Answer: What to Tell Tania
ANSWER:
Tania can list her husband as a non-applicant
and does not need to provide his Social
Security number. The computer may not be
able to electronically verify household
income without the Social Security number,
but she can provide paper documentation of
her husband’s income.
Prepared by Families USA for use in the District of Columbia
Getting an Authorized Representative
• Consumer can designate authorized
representative (power of attorney, authorized
representative form, etc.)
• May also be assigned through a court order
• Can be designated at any time:
• Online through “My Account”
• By mailing a request to a service center
• In person at a service center
• Can be changed at any time
Prepared by Families USA for use in the District of Columbia
What Authorized Representatives Will Do
• Authorized representatives will receive:
• Copies of notices sent to the consumer
• Other communications on behalf of consumer
• Authorized representatives will be able to:
• File an application and renew coverage
• Provide information and documentation
• Explain rights and responsibilities
• Provide representation in an interview or
hearing
Prepared by Families USA for use in the District of Columbia
Verification
• New system uses electronic data sources first
• Will accept attestation for some things (for example,
pregnancy and household composition)
• Will need documentation of income, citizenship, and
immigration status if no electronic data is available
• Some differences between attestation and electronic
data sources will need to be resolved and some will
not
• System will check electronic data sources for you and
tell you when documentation is needed
Prepared by Families USA for use in the District of Columbia
Processing Applications
• Outside time limits for processing Medicaid
applications remain the same
•
•
45 days
90 days for people applying on basis of disability
• Some eligibility determinations will happen right
away
• System will automatically send notices to:
•
•
Applicant
Applicant’s employer, if necessary
Prepared by Families USA for use in the District of Columbia
Open Enrollment
• Time to enroll in DC Health Link plans that can be
purchased with premium tax credits
• First open enrollment season: October 1, 2013 to
March 31, 2014
• Future years’ open enrollment seasons: October
15 to December 7 (enroll in 2014 for coverage to
be effective Jan 1, 2015, for example)
• People can still apply for and enroll in Medicaid at
any time
Prepared by Families USA for use in the District of Columbia
What will happen to people
in non-MAGI Medicaid?
• Screening questions in application will
identify people who might qualify
• Because determinations (for example,
disability) take longer, applicants can enroll in
what their income qualifies them for while
they wait
Prepared by Families USA for use in the District of Columbia
Review: Question #1
QUESTION:
Which of the following groups will have their
Medicaid eligibility determined through the
new online application?
• Pregnant women
• Parents
• Adults under age 65 without children
• Adults over age 65
• People with disabilities
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
ANSWER:
• Pregnant women
• Parents
• Adults under age 65 without children
Prepared by Families USA for use in the District of Columbia
Review: Question #2
QUESTION:
Starting in October, people will be able to
apply in which of the following ways:
a. By phone
b. By mail
c. In person
d. Online
e. All of the above
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
ANSWER:
E – All of the above
People will be able to apply by phone, by mail, in
person, and online.
Prepared by Families USA for use in the District of Columbia
Individual Responsibility
Prepared by Families USA for use in the District of Columbia
Why is this requirement part of the law?
• To encourage people to get coverage now,
rather than wait until they are sick
• To keep insurance affordable
Prepared by Families USA for use in the District of Columbia
Individual Responsibility
Starting in 2014, each individual, including children
and seniors, must:
1. Have minimum essential coverage (which we’ll
explain in a minute); OR
2. Qualify for an exemption; OR
3. Make a payment when filing his or her federal
tax return. This payment is the “individual
shared responsibility” payment.
Prepared by Families USA for use in the District of Columbia
What is “minimum essential coverage”?
• A basic set of benefits and financial protections
that a plan must have to be considered adequate
health coverage
• Most people in the U.S. already have minimum
essential coverage through:
• An employer (their own employer or employer of spouse
or parent)
• A government program, such as Medicaid, Medicare, or
Tricare
• Health insurance purchased by an individual or family
Prepared by Families USA for use in the District of Columbia
What is not minimum essential coverage?
• A “limited benefit” plan that covers only a
particular condition, such as a cancer-only policy
•
Self-funded student plans are minimum essential
coverage
• A medical discount plan
• A plan that pays a fixed amount per day
(example: a policy that pays $250 for each day
someone is sick, but nothing else)
• DC Alliance
Prepared by Families USA for use in the District of Columbia
Exemptions from the Individual
Responsibility Requirement
• Some people are exempt from individual
responsibility, but many will need to get a
certificate from HHS showing that they are
exempt
• Others will claim their exemption when
they file taxes
• Exemptions are time-limited
Prepared by Families USA for use in the District of Columbia
Who is exempt from the individual
responsibility requirement?
1. People with a coverage gap of less than three months
2. People with certified financial hardships
3. People with incomes below the minimum tax filing
threshold
4. People whose premiums would be more than 8% of their
income
5. Those who are incarcerated
6. Those who are not lawfully present in the United States
7. Religious sects opposed to accepting insurance benefits
8. Members of recognized health care sharing ministry
9. Federally recognized Indian Tribes
Prepared by Families USA for use in the District of Columbia
Penalties for Going without Coverage
(If Not Exempt)
In 2014:
• $95/adult, $47.50/child
• Up to $285 per family or 1% of family income,
whichever is greater
In 2016:
• $2,085/family or 2.5% of family income
Prepared by Families USA for use in the District of Columbia
Handling Questions about
Individual Responsibility
Refer to consumers to the HHS call center
if they have questions about the individual
responsibility requirement.
Prepared by Families USA for use in the District of Columbia
Milestone Dates for DC Health Link
• Enrollment starts October 1, 2013
• Coverage begins as early as January 2014
Prepared by Families USA for use in the District of Columbia