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.
Prepared by Families USA for use in the District of Columbia
ESA Policy
Training Day 5
Reconciliation
Prepared by Families USA for use in the District of Columbia
Recap: How Premium Tax Credits Work
• Size of credit based on annual household
income as a percent of poverty
• Determined by household size and annual
income
DC Health Link will calculate a household’s
income as a percent of poverty and the size
of a household’s tax credit.
Prepared by Families USA for use in the District of Columbia
Example:
Poverty Level Shifts with Household Size
• Household size of one:
Bianca is single and makes $35,500 a year.
• Bianca’s annual household income is at 308% of
poverty for a household size of one.
• Household size of two:
Kat and Chris are married. Their combined
income is $35,500 a year.
• Kat and Chris’s annual household income is at
229% of poverty for a household size of two.
Prepared by Families USA for use in the District of Columbia
Three Ways to Take Premium Tax Credits
• Take credit in advance: Credit goes to DC
Health Link plan directly to lower monthly
premium
• Based on estimation of income and family size at
time of enrollment
• Take credit at tax time: Receive full annual
credit as part of tax refund
• Must pay full health insurance premiums up front
• Take some credit in advance, some at tax time:
• Take only a portion of credit up front to lower
premium
Prepared by Families USA for use in the District of Columbia
Recap: Reconciliation
People who opt to take some or all of their tax
credit in advance must recalculate their credit at
the end of the year.
Reconciliation:
• IRS recalculates credit based on total annual
income and family size at end of year
• If too much was taken in advance, people must
pay back portion of credit at tax time
• If too little was taken in advance, people get
additional portion of credit through tax refund
Prepared by Families USA for use in the District of Columbia
Example: Reconciliation
When Jody applies for coverage, she is found eligible for
a $3,000 premium tax credit. She takes $2,500 in
advance to lower her premiums ($208/month). At the
end of the year, based on her total annual income, it
turns out she was eligible for only a $2,800 premium tax
credit.
Since she took only $2,500 of the credit in advance,
she gets the remaining amount ($300) back as part
of her tax refund.
Prepared by Families USA for use in the District of Columbia
Example: Increase in Income
Gloria and Sean are married. Their estimated annual
household income is $46,500 (almost 300% of poverty)
when they apply. They are found eligible for a premium tax
credit of $2,146 ($178.83/month). Mid-way through the
year, Sean’s salary increases so that their total annual
income at the end of the year is $48,000 (309% of poverty).
Sean forgets to report the change to DC Health Link.
This decreases their tax credit to $2,001. This is $145
less than what they received in advance over the
course of the year. They must pay back the $145 when
they file their taxes.
Prepared by Families USA for use in the District of Columbia
Example: Increase in Household Size
The next year, Gloria and Sean apply for tax credits again.
This year, they estimate their annual income to be $48,000
(309% of poverty). They are eligible for a premium tax credit
of $2,001 ($166.75/month). In July, Gloria and Sean have a
baby. Their annual income for that year stays as expected at
$48,000, but their household size increases that year. Again,
they forget to tell DC Health Link about the change.
With a household size of three, they are actually at
245% of poverty at the end of the year. They are eligible
for a larger tax credit of $4,685 a year. They get $2,684
back in their tax refund.
Prepared by Families USA for use in the District of Columbia
Common Changes
• Increase in income: lowers premium tax credit
• Decrease in income: increases premium tax
credit
• Changes in family size (marriage/divorce,
baby): could increase or decrease credit,
depending on family
Prepared by Families USA for use in the District of Columbia
Key Points to Remember
• Consumers can choose to take credit in advance,
at the end of the year, or a mix
• Mid-year changes in household size and income
will affect the size of a household’s tax credit
• Consumers must report changes promptly to avoid
having to pay back a portion of the credit at the
end of the year
• Consumers can opt to take only a portion of their
premium tax credit in advance to help
compensate for mid-year changes
Prepared by Families USA for use in the District of Columbia
Plan Enrollment
Prepared by Families USA for use in the District of Columbia
Overview
• What is the enrollment process?
• When can people enroll?
• When will coverage begin?
• Why is it important to maintain coverage?
Prepared by Families USA for use in the District of Columbia
The Enrollment Process:
Three Groups of People
• Group #1:
Found eligible for Medicaid
• Group #2:
Found eligible for a DC Health Link plan with
premium tax credits
• Group #3:
Found eligible for a DC Health Link plan
without premium tax credits
Prepared by Families USA for use in the District of Columbia
Group #1:
People Who Are Eligible for Medicaid
• MAGI groups (parents/caretaker relatives,
children, pregnant women, adults 21-64 without
dependent children) enroll in Medicaid managed
care
• Will receive information from Medicaid
enrollment broker
• Enrollee automatically assigned to a plan if he or
she does not choose one in 30 days
Prepared by Families USA for use in the District of Columbia
Group #2:
People Who Are Eligible for a DC Health Link Plan with
Premium Tax Credits
DC Health Link:
• Notifies applicant of premium tax credit amount
• Asks how much person wants to take in advance
• Provides plan choice information, including share of
premiums person will pay in various bronze, silver,
gold, and platinum plans
• People with incomes at or below 250% of poverty
qualify for plans with lower cost-sharing
Important: Applicants must choose a plan for
coverage to go into effect.
Prepared by Families USA for use in the District of Columbia
Group #3:
People Who Are Eligible for a DC Health Link
Plan without Premium Tax Credits
• This group either does not qualify or chooses
not to apply for premium tax credits
• Must select a DC Health Link plan in order for
coverage to take effect
Prepared by Families USA for use in the District of Columbia
Getting Help with Enrolling
in a DC Health Link Plan
• ESA staff will not help applicants choose plans
• Applicants can go online and choose a plan
• Applicants can get help from:
• In-person assisters
• Insurance brokers
• You will have a list of those who can help
applicants choose plans
Prepared by Families USA for use in the District of Columbia
When can people enroll in Medicaid?
• Apply for Medicaid anytime throughout
the year
• Pick a Medicaid managed care plan within
30 days of being found eligible or be autoassigned
• Change plans anytime for “good cause”
and once a year for other reasons
Prepared by Families USA for use in the District of Columbia
When is open enrollment for DC Health Link?
Prepared by Families USA for use in the District of Columbia
Review: Question #1
James wants to enroll in Medicaid.
When can he do this?
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
He can apply and enroll at any time. After he
is found eligible, he has 30 days to select a
plan before he is automatically assigned to
one.
Prepared by Families USA for use in the District of Columbia
Review: Question #2
Dan knows that he is not eligible for
Medicaid. He is uninsured and wants to be in
a DC Health Link plan in 2014.
When can he apply and enroll?
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
Dan can apply at any time, but in order to
start coverage in 2014, he must apply and
enroll between October 1, 2013, and March
31, 2014, unless he qualifies for a special
enrollment period.
Prepared by Families USA for use in the District of Columbia
When will Medicaid coverage begin?
• No changes to when Medicaid coverage
starts
• Coverage starts on the first day of the month
the beneficiary applied
• Beneficiaries can get three months covered
retroactively if they have medical expenses
and meet all of the eligibility requirements
during the three-month period
Prepared by Families USA for use in the District of Columbia
When will DC Health Link coverage begin?
• Select plan and premium payment received
on or before the 15th of the month: coverage
will start the following month
• Enroll after the 15th of the month: wait
another month for coverage
• Enroll October 1, 2013 – December 20, 2013
for coverage effective January 1, 2014
Prepared by Families USA for use in the District of Columbia
Example: Dan
• Dan enrolls in a DC Health Link plan November 1,
2013. His coverage is effective January 1, 2014,
when DC Health Link plans begin.
• Dan enrolls January 21, 2014. Since it is later than
the 15th of the month, his coverage is effective
March 1, 2014.
• Dan picks a plan on January 15 and pays his first
premium on January 15, but DC Health Link does
not receive the payment until January 20. His
coverage is effective March 1, 2014.
Prepared by Families USA for use in the District of Columbia
Example: Dan (cont’d)
• Dan enrolls and pays his premium is received
on January 15, 2014. His coverage is effective
February 1, 2014.
• Dan tries to enroll April 1, 2014. Open
enrollment is closed, so he has to either wait
until 2015 to get coverage or apply for a
special enrollment period.
Prepared by Families USA for use in the District of Columbia
Example: Candace and Peyton
Candace receives premium tax credits that
help her pay for a DC Health Link plan. She
adopts a baby named Peyton on July 3. She
is too busy to tell DC Health Link about the
adoption until July 20. Peyton is found
eligible for Medicaid.
When does Peyton’s coverage start?
Prepared by Families USA for use in the District of Columbia
When does Peyton’s coverage start?
• Peyton’s coverage starts on the first day of
the month he was adopted (July 1)
• Medicaid will pay any covered benefits
from Medicaid providers received in the
month of July
Prepared by Families USA for use in the District of Columbia
What if applicants experience
major life changes?
There are certain special periods when you
can enroll in a DC Health Link plan outside of
open enrollment season.
Prepared by Families USA for use in the District of Columbia
Special Additional Periods for
Enrolling in DC Health Link Plans
• People can enroll outside of open enrollment if one of
the following occurs:
• Birth, adoption, placement for adoption
• Marriage
• Loss of other coverage, but not due to failure to pay
•
•
•
•
premiums
Change in immigration status (e.g., becoming a lawfully
present resident)
DC Health Link or broker/assister error/non-enrollment
Move
Applicant is newly eligible or ineligible for premium tax
credit
• American Indians can change/enroll anytime
Prepared by Families USA for use in the District of Columbia
What is the timing of special enrollment?
• Generally, the person has 60 days after the
special event to enroll
• In the cases of birth, adoption, or
placement for adoption:
• Coverage retroactive to the date of event
• Premium tax credits and cost-sharing
reductions begin the first of the next month
• You’ll receive more training on this later in
the year
Prepared by Families USA for use in the District of Columbia
Examples
• Dan had a job that offered health insurance. He
lost that job and the insurance in April. He has a
special 60-day period to enroll in a DC Health
Link plan.
• Sabrina pays a lot for her job-based coverage, but
her income is pretty high. Her income goes down
when her hours are cut in June. She is now
eligible for premium tax credits. She has 60 days
to enroll, starting on the day she is determined
newly eligible for premium tax credits.
Prepared by Families USA for use in the District of Columbia
What happens after people
enroll in a DC Health Link plan?
• Enrollees pay a share of premiums monthly
• Government will directly pay its share of premiums (tax
credit amount) to the plan
• Coverage can be terminated if people do not pay
• If eligible for tax credits, three-month grace period to catch up and
maintain coverage
• If not eligible for tax credits, one-month grace period
• If coverage is terminated, it will end on the last day of the last
month for which the premium was paid
• People can cancel their coverage at any time
• Must give 14 days notice before coverage ends, unless health plan
agrees otherwise
Prepared by Families USA for use in the District of Columbia
The Importance of Maintaining Coverage
Remind people that they:
• Will need coverage if they get sick
• May be subject to individual responsibility
penalties if they go three months without
coverage
• Cannot get back into a plan if they lose coverage
unless it is an open or special enrollment
opportunity
Prepared by Families USA for use in the District of Columbia
Movement
between Medicaid
and DC Health Link
Prepared by Families USA for use in the District of Columbia
Transitioning from
Medicaid to DC Health Link
• If enrollee becomes ineligible for Medicaid, notice
received at least 15 days before coverage ends:
• Terminates end of month, if 15 days remaining
• Terminates end of next month, if less than 15 days
remaining
• Must choose a health plan for DC Health Link
coverage to start
• Must choose within 60 days of re-determination
• Enroll on or before 15th of month before Medicaid
coverage ends to avoid coverage gap
• Choosing early will ensure DC Health Link coverage
starts when Medicaid coverage ends
Prepared by Families USA for use in the District of Columbia
Transitioning from
DC Health Link to Medicaid
Medicaid coverage is retroactive to the first day
of the month in which the re-determination is
made.
Example: James had a DC Health Link plan and
premium tax credits. He loses his job and
reported the change in mid-March. He is found
eligible for Medicaid.
His Medicaid coverage begins March 1.
Prepared by Families USA for use in the District of Columbia
Example: Jodi
Jodi has been getting coverage through Medicaid.
In July, she gets a new job with higher pay. She
reports the change.
On July 18, DC Health Link sends her notice that
she is no longer eligible for Medicaid, but she is
eligible for premium tax credits to buy a DC Health
Link plan.
When does Jodi’s Medicaid coverage end? What
does she need to do to avoid a gap in coverage?
Prepared by Families USA for use in the District of Columbia
Example: Answer
Jodi will maintain Medicaid coverage through the
end of August.
In order to not have a gap in coverage. Jodi must
enroll in a DC Health Link Plan by August 15.
Prepared by Families USA for use in the District of Columbia
Referrals
Prepared by Families USA for use in the District of Columbia
When to Make a Referral
Refer consumers who need help with:
• Plan selection: Picking a Medicaid managed
care plan or a DC Health Link plan
• Appeals: Gathering documentation, getting
representation, or checking on status of a
decision
• Getting health services: Finding a provider,
appealing a coverage denial, or
understanding benefits
Prepared by Families USA for use in the District of Columbia
Help Selecting a Medicaid Plan
For help enrolling in a Medicaid managed
care plan, refer consumers to the Medicaid
enrollment broker (Maximus).
If consumers do not select a Medicaid
managed care plan, they will be
automatically assigned to one.
Prepared by Families USA for use in the District of Columbia
Help Selecting a DC Health Link Plan
Those who are eligible for DC Health Link plans can get
help choosing a plan from:
• In-person assisters, who are trained to provide
free help with choosing DC Health Link Plans
• An insurance agent or broker, who can make a
recommendation about which plan to choose
There will be a directory of in-person assisters, agents,
and brokers on DC Health Link.
Remind consumers that their coverage will not start
until they choose and pay for a health plan.
Prepared by Families USA for use in the District of Columbia
In-Person Assisters
• Located in community-based organizations
throughout the District
• Receiving special training to help
consumers choose DC Health Link plans
Prepared by Families USA for use in the District of Columbia
Choosing an In-Person Assister
• Location
• Hours of operation
• Availability of bilingual staff
• Expertise in specific health care needs
• Ability to do home visits
Prepared by Families USA for use in the District of Columbia
Help with Appeals
After an appeal of an eligibility determination is
started, if a consumer needs help with the
appeals process, refer to:
• Office of the Health Care Ombudsman
• Legal services programs
Prepared by Families USA for use in the District of Columbia
Help Getting Health Services
After consumers enroll in a health plan, if
consumers need help connecting with health
care services or understanding their coverage:
• Medicaid enrollees should contact their
MCO directly
• Refer DC Health Link enrollees to the Office
of the Health Care Ombudsman and/or
their health plan
Prepared by Families USA for use in the District of Columbia
Making Referrals
• Referrals will be necessary, but consumers may
not always follow through
• To make it easier for consumers to connect
with the help they need, when possible:
1) Help consumers find contact information
for an appropriate resource
2) Call a resource from the service center to:
•
•
Get consumers help on the spot, or
Schedule appointments
Prepared by Families USA for use in the District of Columbia
Review: Question #1
TRUE or FALSE:
ESA workers will be helping people choose a
Medicaid or DC Health Link plan once their
eligibility has been determined.
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
FALSE
ESA workers will not be helping with plan
selection. Applicants should be referred to a
Medicaid enrollment broker, in-person assister,
insurance agent, or broker.
Prepared by Families USA for use in the District of Columbia
Review: Question #2
Where will you be able to find information
about who to refer someone to for help with
plan selection?
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
• There will be a directory with the contact
information of in-person assisters,
insurance agents, and brokers.
• The customer service call center can also
help with finding assistance.
Prepared by Families USA for use in the District of Columbia
Things to Remember
• Make referrals for help with:
1.
2.
3.
Selecting a health plan
The appeals process
Getting health services
• You will have a list of referral resources
• If you do not know where to refer, call the DC
Health Link customer service call center
• When possible, help consumers get contact
information and help them set up an appointment
Prepared by Families USA for use in the District of Columbia
The New
Renewal Process
Prepared by Families USA for use in the District of Columbia
Renewals
• Enrollees need to renew coverage once a year for:
• Medicaid
• DC Health Link plans
• Use electronic data sources to:
• Renew eligibility without requiring action by
recipient if possible
• Pre-populate renewal form
• Renewals for non-MAGI groups still handled by
ESA until Release 2 (in 2014)
Prepared by Families USA for use in the District of Columbia
Three Possible Outcomes
There are three possible outcomes of DC
Health Link attempts to renew eligibility
using electronic data sources:
1. Eligibility can be renewed automatically
2. More information is needed
3. Eligibility has changed
Prepared by Families USA for use in the District of Columbia
Outcome 1:
Eligibility Can Be Renewed Automatically
If DC Health Link has enough information to redetermine eligibility, coverage is automatically
renewed:
• Recipient has the opportunity to correct prepopulated information
• If recipient does nothing, coverage continues
in Medicaid
• DC Health Link enrollees need to sign and
return form
Prepared by Families USA for use in the District of Columbia
Outcome 2:
More Information Is Needed
If electronic data does not have enough information
to renew eligibility:
•
•
•
Recipient instructed to fill in rest of enrollment
form and return to ESA within 30 days (DC Health
Link) or 60 days (Medicaid)
Can do this online, by phone, in person, or by mail
Eligibility determined based on available data, and
may end if recipient does not act
Prepared by Families USA for use in the District of Columbia
Outcome 3:
Eligibility Has Changed
If DC Health Link finds information that shows a
change in eligibility, DC Health Link sends
recipient:
• Information on change in eligibility
• Recipient can correct information
• Information on how to enroll in new
coverage
Prepared by Families USA for use in the District of Columbia
The Renewal Timeline for Medicaid
• Medicaid renewals happen throughout the
year because anyone can enroll in Medicaid
at any time
• The system will automatically re-determine
eligibility during the year if it has information
from:
• SNAP recertification
• Report of a change in circumstance
Prepared by Families USA for use in the District of Columbia
The Renewal Timeline for DC Health Link
• Everyone renews during open enrollment
every year
• This is true even if enrollee has had a DC
Health Link plan for less than one year
Prepared by Families USA for use in the District of Columbia
Special Medicaid Renewal Situation
• For MAGI groups, renewals will be postponed
from January 1, 2014-April 2014.
• Electronic data will be used to re-determine
eligibility
• If electronic data does not have enough
information to renew eligibility, pre-populated
form will be sent
Prepared by Families USA for use in the District of Columbia
Review: Question #1
TRUE or FALSE:
Coverage will continue for some enrollees
even if they do nothing at renewal time.
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
TRUE
If DC Health Link has enough information
from electronic data sources to determine
that consumers are still eligible at renewal
time, they will keep getting coverage even if
they do not do anything.
Prepared by Families USA for use in the District of Columbia
Review: Question #2
Maggie has been on Medicaid for several years. In
July, she gets a new job and starts making more
money. She reports this change to DC Health Link
and is found eligible for premium tax credits and
signs up for a DC Health Link plan. Her coverage
starts in August.
TRUE or FALSE:
Maggie will not need to renew her DC Health Link
coverage until next August
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
FALSE
Maggie is getting a DC Health Link plan with
premium tax credits, so her coverage needs
to be renewed during the fall open
enrollment period even if she has not had a
full year of coverage.
Prepared by Families USA for use in the District of Columbia