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 2
MAGI, Non-MAGI, and
Eligibility Categories
Prepared by Families USA for use in the District of Columbia
What is MAGI?
• The Affordable Care Act defines how
eligibility will be determined for:
• Most Medicaid beneficiaries
• All people who get premium tax credits and
cost-sharing reductions
• Modified Adjusted Gross Income (MAGI) is
the new way of looking at household
composition and income
• MAGI won’t be used for certain populations
Prepared by Families USA for use in the District of Columbia
Who are the MAGI groups?
• Four groups:
• Parents and caretaker relatives
• Children
• Pregnant women
• Adults aged 21-64 without dependent
children
• About 158,000 beneficiaries
Prepared by Families USA for use in the District of Columbia
Parents and Caretaker Relatives
• Includes parents and caretaker relatives and, if
living with them, their spouses
• One group called 1931 Low-Income Families
• Eligible for Medicaid with incomes up to 221%
of poverty
• Those over age 65 can receive MAGI Medicaid
as parents/caretaker relatives
Prepared by Families USA for use in the District of Columbia
Who is a caretaker relative?
• Relative (based on blood, adoption, or
marriage) with whom dependent child is
living who assumes primary responsibility for
child’s care
• The spouse of a parent or caretaker relative
Prepared by Families USA for use in the District of Columbia
Children
• Children under age 19 are eligible with
incomes up to 324% of poverty
• Children age 19 and 20 are eligible with
incomes up to 221% of poverty
• System will automatically identify:
• Medicaid kids
• Targeted Low-Income Children
Prepared by Families USA for use in the District of Columbia
Continuous Eligibility for Children
• All children get a full year of Medicaid
coverage even if eligibility changes
• Children who are hospitalized and turn 21
while hospitalized continue to be eligible
for Medicaid until the end of hospital stay
Prepared by Families USA for use in the District of Columbia
Example: Continuous Eligibility
Marika and her nine-year-old daughter Chloe
have an income at 275% of poverty. Marika
has a DC Health Link plan with a premium tax
credit, and Chloe has Medicaid.
Marika’s hours increase over the summer and
her income rises to 350% of poverty. Marika
reports the change.
Prepared by Families USA for use in the District of Columbia
Example: Continuous Eligibility (cont’d)
DC Health Link updates Marika’s premium
tax credit amount to reflect the change.
Chloe stays in Medicaid even though she is
above 324% of poverty.
Marika’s hours return to normal at the end
of the summer. She reports the change,
and DC Health Link adjusts her premium
tax credit amount. Again, Chloe stays in
Medicaid.
Prepared by Families USA for use in the District of Columbia
Pregnant Women
• Eligible for Medicaid with incomes up to
324% of poverty
• Eligibility as pregnant woman ends the
month that includes the 60th day postpartum
• System will automatically identify:
• Medicaid pregnant women
• Targeted Low-Income Pregnant Women
Prepared by Families USA for use in the District of Columbia
Continuous Eligibility for Pregnant Women
Eligibility continues to the end of the postpartum period even if a pregnant woman’s
income goes above 324% of poverty.
Prepared by Families USA for use in the District of Columbia
Adults Ages 21-64 without
Dependent Children
• Eligible for Medicaid with incomes up to
215% of poverty
• DC expanded Medicaid early
• System will automatically identify:
• CAM group
• Program Code 775 group
Prepared by Families USA for use in the District of Columbia
Presumptive Eligibility for
Pregnant Women
• Certain Medicaid providers can determine a
pregnant woman presumptively eligible for
Medicaid without a full application
• Presumptive eligibility is for a maximum of
60 days
• Beneficiary must also file a full Medicaid
application within 60 days
• Eligible only for outpatient services
Prepared by Families USA for use in the District of Columbia
Hospital Presumptive Eligibility
• Under new rules, all Medicaid hospitals can
make presumptive eligibility determinations
for MAGI populations
• Eligible for all services
• Anyone determined presumptively eligible
has 60 days to complete an application
Prepared by Families USA for use in the District of Columbia
Non-MAGI Populations
• SSI recipients
• Deemed newborns
• Foster care youth
• Project Wish beneficiaries
• Former foster care youth up to age 26
Prepared by Families USA for use in the District of Columbia
Non-MAGI Populations (cont’d)
• Those who are aged, blind, or disabled
• Those seeking long-term services and
supports (nursing home and home- and
community-based services)
• Medicare Savings Program beneficiaries
• Dual eligibles
• Medically needy/spend-down
beneficiaries
Prepared by Families USA for use in the District of Columbia
Former Foster Care Youth
New eligibility category
• Young adults who:
• Are under age 26
• Were in foster care in DC
• Were receiving Medicaid when they
turned 18 (or were emancipated) or
left foster care (after age 18)
Prepared by Families USA for use in the District of Columbia
Why is the distinction between MAGI
and non-MAGI important?
• In some cases, non-MAGI populations can
get additional benefits
• Helps determine whether a person is
placed in fee-for-service or managed care
Medicaid
• Determining eligibility for non-MAGI
populations sometimes has extra
requirements
Prepared by Families USA for use in the District of Columbia
How will you know if someone is
in a non-MAGI category?
• Answers to screening questions in application
or renewal form
• Request for a full determination
• Submission of supplemental non-MAGI
application forms
• Agency has information about the person’s
non-MAGI eligibility
Prepared by Families USA for use in the District of Columbia
What happens to non-MAGI applications?
Goal: Get applicant covered as quickly as possible
• If possible, make non-MAGI eligibility
determination promptly
• If non-MAGI determination will take longer,
enroll applicant in either MAGI Medicaid or
a DC Health Link plan with tax credits until
non-MAGI determination is done
Prepared by Families USA for use in the District of Columbia
Example: Ron
Ron is 49 years old and works part-time earning
$15,000 per year. He has some medical
conditions that make it difficult for him to do
certain daily tasks. When he fills out the
application, he answers “yes” to the non-MAGI
screening questions.
Prepared by Families USA for use in the District of Columbia
Ron’s Application
• Ron may be eligible for non-MAGI Medicaid
based on having a disability
• Because disability determinations take time,
determine Ron’s MAGI eligibility
• Ron is eligible for MAGI Medicaid until his
non-MAGI eligibility determination is
complete
Prepared by Families USA for use in the District of Columbia
Review: Question #1
Martin is 21 years old. His income was at
175% of poverty when he applied and got
Medicaid. Three months later, he got a
second job and his income went up to
230% of poverty.
TRUE OR FALSE:
Since this change happened during the
year, Martin can keep his Medicaid because
of continuous eligibility.
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
FALSE
Only children and pregnant women
have continuous eligibility.
Prepared by Families USA for use in the District of Columbia
Review: Question #2
ESA will determine eligibility for which of the
following groups in 2014?
a. Childless adults aged 21-64
b. People with disabilities
Pregnant women
d. Dual eligibles
e. The medically needy/spend-down
beneficiaries
c.
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
ANSWER: B, D, and E
ESA will still determine eligibility for non-MAGI
populations, which includes those who are
disabled, dual eligibles, and those who are
medically needy/spend-down beneficiaries in
2014.
Pregnant women and childless adults aged 21-64
are MAGI populations and will use the new
system.
Prepared by Families USA for use in the District of Columbia
Review: Question #3
TRUE or FALSE:
If an applicant might be eligible for
Medicaid on a non-MAGI basis, she must
wait until her non-MAGI eligibility has been
determined to get coverage.
Prepared by Families USA for use in the District of Columbia
Answer: Question #3
FALSE
Applicants who are waiting for a nonMAGI determination should be
enrolled in Medicaid or a DC Health
Link plan based on their income.
Prepared by Families USA for use in the District of Columbia
Recap of Eligibility Categories
• What you will do:
• Enter applicant’s information into DC
Health Link
• Enter changes into DC Health Link
• What the system will do for you:
• Determine eligibility category for each
applicant automatically
Prepared by Families USA for use in the District of Columbia
Overview of
Eligibility Factors
Prepared by Families USA for use in the District of Columbia
Eligibility Factors at a Glance
Eligibility Factors
Household Income
Medicaid
DC Health Link with
Premium Tax Credit
DC Health Link
without Premium
Tax Credit
Household income up to
Medicaid eligibility level
for MAGI group
Household income above
100% and below 400% of
poverty
Citizenship/Immigration Citizen or qualified alien
Status
(pregnant women and
children under 21 also
eligible if lawfully
present)
Citizen or lawfully present
Citizen or lawfully
present
Residency
Resident of DC
Resident of DC
Incarceration Status
Not incarcerated
Not incarcerated
Tax Filing Status
Agrees to file taxes (jointly
if married)
Job-Based Coverage
No offer of coverage
through employer, family
member’s employer, or
government
Resident of DC
Prepared by Families USA for use in the District of Columbia
Household Composition
• New rules are based on tax household
• Special rules for certain family situations
and families that do not file taxes
Prepared by Families USA for use in the District of Columbia
Income
• New rules are based on tax income
• Changes to income disregards and
no more deductions
Prepared by Families USA for use in the District of Columbia
Citizenship and
Immigration Status
Prepared by Families USA for use in the District of Columbia
Immigration Status and Medicaid
• Citizens are eligible for full Medicaid, as are
individuals who have an immigration status that
makes them a “qualified alien”
• Depending their type of immigration status, some
people who are “qualified aliens” are subject to the
five year bar
• Pregnant women and children who are
“lawfully present” are also eligible for full
Medicaid
• Pregnant women and children are exempt from the
five year bar
Prepared by Families USA for use in the District of Columbia
Immigration Status and
DC Health Link
• Must be a citizen or “lawfully present”
• More types of immigration status are included in
the “lawfully present” category, than in the
“qualified alien” category
• No five year bar for DC Health Link plans, premium
tax credits and cost sharing reductions
Prepared by Families USA for use in the District of Columbia
DC Alliance
• For people under 200% of poverty not
eligible for Medicaid, including
• People subject to five-year Medicaid bar
• Some other immigrants, such as DACA
• No premiums, but limited benefits
• Is not minimum essential coverage
• Separate application and face-to-face
interview required
• Eligibility will still be determined by ESA in
2014
Prepared by Families USA for use in the District of Columbia
Immigrants Have a Choice during
the Five-Year Bar Period
Immigrants can get:
• DC Alliance
• DC Health Link plan with premium tax credits
and cost-sharing reductions
DC Alliance
DC Health Link
No premiums
Level of premiums depends on
premium tax credit amount
No copayments
Copayments
Limited benefits
Full benefits
Very limited network of
providers
Regular private insurance
provider network
Not minimum essential
coverage
Minimum essential coverage
Prepared by Families USA for use in the District of Columbia
Including Non-Applicants
• People should list all household
members when they apply for DC Health
Link coverage and Medicaid
• They should note which members are
seeking coverage and list other members
as non-applicants
Prepared by Families USA for use in the District of Columbia
Verifying Citizenship and
Immigration Status
• DC Health Link will automatically attempt to
confirm information through electronic data
sources
• If DC Health Link can’t confirm:
• Applicant has 90 days to provide documentation
• Applicant receives coverage during that time, if
eligible based on the information they provide
Prepared by Families USA for use in the District of Columbia
Documenting Citizenship and
Immigration Status
• Documentation requirements for citizenship
• One form of primary documentation, or
• Two forms of secondary documentation:
1.
2.
ID with photo or other identifying information
Other documentation from list
• See handout for documentation types
• An official government document will be
needed to verify immigration status
• See handout for list of acceptable documentation
Prepared by Families USA for use in the District of Columbia
Working with Immigrant Applicants
Things to consider:
• Applying for health coverage is not a “public charge”
• Be clear on how information will and will not be used
• Be sure that applicants understand what information is
required for non-applicants
• If citizenship or immigration status cannot be verified
right away:
• Applicant has 90 days to provide documentation
• Applicant receives coverage during that time, if
eligible based on other information (eligibility based
on other factors must be verified for Medicaid)
Prepared by Families USA for use in the District of Columbia
Review: Question #1
Which of the following groups with incomes
below 200% of poverty have a choice between
DC Alliance and DC Health Link:
a. Lawfully present children
b. Lawfully present adults subject to five-
year bar
c. U.S. citizens
d.
Deferred Action Childhood Arrivals
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
ANSWER: B
Lawfully present adults subject to the fiveyear bar
• Lawfully present children get Medicaid
• U.S. adult citizens get Medicaid
• Qualified aliens who are not subject to five-year
bar can get Medicaid
• Deferred Action Childhood Arrivals get DC
Alliance
Prepared by Families USA for use in the District of Columbia
Review: Question #2
TRUE or FALSE:
Applicants who attest to an eligible
immigration status and are eligible for
coverage based on other factors have 90 days
to document immigration status if it cannot
be verified electronically, but they do not
receive coverage until their immigration
status has been verified
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
FALSE
Immigrant applicants do have 90 days to
document immigration status if
documentation is needed, but they do get
coverage during this time.
Prepared by Families USA for use in the District of Columbia
Residency Requirements
Prepared by Families USA for use in the District of Columbia
Medicaid Residency
In general, those over age 21 not living in an
institution are residents of DC if:
• They live and intend to continue living in DC
• People do not need to have a fixed address to be
residents
• No minimum length of time in DC
• People entering DC with a job commitment or
looking for a job are considered residents
Prepared by Families USA for use in the District of Columbia
Medicaid Residency for
People under Age 21
In general, those under age 21 are considered
DC residents if:
• They live in the District (even without a
fixed address) or
• Their parent or caretaker relative lives in the
District
Prepared by Families USA for use in the District of Columbia
Special Situations for Residency
Situation
Residency
In an institution
Resident of state that made the
placement
In an institution, but not placed by
the state
Resident where person lives and
intends to reside
Getting SSI supplement
Resident of state that pays it
Prepared by Families USA for use in the District of Columbia
Residency Requirements for
DC Health Link
In general, people over age 21 are considered DC
residents if:
• They live in and intend to continue living in DC,
including:
• Those with no fixed address who intend to live in
DC
• People who have a job commitment or are
seeking employment and living in DC
Those under age 21 can be considered residents:
• Where they live, or
• Where their parent/caretaker lives (if the child
claims the same residence)
Prepared by Families USA for use in the District of Columbia
What if a household includes someone
who lives in a different state?
• Some tax households will include members
who do not live in DC
• Include their information on the application
• Application needs this information to
determine eligibility of the DC residents
in the household
Prepared by Families USA for use in the District of Columbia
Example
Jim (26) and Liz (28) are married and have a child, Sam
(5). Jim and Sam live in the District. This year, Liz will
live in North Carolina for a job. Jim has a DC Health Link
plan, and Sam qualifies for Medicaid.
Liz is in a separate plan in North Carolina.
Their income is just under 250% of poverty, so Liz and
Jim are eligible for premium tax credits and costsharing reductions, and Sam is eligible for Medicaid. Liz
gets a premium tax credit and cost-sharing reductions
in her plan, and Jim gets a premium tax credit and costsharing reductions in his plan.
Prepared by Families USA for use in the District of Columbia
Verifying Residency
• DC Health Link will automatically attempt to confirm
residency
• If it can’t, use one of the following current
documents:
• Driver’s license
• Lease (signed within one year)
• Rent receipt
• Utility bill
• Letter from landlord
• Homeless applicants need to indicate an intent to
reside in DC, no documentation needed
Prepared by Families USA for use in the District of Columbia
Incarceration
• Medicaid:
• Eligible if incarcerated
• Coverage is suspended during incarceration
• DC Health Link and premium tax credits:
• Ineligible if incarcerated
•
Does not include those who are incarcerated
“pending disposition of charges” (those who
have been charged but not convicted or
acquitted)
Prepared by Families USA for use in the District of Columbia
Pregnancy
• It is important to include pregnancy on
application because:
• Pregnant women are eligible for
Medicaid at higher levels of income
• Pregnancy can affect household size
• Application will accept self-attestation for
pregnancy
Prepared by Families USA for use in the District of Columbia
Job-Based Coverage
Prepared by Families USA for use in the District of Columbia
Why does job-based coverage matter?
Job-based coverage must be:
1. Minimum value: plan covers at least 60% of
health care expenses on average
2. Affordable: premiums cost no more than 9.5%
of household income
If an offer of job-based coverage is not minimum value
and affordable, applicant could still be eligible for
premium tax credits.
DC Health Link figures this out, but consumers may
have questions.
Prepared by Families USA for use in the District of Columbia
How to Get Insurance Information
from Employers
• DC Health Link website will have a form
that people can print and ask their
employer to fill out with insurance
information
• Handout materials include an example of
what this form will likely look like:
“Employer Coverage Tool”
Prepared by Families USA for use in the District of Columbia
What is “minimum value”?
• Plan covers, on average, at least 60% of
enrollees’ health care expenses
• Based on deductible, co-pays, and co-insurance
• Employer must calculate this information and
include it on:
1.
2.
Summary of Benefits of Coverage
Employer Coverage Tool
Individuals never should have to calculate
minimum value.
Prepared by Families USA for use in the District of Columbia
What is “affordable” coverage?
The premium for employee-only coverage in
the least expensive comprehensive plan costs
no more than 9.5% of household income.
Prepared by Families USA for use in the District of Columbia
Affordability: Family Members
• Affordability for family members with offer
through employer still based on employeeonly coverage
• Does not matter if family coverage costs more
than 9.5% of household income
• Family members with unaffordable family
coverage offer will not be able to get
premium tax credits
Prepared by Families USA for use in the District of Columbia
Family Example: The Rodriguez Family
Joe and Rita Rodriguez are married with two kids. They make
about $55,000/year. Joe’s employer offers coverage to Joe
and the rest of his family. Rita works part-time and can’t get
health coverage through her employer. They want to know if
they could be eligible for premium tax credits:
• Premium to cover just Joe: $250/month
5.4% of income
• Premium to cover entire family: $500/month
10.9% of income
Who in the Rodriguez family may be eligible for premium
tax credits?
Prepared by Families USA for use in the District of Columbia
Rodriguez Family: Answer
No one in the Rodriguez family is eligible for
premium tax credits.
REASON:
The premium they must pay for employee-only
coverage costs less than 9.5% of their household
income.
Prepared by Families USA for use in the District of Columbia
Family Example 2: The Rodriguez Family
The next year, Joe’s employer decides to stop
offering family coverage and offers coverage only to
employees. The cost to cover Joe is still
$250/month. The family still estimates their annual
household income to be $55,000 and Rita’s
employer still does not offer coverage.
Who in the Rodriguez family may be eligible for
premium tax credits now?
Prepared by Families USA for use in the District of Columbia
Rodriguez Family: Answer
• Joe is still not eligible for premium tax credits.
• Rita and the kids might be eligible for
premium tax credits.
REASON:
Joe’s offer of coverage through his employer still
makes him ineligible because it costs less than
9.5% of his household income. Since Rita and
the kids no longer have an offer of coverage
through Joe’s employer, they may be eligible for
premium tax credits.
Prepared by Families USA for use in the District of Columbia
How long does an affordability
determination last?
Once DC Health Link finds job-based coverage
unaffordable, it’s considered unaffordable for the
entire employer plan year
• Protects consumers regardless of increases
in income
Prepared by Families USA for use in the District of Columbia
Maintaining Eligibility for
Premium Tax Credits
If the employer plan year spans two calendar years, DC
Health Link will ask a person to confirm income in the
new calendar year.
• The person must respond to this request to
protect eligibility for premium tax credits for full
employer plan year
• If the person does not respond and his or her
income increases, he or she could lose premium
tax credit eligibility for the second calendar year
Prepared by Families USA for use in the District of Columbia
Example: Gloria
Gloria is single and makes $25,000/year. Her employer’s
offer of coverage would cost her $250/month. This is more
than 9.5% of her expected household income. Her
employer’s plan year is September 2014-August 2015.
• September 2014: Gloria starts receiving premium tax credits
• January 2015: DC Health Link asks her to verify her income
for 2015; Gloria responds to the request
• July 2015: Gloria gets a raise; her new annual income for
2015 is $30,000/year (making $250/month premiums
affordable)
Gloria is still eligible for premium tax credits for her
employer’s full plan year, including January-August 2015,
because she responded to the DC Health Link request.
Prepared by Families USA for use in the District of Columbia
When does an employee need to reassess
affordability or minimum value?
• Re-determine employee eligibility at the
start of every new employer plan year.
• If cost or value of employer plan changes in
new plan year, employee might lose
eligibility for premium tax credits.
Prepared by Families USA for use in the District of Columbia
Example
Employer plan year:
October 2013-September 2014
DC Health Link plan year:
January 2014-December 2014
Even though it is the middle of the DC Health Link
plan year, employees need to re-determine
whether they qualify for premium tax credits
before the start of October 2014, based on their
employer’s new plan.
Prepared by Families USA for use in the District of Columbia
Review: Question #1
A family of four has an offer of job-based
coverage through the father’s employer that
meets minimum value requirements. The
premium for employee-only coverage would
cost 6% of their household income. The
premium for family coverage costs 10% of their
household income.
Does this offer of coverage make the family
ineligible for premium tax credits?
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
Yes, this offer of coverage does make the
family ineligible for premium tax credits.
REASON:
The coverage is of minimum value, and the
premium for employee-only coverage costs
less than 9.5% of their household income.
Prepared by Families USA for use in the District of Columbia
Recap of Eligibility Factors
• What you will do:
• Enter applicant information into DC Health Link
• Explain eligibility determination to applicants
• Examine documentation as needed
• What the system will do for you:
• Check data sources
• Determine eligibility
• Tell you where additional verification is needed
Prepared by Families USA for use in the District of Columbia