Medicaid Expansion
&
MAGI Budgeting
Belkys Garcia & Arielle McTootle
October 10, 2013
Today’s Agenda
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Background
New categories of eligibility
5 aspects of eligibility – what’s changed?
Applications and enrollment
Issues to watch
Background
Goal of the Patient Protection Affordable Care
Act (ACA) is to provide all Americans with
quality, affordable health insurance
1.
2.
3.
4.
5.
Expand Medicaid
Individual and Employer Requirements
Insurance Reforms
Health Insurance Exchange
Federal Tax Subsidies
Medicaid Expansion
For States that opt-in, the ACA expands
Medicaid coverage to a new eligibility
population that includes single adults, up to
138% of the federal poverty level (FPL).
42 U.S.C. § 1396a(a)(7); 42 C.F.R. § 435; N.Y. Soc. Serv. § L. 336
Timeline
• October 1, 2013 – MAGI population can apply for Medicaid
through the New York State of Health & receive eligibility
determinations using new MAGI rules, but coverage through
Medicaid Managed Care plans will not begin until January.
– Individuals can shop for QHPs on the exchange.
• December 31, 2013 – No new FHP applications will be
taken.
• January 1, 2014 – Coverage begins for PHI and QHPs.
• April 1, 2014 – New MAGI budgeting applies upon renewal
for all MA recipients.
New Eligibility Categories
MAGI
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Pregnant women
Children under 19
Parents/caretaker relatives
Childless adults:
Non-MAGI
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– Not pregnant
– 19 – 65
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19 & 20 year olds living with
parents
Child in foster care (Chaffee)
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Age 65 or older;
Certified disabled
TANF, SSI, Foster Care children,
adopted child receiving medical
subsidy, child for whom kinship or
guardianship assistance payments
are made
Spend down, LTC needs, MBI,
MSP, cobra continuation, Pickle
Cancer programs, Former Foster
Care, waiver programs
Residents in adult homes,
treatment centers, OMH facilities
42 U.S.C. § 1396a(a)(10)(VIII); 42 C.F.R. § 435.603(j); N.Y. SSL § 366(b)
Can Choose MAGI or nonMAGI
• Certified disabled, but not yet receiving
Medicare.
• Parent/caretaker relatives, even if they are
disabled and/or over 65, and start
receiving Medicare.
• Disabled children, unless they are in a
waiver program.
Five Eligibility Criteria
1.
2.
3.
4.
5.
Residency
Immigration Status
Category
Income
Resources
1. Residency
Old Rule = Must be a New York Resident to receive
Medicaid in New York.
N.Y. Soc. Serv. L. § 366-a
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Resident = intend to remain in New York “permanently or
indefinitely.”
42 C.F.R. § 435.403
New Rule = NO CHANGE. Must be a New York Resident
to receive Medicaid in New York.
N.Y. Soc. Serv. L. § 366-a
•
Resident = intend to remain in New York “permanently or
indefinitely.”
42 C.F.R. § 435.403
2. Immigration Status
Old rule = qualified immigrant including PRUCOL.
Undocumented immigrants eligible for emergency MA.
New rule = NO CHANGE. PRUCOL immigrants still eligible for
MA. Undocumented immigrants eligible for emergency MA.
– As of January 2014, undocumented immigrants can apply for
emergency Medicaid through the Exchange
NYSSL 122[1](c); Aliessa, et al. v. Novello (96 N.Y. 2d 418); 8 USCA 1611(b)(1)(A); 1621.
3. Category
Old Rule = various categories depending on age,
disability status, living with children, etc.
New rule = 4 categories
1.
2.
3.
4.
Pregnant women
Children
Parents/caretaker relatives
Childless adults
1. 42 CFR §435.116; 2. 42 CFR §435.118; 3. 42 CFR §435.110. 4. 42 CFR §435.119
Category (cont’d): Household
Size
• MAGI household is the IRS filing unit
• Exceptions for children:
– Children living with relatives who are not their parents;
– Children living with both parents, although the parents file separately;
– Children claimed as dependents by non-custodial parents.
• Pregnant women counted as self + number of expected
children
• Married spouses living together are in each other’s
household, regardless of whether they file jointly or
separately.
42 CFR 435.603(d); 42 CFR 435.603(b); 42 CFR 435.603(f)
Category (cont’d): Household Size
If an individual is claimed as a tax dependent and not the
spouse or child of the taxpayer
OR
If an individual is not expected to file tax return and not
claimed as dependent in that year,
The household size would include:
•
Self, spouse, and children less than 19 years
old (or, if full-time student, less than 21 years
old)
42 C.F.R. 436.603(f)
Household Case Example # 1
James (the taxpayer) and Alexis (James’s wife)
live together with two minor children, John and
Susan, as well as James’s Aunt Patricia (who
does not file taxes). James claims all of them
as dependents.
Household Case Example
Q. What is James’ household size?
A. James’ household size is five. His
household includes James plus his four
dependents.
Household Case Example
Q. What is the household size of the
dependents?
A1. As long as Alexis and James are filing
jointly, the household size for Alexis, John
and Susan (dependents) is five, the same
as James (taxpayer).
Household Case Example
(cont’d)
A2. Aunt Patricia’s household is a household
of one because Aunt Patricia has no
parents, spouse or siblings living in the
same household.
Household Case Example #2
James and Alexis are separated. Alexis
lives with their children, John and Susan.
Alexis also lives with her new child, Mary.
James claims John and Susan as a
dependent on his taxes. Alexis claims
Mary as her dependent.
Q. What is Alexis’ household size?
A. Alexis’ household size is two – Alexis
and her tax dependent, Mary.
Q. What is James’ household size?
A. James is a household of three – James
and his two dependents, John and Susan.
Q. What is John’s household size?
A. John household size is four – John,
Susan, Alexis and Mary.
Q. What is Susan’s household size?
A. Susan’s household size is four – Susan,
John, Alexis and Mary.
Q. What is Mary’s household size?
A. Mary’s household size is two – Mary and
Alexis.
4. Income
Old rule = 10 income categories
New rule = 5 income categories
1. Pregnant women
42 CFR §435.116 ; N.Y. Soc. Serv. L. §366(1)(b)(2);
2. Infants
42 CFR §435.118; N.Y. Soc. Serv. L. §366(1)(b)(2);
3. Children
42 CFR §435.118; N.Y. Soc. Serv. L. §366(1)(b)(3);
4. Parents
42 CFR §435.110; N.Y. Soc. Serv. L. §366(1)(b)(4);
5. Childless Adults
42 CFR §435.119; N.Y. Soc. Serv. L. §366(1)(b)(1);
Income (cont’d)
1.
Pregnant women = 223% FPL
N.Y. Soc. Serv. L. §366(1)(b)(2)
2.
Infants = 223%
3.
Children = 154% (with some
exceptions)
N.Y. Soc. Serv. L. §366(1)(b)(2)
N.Y. Soc. Serv. L. NYSSL §366(1)(b)(3)
4.
Parents = 138%; 155% = wrap
N.Y. Soc. Serv. L. NYSSL §366(1)(b)(4)
5.
Childless Adults = 138%
N.Y. Soc. Serv. L. §366(1)(b)(1)
Family Health Plus (FHP)
FHP used to cover parents living with children under 21 and
children 19 – 20 years old living with parents, up to 150%
FPL.
Family Health Plus program will end on January 1, 2014.
People with children who are between 138% -150% of FPL will
need to enroll in a silver-level plan through the Exchange and
will pay NO premiums.
N.Y. Soc. Serv. L. § 367-a(3)(e); 2013-14 NEW YORK STATE EXECUTIVE BUDGET Art. VII
Part D § 14, 14a, 15, 16.
Exceptions to 154% FPL for
MAGI-children
Children 19 or 20 living with parents will be eligible for MA
up to 155% of FPL through September 2019.
N.Y. Soc. Serv. L. § 366(a)(9)(b) (7)
A child under 21 years of age and who was in foster care
under the responsibility of the State on his or her 18th
birthday is eligible for Medicaid with no income test.
N.Y. Soc. Serv. L. § 366(a)(9)(b)(5)
Income (cont’d)
MAGI
MAGI is Modified Adjusted Gross Income is
based on IRS rules.
Section 36B(d)(2) of Internal Revenue code of 1986; 42 C.F.R. § 435.603(d); 42
C.F.R. § 435.603(e)
Gross Income
Gross income = wages, SS income, investment income, unemployment,
pensions, IRA distribution, alimony, and income from self-employment,
Not Income
• Child Support
• Income from child or tax dependent who is not
expected to be required to file a tax return in the
taxable year for which MA eligibility is determined.
• Medicaid rules apply to lump sums, and certain
educational scholarships and payments to Native
Americans.
Sec. 36B(d)(2) of IRC of 1986; 42 C.F.R. § 435.603(d); 42 C.F.R. §435.603(e)
Self-Employment Income
Self employment income is income after expenses claimed on schedule C.
Adjustments
Adjustments = alimony, moving expenses, student loan
interest, and self-employed health insurance
contributions
Income Disregards
Old Rule = Many disregard rules.
New Rule = Only 1 disregard: 5% of your
Modified Adjusted Gross Income. 133%
becomes 138%
42 U.S.C. § 1396a(14)(I)(i); 42 C.F.R. § 435.603(d)(1)
5. Resources
Old Rule – No Resource Test
New Rule – NO CHANGE. No Resource
Test
42 U.S.C. § 1396a(C); 42 C.F.R. § 435.603(g)
Eligibility Example
Alexis is a single mother with 2 children Susan age 5 and John age 3. Alexis is
employed, earning $24,000 a year. She also receives $4,000 per year in child
support and pays $3,000 per year for child care.
Current Medicaid Rules
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Family size: 3
Income:
– Wage $24,000
– Child support $4,000
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Total Income: $28,000
Deduction: $90 per month for earning, $100
per month for child support, and child care
expenses: $5,280
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Medicaid income: $22,720
FHP income: $28,000
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Children Medicaid Eligible, Mom eligible for
Family Health Plus
MAGI Rules
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Family size: 3
Total Countable Income: $24,000
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All Three Medicaid eligible
Income & Benefit Levels for MAGI Groups
Income Levels for MAGI Groups
Medicaid
Medicaid Benchmark
FHP Wrap
PTC
CHIP
400%
350%
300%
400%
400%
400%
400%
400%
% FPL
250%
200%
150%
100%
150%
223%
138%
154%
155%
50%
138%
83%
0%
Pregnant
Women &
Infants
Children (ages Children ages
1 - 18)
19 & 20 (living
with parents)
Parents
Childless
Adults
Courtesy of Empire Justice Center
Medicaid Benchmark
Benefit
• ACA establishes Medicaid Benchmark Benefit
for newly eligible MAGI applicants
– Medicaid benefit will not be uniform; benchmark
benefit is not “full” Medicaid
– Benchmark benefit includes all covered Medicaid
benefits except long-term care
Applications and Enrollment
Applications
October 1, 2014 – new MAGI Medicaid
applicants can apply through the NY State
of Health via:
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Online
Navigators
Certified Application Counselors
Brokers
By Mail
42 C.F.R. § 435.907(a)
Application Timeline
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October through December 2013, MAGI applicants will have
a two-step process:
1. Receive an eligibility determination,
2. Return in December to pick a plan.
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Coverage will not begin until January 2014.
FFS will pick up bills incurred after the eligibility determination
and before plan coverage starts.
Advocate tip: People should continue to apply through local
district until January 1, 2014.
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Applications for retro coverage will be forwarded to local
districts for old rules & LDSS will follow-up with applicant.
In-Person Assistors &
Navigators
The old “Facilitated Enrollers” have been replaced
with “In Person Assistors” and “Navigators,” who
counsel applicants and submit applications directly.
Verification
Data-matching: States must develop secure, electronic interfaces to allow for
data-matching and eligibility determinations. States must use datamatching to the maximum extent practicable.
Self-attestation: Exchange may accept attestation of information and conduct
database verification needed to determine eligibility without further
documents.
42 CFR 435.945
Reasonable Compatibility: Standard for assessing whether verification can
be considered complete, or if additional information is necessary. When
data obtained is “reasonably compatible” with an applicant’s attestation,
State agencies are prohibited from requiring additional documentation.
42 C.F.R. 435.952(c)
Renewal & Reporting
• Renewal – State must use available information
to facilitate annual re-determination process.
42 CFR 435.916
• Reporting – Individuals must report changes
with respect to eligibility standards through the
same modalities they can apply for coverage.
42 CFR 435.916(c)
Pop Quiz
Bob and Brenda are married. They have two children, Arthur age 2 and Hank age 19. Bob claims
Brenda, Arthur and Hank as his dependents. Bob and Brenda’s income is 155% of FPL for a
household of four. Arthur works and earns $5,000 per year and isn’t required to file taxes.
Brenda’s mother, Beatrice also lives with them. Beatrice is 75 years old. She received $500 per
month Social Security Retirement and Medicare. Beatrice does not file taxes.
Household size?
Bob, Brenda, Arthur and Hank = Household of four
Beatrice = Household of one
Benefit?
Bob and Brenda are eligible for FHP wrap.
Arthur is eligible for CHIP.
Hank is eligible for full Medicaid.
Beatrice gets full Medicaid.
Category?
Bob and Brenda are MAGI as parents.
Arthur is MAGI as a child under 18.
Hank is MAGI as a 19 year old living with his parents.
Beatrice is non-MAGI.
Issues to Watch
How is it working?
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What data is collected?
What notices do applicants receive?
How are they dealing with mixed households?
How are they treating applicants with sporadic
income?