north carolina
medicaid
Health Care Reform and
Medicaid/NCHC Eligibility
WSS Leadership Summit
Carolyn McClanahan
Chief, Medicaid Eligibility
Division of Medical Assistance
April 22, 2014
DMA
north carolina
medicaid
Health Care Reform Legislation
• Federal
– The federal Patient Protection and Affordable Care Act,
P.L. 111-148, (ACA) as amended
– March 23, 2010 – signed by President Obama
DMA
north carolina
medicaid
Summary Provisions
• Expanded coverage optional for states
• Implementation of Health Benefit Marketplace for
uninsured (formerly called “exchange”)
• Medicaid/NCHC Eligibility Changes
• Enrollment streamline and simplification
DMA
north carolina
medicaid
Expanded Coverage Optional for States
• Original federal legislation required Medicaid expansion
to most individuals up to 133% (138%) fpl in new eligibility
group
• Included childless adults, caretakers above current
coverage limit
• Did not include age 65+, pregnant women, individuals
with Medicare
• Supreme Court decision – Congress could not require
states to expand – must be optional for states
DMA
north carolina
medicaid
Expanded Coverage Optional for States
• NC Session Law 2013-5
• NC will not expand Medicaid as provided in ACA
• NC will maintain the current coverage groups
DMA
north carolina
medicaid
Summary Provisions
• Expanded coverage optional for states
• Implementation of Health Benefit Marketplace for
uninsured (formerly called “exchange”)
• Medicaid/NCHC Eligibility Changes
• Enrollment streamline and simplification
DMA
north carolina
medicaid
Implementation of Health Benefit Marketplace
• Federal Health Benefit Marketplace created:
– States can build State Marketplace
– States can build Partnership with Federally Facilitated
Marketplace (FFM)
– States can use the FFM
• NC Session Law 2013-5
• NC will utilize the Federally Facilitated Marketplace
DMA
north carolina
medicaid
Implementation of Health Benefit Marketplace
• Individuals/families can purchase insurance
• Income < 400% fpl – may qualify for Advance Payment Tax Credits
(APTC)/cost-sharing assistance
– Must have income above 100% fpl
• Eligibility determination for APTC and cost-sharing similar to
Medicaid/NCHC
• Household/income based on IRS rules
– Income eligibility based on MAGI (Modified Adjusted Gross Income)
DMA
north carolina
medicaid
Summary Provisions
• Expanded coverage optional for states
• Implementation of Health Care Marketplace for uninsured
(formerly called “exchange”)
• Medicaid/NCHC Eligibility Changes
• Enrollment streamline and simplification
DMA
north carolina
medicaid
Medicaid/NCHC Eligibility Changes
• No changes to ABD/MQB eligibility
– Excluded from MAGI methodology
• All Family & Children’s Medicaid programs affected
– Use tax definition of household and income
– MAGI income methodology
• New coverage group
– Former foster care children up to age 26
DMA
north carolina
medicaid
Eligibility Change: IRS – based methodology
• MAGI – a methodology for how income is counted
and how household composition and family size are
determined
• Household composition – tax household
– includes stepparent, if in tax household
– Includes siblings (biological, adopted, step)
• Income – based on federal tax rules for determining
adjusted gross income (with some modifications)
• No asset test or disregards (except 5% disregard
across the board)
DMA
north carolina
medicaid
Eligibility Change: New questions
To help determine
household composition:
• Is the individual a tax
filer?
• Does the individual
expect to be claimed
as a tax dependent?
DMA
north carolina
medicaid
Eligibility Changes:
• If not tax filer or tax dependent, build household
similar to tax household
• Household - adult:
– Individual
– Spouse
– Natural, adopted or step children
• Household – child:
– Individual
– Natural, adopted, step parent
– Natural, adopted, step siblings
• Child: individual under age 19 or, at state option, 19
or 20 and a full-time student
DMA
north carolina
medicaid
Eligibility Change: Income
• May disregard income of child/tax dependent if do not
plan to file taxes
• Child support is non-countable income
• Social security – countable based on amendment to
ACA
DMA
north carolina
medicaid
Eligibility Change: MAGI
• Taxable Adjusted Gross Income (AGI) with a few
modifications
• Disregards/exclusions
– States cannot give current disregards
• Earned income disregards ($90, 27-1/2 %, child care)
– Only disregard is 5% from the MAGI calculation
DMA
north carolina
medicaid
MAGI-Equivalent Income Limits
• Income limits adjusted due to difference in
deductions
• Purpose: to “hold harmless” eligibility standards so,
as a group, individuals do not lose eligibility
• CMS – contracted with vendor to provide calculations
for states
• Revised income limits:
– Example: current 185% may be converted to 192%
(not actual converted amount)
– Should receive the converted income limits sometime
later this month
DMA
north carolina
medicaid
Summary Provisions
• Expanded coverage optional for states
• Implementation of Health Care Marketplace for uninsured
(formerly called “exchange”)
• Medicaid/NCHC Eligibility Changes
• Enrollment streamline and simplification
DMA
north carolina
medicaid
Streamline/Simplification
• ACA mandates individuals may apply for all
insurance affordability programs:
–
–
–
–
In person
Mail
Electronic
Phone
• Insurance affordability programs:
– Medicaid
– CHIP (NCHC)
– APTC (Advance Payment of Tax Credits)/Cost-sharing
DMA
north carolina
medicaid
Streamline/Simplification
• States and Marketplace:
must have web portal for
applications
• “No Wrong Door” Individuals may apply at
any agency/site for all
insurance affordability
programs
DMA
north carolina
medicaid
Streamline/Simplification
• One application for all insurance affordability programs
• CMS is developing the model paper and on-line
application
• Individuals who only want medical coverage must have
streamlined model application available
• States can get alternate application approved – must
submit State Plan Amendment (SPA)
DMA
north carolina
medicaid
Streamline/Simplification
• Must rely on electronic data for verification
• Request info from applicant only if not available
electronically or discrepancy
• Move to “real-time” eligibility determinations as much as
possible
• Experience should be as seamless as possible for
applicant – no duplicate requests for information
• Renew coverage based on information available
DMA
north carolina
medicaid
Final: Time Frames
• October 1, 2013
– Open enrollment for insurance affordability programs
– Must accept single streamlined applications and apply
new rules
– Must be able to transmit information to Marketplace
– Evaluate under current rules for eligibility prior to
1/1/14
• January 1, 2014
– Coverage under insurance affordability programs can
begin
DMA