THE ACA, ELIGIBILITY & ENROLLMENT
Shanna Hanson, FHFMA
100 Years Ago (1906)
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Life expectancy 47
Bathtub 14%
Telephone 8%
Cars 8,000
Paved roads 144 miles
Speed limit 10 mph
CA 21st most populated
state
 Births at home 95%
 Avg worker $200-$400
per year
 Drs 90% no college
 Women washed hair
once a month
 Las Vegas pop. 30
 High school grads 6%
 Marijuana, heroin,
morphine all legal
Health Coverage Memory Lane
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19th Century: Little or no money
1930’s: Insurance
1962: Medicare
1965: Medicaid – Low-Income Families; ABD
– 1986: Pregnant Women and Infants (State Option)
– 1989: Pregnant Women and Children (Mandated)
– 1990: Children 6-18 (Phased In)
– 1997: SCHIP
 2010: PPACA
 2014: TOMORROW!!!
Objectives
 Review areas of eligibility and
enrollment process impacted by the
ACA, regardless of expansion
 Examine what changes and how
 Help you prepare your staff and
facilities for changes
Today’s Agenda
Language is Important
 States May vs. States Must
 State Option vs. Required by States
 Proposed vs. Final (Rules)
 MAGI – Modified Adjusted Gross Income
 Medicaid, Marketplace or both?
 Marketplace (a.k.a., Exchange)
– FFM – Federally Facilitated Marketplace
– FSP – Federal State Partnership Marketplace
– State-Based Marketplace
Language is Important
 QHP – Qualified Health Plan.
Insurance coverage sold through the
Marketplace, subsidized or not.
 APTC – Advanced Payment of
Tax Credits. Subsidies received for QHP
coverage in the Marketplace.
 IAP – Insurance Affordability Programs.
Medicaid, CHIP, APTC Subsidized QHP.
 IPA – In-Person Assister.
State program, separate from the Navigator program.
 CAC – Certified Application Counselor
Unfunded assister.
Expansion vs. Non-Expansion
Overview
 Supreme Court Decision
– Can’t penalize a state that does not
expand Medicaid to 133% of Federal
Poverty Level.
 No other provisions of the law affected.
– Example: coordination with the
Marketplace, including use of standard
income eligibility methods, apply.
Expansion vs. Non-Expansion “So What?”
Impact on Medicaid Program Administration
 State policies and procedures will change
 Materials published
 Training provided
 Culture shifts
 State Medicaid systems must communicate electronically
with the Marketplace
 Coverage gap in states that choose not to expand
 Other expansion models being considered
Impact of ACA on Eligibility and Enrollment
 Application
 Assistance
 Presumptive Eligibility
 Eligibility
 Verifications
 Technology
Application
Process designed to be more consumer friendly
 Forms: single streamlined, multi-benefit
or supplemental
 Interview: no face-to-face for MAGI
 Reconsideration: 90 days without new
application
 Signatures: electronic, phone, fax, other
 Submission: online, phone, in person,
mail or IAP agency (no “wrong door”)
No Wrong Door!
Application “So What?”
Path to eligibility will be easier, less burdensome,
and take less processing time.
 Federal government published three applications
 Additional supplemental forms may be needed
 Other application options exist
 Application assistance is a necessity
– Massachusetts: less than 1 in 18 finish online
Approved!
How Many Assisters Do We Need?
New Hampshire  $73,000 per assister estimated, plus overhead costs
Arkansas
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$600,000 grant
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8 or less navigators

2.25 hours estimated per consumer
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211,000 consumers

475,445 total hours of assistance
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Assuming assisters are using 85% of their time over
six months of open enrollment to help consumers
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884 hours per assister
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475,445 / 884 = 538 assisters needed
Georgetown University Health Policy Institute Center for Children and Families
Assister by Marketplace Type
Navigator: program
development
Navigator: program
management
Navigator: funding
In-person assister:
program development
In-person assister:
program funding
Certified Application
Counselor: program
development
Certified Application
Counselor: funding
Federally Facilitated
State-federal Partnership
State-based
Federal government
Federal government
State
Federal government
Federal government with
state participation
State
Federal government
awards grants to a
minimum of two entities in
the state, one of which
must be a communitybased organization
Federal government
awards grants to a
minimum of two entities in
the state, one of which
must be a communitybased organization
State can use federal
exchange establishment
grants for planning, but
cannot use that funding
for operations
Will not have them
Required
Optional
Not applicable
State can use federal
exchange establishment
grants to establish and
operate the program
State can use federal
exchange establishment
grants to establish and
operate the program
Required for marketplace,
optional for Medicaid
Required for marketplace,
optional for Medicaid
Required for marketplace,
optional for Medicaid
None
None
None
Navigator and IPA Duties
1. Maintain expertise
2. Maintain a fair, accurate and
impartial manner
3. Facilitate selection of a QHP
4. Provide referrals for enrollees
5. Provide information in a culturally and linguistically
appropriate manner
6. Perform outreach and education
CAC Duties
Marketplace (All)
Medicaid/CHIP (Some or All)
Provide information.
Provide information.
Assist individuals to apply for
coverage.
Help individuals complete an
application or renewal.
Help to facilitate enrollment of
eligible individuals in QHPs and
insurance affordability
programs.
Work with the individual to:
–
–
–
–
–
Provide documentation
Submit to the agency
Interact with the agency
Respond to agency requests
Manage their case
Marketplace CAC Certification Requirements
1. Registers
2. Is trained prior to providing application assistance
3. Complies with applicable authentication and data security
standards, and with the privacy and security standards
4. Provides application assistance in the best interest of applicants
5. Complies with any applicable state law(s)
6. Provides information with reasonable accommodations
7. Enters into an agreement
Authorized Representatives
 Designated by the
applicant/beneficiary
 Has the legal authority to
interact on behalf of the
applicant/beneficiary
 Can sign the application
 Receives notices
 Individual or organization
 Must be allowed by the state
Hospital Enrollment “So What?”
1. Possibility of larger staff focused on assistance
2. Staff space allocations
3. Centralized or decentralized
4. Privacy for applicants
5. Performing tasks outside of your core business
6. Initial and ongoing training
7. Staff certification
8. Staying current with program and policy changes
9. Employing the most efficient and effective processes
Presumptive Eligibility
 Presumptive Eligibility (PE) Enrollment by “Qualified Hospitals”
–
Participate as a Medicaid provider;
–
Notify state Medicaid agency of its decision to make PE
determinations;
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Agree to make determinations consistent with state policies
and procedures;
–
At state option, assist individuals in completing and submitting
the full application and in understanding any documentation
requirements; and
–
Not be disqualified by the state Medicaid agency.
 PE Expansion Groups
Presumptive Eligibility “So What?”
 Provider payment during temporary
eligibility period
– Payment stands even if person found ineligible
 State rules will vary, which may make PE
more or less attractive to hospitals
 Risk of becoming uninsured after PE period
 Staffing, logistics, privacy, training
and certification
Eligibility
 MAGI-Based Medicaid: Collapse into 4 groups
 MAGI-Excepted Medicaid: Aged, disabled, etc.
 Optional Groups: BCCT, working disabled
(exempt from MAGI)
 Emergency Medicaid: No changes
 Retroactive Coverage: Up to three months
 Spend down in 209(b) States not Medically Needy:
Aged, blind, disabled
Eligibility
 Maintenance of Effort: 9/30/19 for children
 Children
– Highest level for age group
– 185% Federal Poverty Level for infants
 Enrollment While Pending (e.g., disability):
– MAGI-based or QHP enrollment while
pending for MAGI-excepted coverage
– Medicaid is retroactive, QHP coverage is not
– MAGI-excepted Medicaid would be a
secondary payer for overlapping eligibility
Eligibility
Criteria
MAGI-Based Medicaid/CHIP
Qualified Health Plan
Household
Tax household with exceptions
Tax household
Income
Tax rules with exceptions
Tax rules
Disregard
5%
Not applicable
Budget Period
Point in time
(current month)
Annual based on
last tax return
Start Date
Up to 3 months retroactive
Prospective
Eligibility “So What?”
 States may drop and/or change
Medicaid programs when the
Maintenance of Effort expires
12/31/13, except for children
 Program options will impact:
– Process the applicant goes through
– Cycle time
– Payment to the provider
Verifications
 What
– Age, DOB, Household Size: States “may” verify
– Income: Process and sequence could vary
– Pregnancy: Self-attestation
 How
– Data-driven Process: Electronic sources
– Documentation Submission: Online, phone, in person,
or via mail
– Electronic Data Matches: States decide usefulness,
frequency and time-frame (could be after enrollment)
Verifications
 How Cont’d
– Self-Attestation: Permitted, except as required by law, or not
permitted by law
– When Documentation is Permitted: Not reasonably compatible
– When State Law Does Not Permit Self Attestation: State option
to accept self-attestation unless ACA does not permit
 Reasonably Compatible: Both attestation and electronic
information are either above or below the eligibility level
 Reasonable Opportunity Period: 90 days for Marketplace;
differs for Medicaid
Verification “So What?”
 Verifications plans will be state specific
 State policy decisions will be based on their
verification plan
 Transparency
Technology
Open enrollment: 10/1/2013 - 3/31/2014
 Online application system must support
single streamlined application
 Electronically Pass Accounts: Medicaid
and the Marketplace
 FFM Medicaid “Determination” or “Assessment”
– Medicaid eligibility determination or
– Medicaid eligibility assessment (at the state’s option)
 Implement state access to “The Hub”
 Systems must support new renewal process
Technology “So What?”
 Open enrollment without the
technology to support it will create
backlogs and frustration.
 State rules dictate the type of Medicaid
decisions that can be made by the FFM.
 A lot to do. Will states be ready?
Wrap-Up
 Reviewed six areas of the eligibility process impacted by ACA,
regardless of expansion.
̶ Application
̶ Assistance
̶ Presumptive Eligibility
̶ Eligibility
̶ Verifications
̶ Technology
 Examined what changes and how.
 Gave you points to ponder as you begin to prepare
your staff and facilities for the changes ahead.
Human Arc Health Care Reform Resources
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Additional Questions? shanson@humanarc.com
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