Transitions in
Health Care Reform
Basic Benefits Training
December 10, 2014
1
Major ACA Improvements in MA
MassHealth eligibility up to 133% -(138% MAGI)
Help paying for health insurance up to 400% FPL
 Fewer gaps in coverage
 One-stop-shopping for health and dental
insurance (online application)
2
Health Insurance Connector Authority
• Massachusetts’ Exchange or Marketplace
• Place to buy private insurance called Qualified
Health Plans
• Subsidized and unsubsidized
• Must be US citizen or “lawfully present”
immigrant
3
New ACA Subsidized Coverage
Construct
•Coverage Types Under ACA in MA
•
•n
•n
•n
MassHealth
•o Standard
•o CommonHealth
•o CarePlus
•o Family Assistance
•o Small Business Employee Premium Assistance
•o Limited
•o CMSP
Health Connector
•o Qualified Health Plan (QHP) only
•o QHP with Premium Tax Credit (PTC)
•o ConnectorCare plans (QHPs which include additional premium and
•cost sharing subsidies)
Health Safety Net
2014 MassHealth Programs
MassHealth Program
Population
Standard
Lower-income kids & young adults age 19-20, parents,
pregnant women, disabled individuals, lower income
HIV positive individuals, certain low income adults
classified as “medically frail”, and elder adults (65+)
CommonHealth
Higher-income people with disabilities
CarePlus NEW
Low-income adults 21-64
Family Assistance
Higher-income kids, higher income individuals with HIV,
certain immigrants
Small Business Employee
Premium Assistance NEW
Qualifying employees of small businesses
MassHealth Limited
Immigrants ineligible for other MassHealth programs
because of their immigration status
Children’s Medical Security
Plan
Kids who are not eligible for any other more
comprehensive MassHealth benefit
6
Coverage Types That Were Discontinued
•
o
•o
o
The plans that were discontinued:
o
MassHealth Basic
o
MassHealth Essential
o
Medical Security Program (Network Health Extend, ending on January 31st)
o
Commonwealth Care (ends January 31st)
o
Insurance Partnership
All the above mentioned populations are eligible for new
programs under the ACA with similar or richer benefits as
compared with the benefits they received.
Static Populations
No Change in eligibility post January 1, 2014
8
New ways of counting income
• Modified Adjusted Gross Income (MAGI)
– Applies to almost everyone except
• Seniors eligible for MassHealth based on age
• People eligible for MassHealth based on need for long
term care
• People for whom MassHealth does not make an income
decision e.g. SSI, TAFDC & EAEDC recipients
– More on MAGI from Vicky later this morning
9
Immigrants
• No change in federal Medicaid (MassHealth Standard)
– “Qualified” adults eligible for MassHealth Standard &
other benefits like US citizens
– “Lawfully present” children under 19 up to 300% FPL & 19
& 20 year olds up to 150% FPL (new in 2014) are eligible
for MassHealth like US citizens
• “Lawfully present” individuals are eligible for benefits
through Connector like US citizens
• BBT on immigrant eligibility March 12, 2015
• See “Understanding ACA: Non-citizen eligibility for
health benefits” in on-line materials
10
What happened in 2014?
• Adults under 133% FPL successfully moved
from other programs to MassHealth CarePlus
• Most new applicants stuck –computer
breakdown
– Commonwealth Care extended to Jan. 31, 2015
– US citizens & eligible immigrants given
“temporary” MassHealth Standard
– Ineligible immigrants given “temporary”
MassHealth Limited
11
Open enrollment is from November 15, 2014-February 15, 2015.
Who should submit a new application?
If you or a family member is a Health Connector member or a
temporary MassHealth member, you need to submit a new
application to stay covered.
Health Connector Qualified Health Plan coverage (including people
receiving ConnectorCare and Advanced Premium Tax Credits) ends
December 31st
Commonwealth Care coverage ends on January 31st
Temporary MassHealth coverage ends based on date of enrollment:
January 15th, January 31st or February 15th
12
Open Enrollment 2014-2015:
Transitioning Populations
What we need to accomplish during the 2015 Open Enrollment period:
Currently Enrolled Populations
Count
(as of
9/8/2014)
End Date of
Existing
Coverage
If eligible for Connector
Coverage, Deadline to
Apply and Select a Plan
(to avoid gap in
coverage)
If eligible for Connector
Coverage, Payment Due
Date
~33K
12/31/2014
12/23/2014
12/23/2014
~100K
1/31/2015
1/23/2015
1/23/2015
MassHealth Temporary Coverage
– Wave 1
~100K
1/15/2015
12/23/2014
1/23/2015
MassHealth Temporary Coverage
– Wave 2
~100K
1/31/2015
1/23/2015
1/23/2015
MassHealth Temporary Coverage
– Wave 3
~100K
2/15/2015
2/15/2015
2/23/2015
Qualified Health Plan (QHP)
Commonwealth Care and
Network Health Extend (formerly
Medical Security Plan -MSP)
13
Qualified Health
Plan
GREY LETTER: Qualified Health Plan members will receive a grey
letter and will need to fill out an application, pick a plan and make
their first premium payment by December 23, 2014
Commonwealth
Care
YELLOW LETTER: Commonwealth Care/Medical Security Program
(MSP) members will receive a yellow letter and will need to fill
out an application, pick a plan and make their first premium
payment by January 23, 2015
Temporary
Coverage
Temporary
Coverage
Temporary
Coverage
PURPLE LETTER: Temporary MassHealth coverage members that
receive a purple letter, in order to avoid a gap in coverage, will
need to fill out an application, pick a plan and make their first
premium payment by December 23, 2014
BLUE LETTER: Temporary MassHealth coverage members that
receive a blue letter, in order to avoid a gap in coverage, will need
to fill out an application, pick a plan and make their first premium
payment by January 23, 2015
GREEN LETTER: Temporary MassHealth coverage members that
receive a green letter, in order to avoid a gap in coverage, will
need to fill out an application and pick a plan by Feb. 15, 2015 and
make their first premium payment by February 23, 2015
14
New hCentive End-to-End
Consumer Experience
Qualified Health Plan
QHP[a]
Shop
1. Front Door
Portal or
Phone
Participant chooses
plan – non state wrap
(hCentive)
3.Verify
Eligibility
Participant enters
through a single
Front Door for CCA
& MassHealth
(hCentive)
Participant is
invoiced and
pays bill
(Dell)
Participant chooses
plan – state wrap
(hCentive)
QHP[b] Notification
Participant provides
verification if
necessary
2. Apply
Portal,
Phone or Paper
Participant
creates
account
(Identity Mgt)
QHP[c] Bill Pay
Participant
completes
application
(hCentive)
Application
data is
verified
(Federal Hub)
Eligibility and
MAGI program
is determined
(hCentive)
Participant
receives
Proof of
Coverage
Participant is noticed
for QHP (Dell)
7
Medicaid
MH [a] Notification
Assessed to be non-MAGI
QHP[d] Enroll
Participant is noticed
(from hCentive to
MassIT)
MH [b] Enrollment
Eligibility information
is sent to MMIS for
enrollment
Non-MAGI manual
processing
(Excel file to MA-21)
15
Not Subject to Open
Enrollment
• Current MassHealth members receiving benefits through the
following MassHealth programs DO NOT need to submit a new
application during the Open Enrollment period but will be
redetermined after Open Enrollment ends using MAGI rules
–
–
–
–
–
–
–
MassHealth Standard
CarePlus
Family Assistance
Limited (except for Temporary MassHealth Limited)
Health Safety Net
Children’s Medical Security Plan
CommonHealth
16
How should you apply?
There are four ways to apply for health
coverage beginning on November 15th:
Online: www.MAhealthconnector.org
By phone: 1-877-MA-ENROLL (1-877-6236765)
In person: Get free in-person help with your
application. Go to:
https://bettermahealthconnector.org/gethelp/ or call 1-877-MA-ENROLL (877- 6236765) to find help near you.
Paper application
Kate will be covering more on these issues
17
Newly eligible for MH Standard
• Pregnant women formerly in Healthy Start-(all
pregnant women (regardless of immigration
status) up to 200% now in Standard
• Young adults 19-20 with income up to 150% FPL
• HIV+ under 65 with income up to 133% FPL (133200% still in Family Assistance)
• Former foster children up to age 26 regardless of
income
• Adults up to 133% FPL eligible for DMH services
or determined “medically frail” & choose
Standard over CarePlus
18
Improvements
for Children in Family Assistance
• Family assistance for children 150-300% FPL
– Children 200-300% FPL no longer have to be
uninsured for prior 6 mo.
– Premium Assistance now available for children
200-300% FPL enrolled in a parent’s employerbased insurance at time of application
– Children who lose coverage for nonpayment of
premiums can re-enroll after 90 days even if back
premiums are not paid
19
MassHealth CarePlus-NEW
 Adults 21-64 with income under 133% FPL &
not eligible for Standard as pregnant, disabled
or parents & not on Medicare
 MassHealth CarePlus unless
“Special Health Care Needs” (also called
“Medically Frail”) & choose MH Standard
20
MassHealth CarePlus
Differences from Essential or Comm. Care
• No eligibility restrictions based on
– Employment, college attendance, access to other
insurance
• Premium assistance with CarePlus secondary is
available (if cost effective)
• Medical coverage 10 days prior to application-Fee for
Service; MCO begins first of month after eligibility
• Better benefits including non-emergency transportation
• No Primary Care Clinician-Partnership option; only MCOs
21
Special Health Care
Needs /Medically Frail
 Medically Frail must be given the option to
enroll in either CarePlus or Standard
 Remain in CarePlus until they affir matively
seek MassHealth Standard
– Standard will begin right away after selection
 Allowed to enroll in PCC Plan with access
to the Par tnership Behavioral Health
providers or MCO & MH Standard benefits
 Don’t confuse with “frail elder waiver”
MassHealth MCOs
• Standard,
CommonHealth &
Family Assistance
– BMC Health Net
– Tufts Network Health
– Neighborhood Health
Plan
– Fallon Health Plan
– Health New England
• CarePlus
– BMC Health Net
– Tufts Network Health
– Neighborhood Health
Plan
– Fallon Health Plan
– Health New England
– CeltiCare
MassHealth Small Business Employee
Premium Assistance (new):
• Have not enrolled in your employer’s insurance in the six months
before the date of application
• Adults ages 19-20 with income above 150% and at or below
300% FPL and those 21-64 with income above 133% and at or
below 300% FPL who:
• Work for a small employer with 50 or fewer employees
• Have access to employer-sponsored health insurance that
precludes them from receiving Premium Tax Credits through the
Health Connector but is not affordable to them according to
Health Connector Affordability Schedule
• Max. $150 PMPM premium assistance for up to 2 adults to enroll
in employer’s insurance
• Minimum premium contribution same as ConnectorCare
24
ConnectorCare Framework &
Summary
 The ConnectorCare program has been designed to replicate the
Commonwealth Care program, including its benefits, premiums and cost-sharing, as
well as carrier and provider choices
 The Commonwealth is using state dollars (with some Federal match) added to the ACA tax
credits and subsidies for the population earning up to 300% FPL that is eligible for
coverage through the Health Connector
•6
ConnectorCare Program
Who can qualify for a ConnectorCare Plan?
Individuals or families living in Massachusetts with
incomes at or below 300% of the Federal Poverty
Level (FPL) may qualify for ConnectorCare.
• If you and your family qualify, your Plan Type will
depend on your household income.
• Those with incomes above 300% FPL cannot
qualify for a ConnectorCare plan, but may
qualify for tax credits that help to lower the cost
of insurance if they have income up to 400%
FPL
• More on ConnectorCare this afternoon with
Suzanne
Process changes: Provisional Eligibility
NEW: MassHealth will provide a 90-day post eligibility verification period, termed a “provisional
eligibility” period. Similar process in Connector is called “inconsistency period.”
•
•
•
•
•
Self-attestation will be accepted for all eligibility factors except for disability status.
If MassHealth is unable to verify self-attested eligibility factors through federal and state data
hubs, or if the information provided by an applicant is not reasonably compatible with the
information available through the data hubs, MassHealth will require verification from the
individual post eligibility determination.
Necessary verifications will be required within 90 days of the eligibility determination in order to
maintain enrollment. The Citizenship and Immigration Reasonable Opportunity Period will also
be aligned for 90 days.
Only one Provisional Eligibility Period in a 12 month period.
No Premium Assistance during Provisional Eligibility Period
27
Hospital Determined Presumptive Eligibility
A qualified hospital may make presumptive eligibility determinations for its patients.
Presumptive eligibility will be determined based on self-declared information.
Categories of Hospital Presumptive Eligibility:
• 1.
MassHealth Standard: for children under age 19; for young adults aged 19 or 20;
pregnant women; parents or caretaker relatives; individuals with breast or cervical cancer;
individuals who are HIV positive; or independent foster care children up to age 26
• 2.
MassHealth CarePlus for adults aged 21-64
• 3.
MassHealth Family Assistance, if the individuals meet the categorical and financial
requirements of MassHealth Family Assistance and are HIV positive, or children who have
a nonqualified PRUCOL immigration status
Note: MassHealth will not charge a premium during the hospital presumptive period. There is
no Premium Assistance available during presumptive eligibility.
28
MassHealth Redetermination/Renewal
• Suspended since Oct 2013 but starting up
again soon
• New process
– Expanded use of SNAP data for automatic renewal
– Renewal through data matches if possible
– Prepopulated form
• If terminated for not returning form, 90 day
grace period to return form & be reinstated
with no gap in coverage
29