North Sound Network In-Person Assister Training
Questions and Answers from IPA Training
9-3-2013 Yellow highlights indicate a new question and answer
Question
HCA – Washington Apple Health (Medicaid)
What kind of dental benefits are covered (i.e., preventive
vs. emergency dental)?
Answer
In general the adult dental benefit will be reinstated to what it
was prior to all of the reductions. A group is currently working
on the benefit package and information will be coming out on the
full details of the packages later this fall. Dental coverage for
adults will be begin 1/1/14.
Will CSO staff (DSHS) continue to enroll individuals into
Medicaid? I have heard competing answers on this, and
DSHS hasn’t been able to answer the question.
The CSO (and ADSA) will continue to do Medicaid determinations
for what we are calling the Classic Medicaid programs (SSI, SSIrelated, Medicare Savings Programs, Healthcare for Workers with
Disabilities, Nursing Homes, waiver services and Medical Care
Services. The family, children’s pregnancy and new adult group
will all have their determination done through the
Healthplanfinder.
Homeless Teens – with MAGI, teens will have their parents
income considered when they are applying for
coverage. This could be a problem for homeless youth,
who may have no contact with their family but who could
be precluded from obtaining coverage because their parents
income will exceed the income thresholds. There are
several workarounds that we have identified with HCA, but
we are unclear where this will be covered in any of the IPA
trainings.
The teen probably will not know if their parents are claiming
them. HCA will take the teen’s word for it if they indicate that
they are not receiving any financial aid from their parents.
Pregnancy churn – for women who churn in and out of
eligibility due to pregnancy. There are no good
workarounds we’ve discovered to deal with this issue and
there are some fairly detailed complications and information
pertaining to this situation, but it will be an important topic
for IPA’s to understand. Do you know if this is included in
the training for IPA’s?
The system will continue Medicaid (WAH) eligibility for the two
months post-partum based on the anticipated EDC. The system
then asks for them to complete a review or otherwise update
their case. Depending upon income they could easily move into
the ‘new adult group’. If nothing else they should receive family
planning services for the next 2 years (if no response to the
request to update their case).
I know MAJI rules will be used to determine eligibility for all
the Medicaid programs not considered "classic." But IRS
uses MAJI to look back one year using the client's tax return
to describe that year. If I understand correctly MAJI is only
the methodology of reviewing some period of income
earned. Precisely how long is the look-back period to which
workers will apply MAJI rules? How far back will HCA
We do not intend to ‘look back’ for income – they system will
make a comparison between current point-in-time income
reported via self-attestation at the time of application or renewal
and that person's last year’s tax return. It will also compare any
state wage data that is available and assuming all sources show
income to be reasonably compatible, then no additional review
will happen. If a post-enrollment audit is required because of
discrepancies between current reported income and the data
source income, then the person will have to provide verification
of income to justify the discrepancy.
workers look?
Homeless teens can be considered ‘non-filers’ which will result in
HPF not counting anything but their declared income – when in
doubt consider them non-filers.
What will eventually replace a client’s attestation when that
client is not self-employed and has not filed a tax return for
this last year, or longer?
Nothing – we accept the clients’ self-attestation in those
situations. If there is no IRS data, we will also have access to
state wage data but if there is nothing, then we accept selfattestation and may audit a percentage of cases that meet these
criteria.
For the non-filing self-employed, will self-prepared profit &
loss "statements" (homemade ledgers or home computer
print-outs, for example) continue to suffice? Will extensive
collections of receipts be required?
At application, we will accept a self-attested statement of income
and deductions and permit the person to average them out to
come up with a monthly income. If the case is pulled for a postenrollment audit, the person would have to provide
documentation to support the amount claimed in income and
deductions.
If a person is applying for Medicaid and they are in the 100138% FPL category (newly eligible), AND in a “classic
Your notes are correct. They should always start in the
Exchange via the Healthplanfinder. If they need to be referred
IPA Q&A, Sept 2013
North Sound Network In-Person Assister Training
Medicaid” category, would they apply via the Exchange or
via the HCA?
Seems like via the Exchange – from my training notes – but
wanted to clarify.
over to WACON the Healthplanfinder will do that.
Please show a work-up of an assistance unit for a Native
American with a NON Native spouse who is pregnant.
If the individual marks that the woman is pregnant; for Medicaid
eligibility one extra person will be added to whatever assistance
unit the pregnant woman is included in.
On the Medicaid side, the unborn child will be considered as part
of the household composition. If the family is not eligible for
Medicaid, then HPF uses the current household composition, and
the family will need to come back into HPF and report their
change in family composition after the child is born.
(If you hover your cursor over the line down the middle,
click and drag to the left you will open up the Additional
Questions section.)
How do people enroll if they don’t have an address?
Eligibility
Verify that incarcerated individuals are not eligible for
Exchange products
What enrollment process they(incarcerated individuals) will
be following (if you have any information on that)
Assume a person is a lawful permanent resident but has not
yet achieved five-year status.
1. If they are below the 138% FPL, would they be
able to access the Exchange for a QHP (not
Medicaid)? Would they be eligible for
subsidies/tax credits?
2. If they are over 138%, would they be able to
access the Exchange for a QHP, even without the
subsidies or tax credits? Is this same resident
subject to penalties for declining the exchange?
You don’t need an address, just a county.
Incarcerated individuals are not eligible for Washington Apple
Health and/or QHPs
Once an inmate has received a pending release date, they will be
able to work with their corrections facility to apply for health care
coverage through the new WA Healthplanfinder web portal.
1.Yes, if someone is below 138% FPL and they have not met the
5-yr bar to be eligible for WAH, they may still be eligible for
HIPTC/QHPs.
2.Yes, however, unfortunately Healthplanfinder (online system)
cannot process someone without a SSN who is applying for a
QHP (without tax credits). The applicant would need to be
processed through the Customer Support Center.
IPA Q&A, Sept 2013
North Sound Network In-Person Assister Training
3.
Is this same resident subject to penalties for
declining the exchange?
Other
Will HBE be making a “how to enroll” video intended for use
by consumers? Our libraries would like to have something
like that available on their web page.
Can you clarify what Authorized representatives under state
and federal law means?
3. Yes, they may still incur a penalty. Under the Affordable Care
Act, any U.S. Citizen and lawfully present resident must have
health care coverage to avoid the penalty.
We are recording some consumer help videos that will be posted
on the website. “Getting Started”, “Managing Your Account”,
“QHP Buyer”, “Washington Apple Health and Health Insurance
Premium Tax Credit Recipient”, “Washington Apple Health
Renewal Recipient”, “Employer”, “Employee”.
An Authorized Representative is an adult designated by the
primary applicant to be sufficiently aware of the household's
circumstances that they can act on the primary applicant’s
behalf.
About the tax penalties: $95/adult (max/$285 for family) or
1% of income, whichever is greater. Is there a maximum
penalty amount on an individual?
$95.00 or 1% of their income, whichever is greater.
The penalty will not be more than a Bronze metal level premium.
I’ve read that Medicare plans are not changing whatsoever,
but many people wonder about how the Exchange impacts
the Medicare Savings Program. Will anything be changing
for that in relation to the Exchange?
Health Savings Accounts: will HSA’s be offered through
Healthplanfinder, and if so, are there age limits to who can
have them (under 30) since they are by definition coupled
with a high-deductible health plan?
For more information about the Medicare Savings Plan, please
contact HCA at 1-800-660-9840.
If an employer is giving a monthly stipend to their
employees to help pay premiums on the private market
(rather than offer employer-based coverage), is that money
considered “income” and countable towards gross monthly?
a. We believe the answer is yes, but want
to confirm.
In most cases, stipends are considered countable income.
Income is determined by using the Modified Adjusted Gross
Income (MAGI) computation method. MAGI is Adjusted Gross
Income as determined under the federal income tax. These are
the amounts on lines 37 and 8b of IRS from 1040. Some
examples of income are: wages, salaries, tips, taxable interest,
certain dividends, business income, capital gains, and
unemployment compensation, as well as annuities, Social
Security payments and some pensions. Assets will not be
considered in determining eligibility.
Yes, an out of state student may still go through the Washington
Healthplanfinder to find health coverage. They may still claim WA
state residency. This is done by indicating that they are a WA
state resident on the Additional Questionnaire Screen. They may
be attending school out-of-state, however, the services provided
will have to be either in-network or possibly out-of network.
HCA Training – Level 1 Access

Is only for those agencies who are currently processing
Medicaid enrollments and will continue to do only
Medicaid enrollments after Healthplanfinder Go Live

They will have one-time only access to a consumer’s
Healthplanfinder application to facilitate enrollment
into Medicaid and will rarely be processing any
financial transactions associated with Medicaid.

The training they receive will focus only on Medicaid
and how to access the Healthplanfinder for this
purpose only.

They will NOT be certified.

They will not receive In Person Assistance grant
funding.
If a college student is from Washington State, but living
out-of-state for school, are they eligible to shop in the
Healthplanfinder? Is this dependent on their residency
status (not established as resident of state where college
is)?
People are interested in learning about the various “access
levels” within the Healthplanfinder (Community Partner
Access, vs. In-Person Assister Access). Is there anything
you can provide to describe what those levels look like?
Yes, HSA are offered through the Exchange, but there is no age
limit.
Certified Application Counselors – Level 1 Access

They will have one-time only access to a consumer’s
Healthplanfinder application to facilitate enrollment
into Medicaid and QHPs.

They will be trained using web-based trainings.
IPA Q&A, Sept 2013
North Sound Network In-Person Assister Training


They will be certified after passing the same exam
required for Level 2 Access.
They will not receive In Person Assistance grant
funding.
HBE Training and Certification for In Person Assisters – Level 2
Access

In Person Assisters will provide the full range of
services to consumers including enrollment into QHP
and Medicaid. They need to be knowledgeable about
QHPs, tax credits, cost sharing and Medicaid.

They need to have a broader and more in-depth
knowledge base to provide these services.

They will need to have the training in order to have
access to and pass the certification exam.

They will have Level 2 Access to the Healthplanfinder
that can only be obtained once they pass the
certification exam.

Their access to the Healthplanfinder creates greater
risk for the Health Benefit Exchange as In Person
Assisters will have access to a broader range of
confidential personal information and consumers’
financial resources when processing payments. There
is a greater risk of impropriety and fraud.

This level of training is required as part of the grant
funding.
Level 3 Access

Same as level 2 with the additional authorization to
assist both individuals and employers with initial
application and ongoing support.
Level 4 Access

Same as level 2 with the additional authorization to
help individual with tribal status.

They will have the authority to verify tribal status.
If a private employer does not provide pediatric dental in their
health insurance plans to employees, can employees then be
eligible to purchase a pediatric dental plan through the
exchange?
At what age are parents no longer “tax responsible” for their
children and won’t be penalized if their children do not have
health insurance? (18? 19?)
Can a student 19 years or older purchase a plan on a state
exchange outside of Washington state (for example, the 19
If a private employer does not provide pediatric dental for the
employee's dependents, it is not meeting the MEC
requirements. Individuals may purchase pediatric dental plans
through the Exchange only if they also purchase a QHP.
Individuals cannot go into the HPF and purchase only pediatric
dental.
After the age of 18
Yes, students may purchase health plans through a different
state's exchange if they are residing there, even if their
IPA Q&A, Sept 2013
North Sound Network In-Person Assister Training
year old resides in California for college), even though their
parents claim them as a tax dependent in Washington?
parents claim them as a tax dependent. The parents may go
onto that state's exchange and submit an application for the
student.
Senario: Employee receives health benefits that are covered
by the employer. In order to put family on the employer plan
it will cost approximately $700 a month to add spouse and two
children. The employer is paying all of the employees
premium of $537.34
Employee 0
Coverage includes Medical, Vision & Dental
If your employer offers you insurance that is deemed
affordable to you and meets minimum essential coverage
requirements, you can purchase a health plan through the
Exchange but you will not be eligible for a tax credit. A plan is
considered unaffordable if the employee's individual
premium costs more than 9.5% of the employee’s household
income or if it pays for less than 60% of covered health care
expenses. So, if the health plans offered by your employer do
not meet this requirement, you will be eligible to receive tax
credits to purchase a qualified health plan through the
Washington Healthplanfinder.
However, an employee may go onto the Washington
Healthplanfinder to apply for and get health coverage for other
household members. The other members in the household can
still be eligible for Washington Apple Health (Medicaid), Health
Insurance Premium Tax Credits, and/or Qualified Health Plans.
So, an individual will go into the Healthplanfinder and submit a
separate application for the other members of their household.
And, part of the premium for the family in the amount of
$462
Employee pays $700
For an additional $69 family members can receive coverage for
dental and vision so now the Employee’s total is $769.00
The employee can only purchase vision for spouse and
children when they purchase the medical as well.
Yes, in the example I am applying for 3 family members,
spouse and 2 children.
So the Employee/Applicant goes on the Health Plan Finder and
finds a more inexpensive plan for the family size:
Household Information Number of people in the household 4
Annual household income 48525
Looking at the calculator: Household Information Number of
people in the household 4
Annual household income 48525
Your federal poverty level 206 Enrollee Information
Only enter members of your household who would enroll in
Exchange coverage.
Age of the first adult 51
Age of spouse 45
Number of children under age 21 2
Number of children age 21-25 [
] Monthly
Cost Estimated monthly silver plan premium (without
subsidy) 1319 Estimated tax credit from the
government 1056
Your estimated monthly silver plan premium $263
So for $263 a month I can purchase insurance for my entire
family. Am I allowed to opt out since the $700 a month is
more than 9.5% of my earnings? Would I be entitled to the
premium subsidy? Or, do I start an application for my spouse
and children get them on a plan and they get the subsidy
premium because I do not opt out of my employer provided
insurance?
We know a little about the five year rule regarding USCIS
residency and Medicaid. However, do H2A or H2B status
holders qualify for Medicaid and if so why does the 5 year rule
not apply to them?
H-2A and H-2B nonimmigrant visa holders are in the U.S. for
temporary agricultural work and temporary work,
respectively.
H-2A and H-2B visa holders
Children under age 19 and pregnant women are potentially
eligible for federally-funded Washington Apple Health.
Adults age 19 and older who are not pregnant are potentially
IPA Q&A, Sept 2013
North Sound Network In-Person Assister Training
eligible for Washington Apple Health Alien Emergency Medical
if they meet the qualifying conditions.
They are considered lawfully present non-qualified aliens. The
5-year bar does not apply to these individuals because they
are not qualified aliens. The 5-year bar only applies to
qualified aliens.
Will copays continue to be in effect for QHPs, even after the
out-of-pocket max has been met?
Co-pays for covered services DO count toward the out of
pocket maximum for that year. Yes, some services have a
defined co-pay amount that is separate from a typical office
co-pay. For example, in many plans, a visit to hospital will
entail a $250 co-pay and 20% co-insurance. If, in that
example, the $250 co-pay and 20% co-insurance meet your
out of pocket maximum then your plan will pay 100%.
Balance billing is when a provider bills you for the difference
between the provider’s charge and the allowed amount
(maximum amount on which payment is based for covered
health care services.). For example, if the provider’s charge is
$100 and the allowed amount is $70, the provider may bill you
for the remaining $30. A preferred provider (a provider who
has a contract with your health insurer or plan to provide
services to you at a discount) may not balance bill you for
covered services.
Is there a list of basic documents we should let consumers
know to bring to their enrollment? (ID, etc.)
Can an adult child (up to age 26) remain on their parent’s
insurance plan if they work and have access to employerbased insurance?
Please clarify if a married couple with an adult child 19-26
years of age needs to have the adult child listed on the
Healthplanfinder for household composition if the adult
child has dependents, is married, or no longer lives at
home. There were questions surrounding it at the
training.
What constitutes a WA residency? How does the
Healthplanfinder verify?
If a person signs up for a gold plan and during the middle of
ear needs to reduce to bronze plan because they are unable to
keep up with payments, (no new job of life event) are they
able to change mid-year?
What if someone is living/working most of the year out of the
country. Will a penalty be assessed?
What happens if spouse is covered by employer, but coverage
is either (a) not provided to family members or (b)
unaffordable? Are remaining family members eligible for tax
credits? Likewise, what if the employee and children are
covered, but not the spouse



Social Security Numbers
Dates of Birth
Passport, alien, or other immigration numbers for
any legal immigrants who need health care coverage

Income information for all adults and minors under
age 18 who are required to file a tax return

Information about family members’ health care
plans if any member of the family is currently
enrolled in other health care plans.
The adult child may stay on their parent's health insurance up
to the age of 26, even if their employer offers health
insurance. However, if the insurance offered by the employer
is affordable to the child, then the parents will not receive a
tax credit for the child.
A married couple may include their adult child in their
household composition if the child is a tax dependent. If the
child is not a tax dependent, the parents may still include the
child onto their coverage unit (up to age 26), but may not get
a tax credit for the child. The adult child may be included in
the parents' coverage unit if he is married, but the child's
spouse may not be included in the coverage unit. Also, the
parents may include their grandchild in their household comp,
as long as their child is under 18.
WA residency is self-attested by the individual. Generally, if an
individual has an intent to reside in Washington, for example,
they work/live here, they are a Washington state resident.
An individual may only change plans during the middle of the
year if they qualify for special enrollment.
If they file taxes, they may be assessed a penalty if they do
not have coverage. Exemptions to the mandate (and penalty)
can be filed for religious, financial, and other reasons.
Yes. The remaining family members could apply for coverage
through Healthplanfinder. Any tax-filing member of the
household would be eligible for tax credits if criteria (a) or (b)
were met.
IPA Q&A, Sept 2013
North Sound Network In-Person Assister Training
What if there are breaks in coverage throughout the year of
varying lengths? How will the penalty be charged?
Does the Healthplanfinder work with Chrome?
Could an individual purchase only dental for children?
What is the idle time?
Can someone in the 5 year waiting period purchase a QHP at
published price (no tax credits)?
Can a child under age 26 still be covered by his/her parents if
the under 26-year-old child also has a child?
If not mandated, how is penalty waived? Need to do
something in Healthplanfinder?
The penalty is not assessed if the break in coverage is less
than 63 consecutive days. If the break in coverage is greater
than 63 days, then the penalty would be calculated on a
monthly basis based on income and age.
Healthplanfinder is optimized to work with the most commonly
used internet browsers. We have tested Healthplanfinder in a
variety of IE, Chrome, Firefox and Safari versions.
There is a mandatory purchase of a pediatric QDP with a QHP
because pediatric dental is one of the 10 EHBs (part of the full
package). At this time, a QHP and pediatric QDP must be
purchased together.
After fifteen minutes, Washington Healthplanfinder times out.
If someone is logged into an account, they will need to log
back in. If they have not established an account their
application information may be saved under an application ID
number but they will need to call the Customer Support Center
to finish their application.
Yes, however, unfortunately Healthplanfinder (online system)
cannot process someone without a SSN who is applying for a
QHP (without tax credits). The applicant would need to be
processed through the Customer Support Center.
A child can be included in the parent's coverage unit until the
age of 26. If the child is a tax-dependent of the parents, the
parents may qualify for a tax credit for the child. If the child is
not a tax dependent under the parents, the parents may not
be eligible to receive tax credits for the child. The parents can
include their grandchild in their coverage unit if their child
is under the age of 18. The parents could also include their
grandchild in their coverage unit if they are the grandchild's
Legal Guardian.
AI/AN do not need file an exemption. The mandate is simply
waived for AI/AN.
IPA Q&A, Sept 2013