Maintaining Health
Coverage:
New Rules for HIV Clients under
the Affordable Care Act
Presented by:
Amanda Gallipeau
Today’s training
• Applying through the Marketplace – what to expect
• Types of coverage
• Expanded Medicaid (MAGI)
• Private health plans and help with cost sharing
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Special populations
Medicare and the Marketplace
HIV Uninsured Programs (ADAP) and the Marketplace
Questions?
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Applying Through The
Marketplace
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What is the Marketplace?
 The Marketplace is a “one stop shop” that allows
individuals and small businesses to compare public and
private insurance coverage on an “apples to apples” basis
- benefits, out of pocket costs, plan performance, and
customer satisfaction data.
 New York State operates its own marketplace, called NY
State of Health (https://nystateofhealth.ny.gov/)
 2014 is the inaugural year for the Marketplace, with
coverage available as early as (but not before) January 1,
2014.
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When can people apply through the
Marketplace?
 Enrollment in private coverage is not available year-round. Open
enrollment periods are:
• For 2014:
o October 1, 2013 – March 31, 2014
• For 2015:
o November 15, 2014 through February 15, 2015 (HHS to release future
dates)
 You can also enroll after a “qualifying life event”
• Have 60 days from date of qualifying life event to access special
enrollment period
 People who qualify for Medicaid and Child Health Plus are not
restricted to the open enrollment period. They can apply throughout
the entire calendar year.
 Small businesses with fewer than 50 employees can access the
Marketplace any month of the year
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Starting the process
There are several ways to apply
1) Online at https://nystateofhealth.ny.gov/
• Set up your own account and apply through the portal
2) By phone
• Call the Customer Service Center (1-855-355-5777)
3) In-person
• Through an “assistor” – navigator, certified application
counselor, or certified broker
4) Via paper (least preferred method)
 Single application process for public and private coverage
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Household composition
 Now defined by IRS tax filing rules, with some exceptions:
• Individuals (other than a spouse or child) who expect to be
claimed as a tax dependent by another tax payer
• Children who expect to be claimed by one parent as a tax
dependent and are living with both parents who do not expect to
file a joint tax return (for example, unwed parents)
• Children claimed as a tax dependent by a non-custodial parent
 Household composition is determined on expected filing
status; not a previous year’s return
 Don’t have to be a tax filer to qualify for Medicaid or CHP.
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Household composition
 Example
• A married couple - Heather and Joe
• In 2012 got married, filed 2012 return as
“Married, filing jointly”
• In September 2013, had their first daughter.
o What would their household composition
be when they went into the Exchange in
October 2013?
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Household composition
 Example
• They would be a household of 3 because they
expect to be so in 2014 (year which coverage
would be effective and the advance premium
tax credits would apply to their monthly
premium amount)
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What kind of information is collected?
 For each household member, information is
collected on:
• Identity (name and social security number)
• Marital Status
• Citizenship/Immigration status
• Race & Ethnicity (optional)
• Income
• Residency
• Other available insurance
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How is information treated in the
Marketplace?
 Information people submit will be data checked through
government databases for accuracy to
• Prove identity
• Verify household information
• Verify income information
 Information is kept confidential and is not used for any
purpose other than determining whether people qualify
for buying insurance and getting help affording it.
 Navigators and other assistors have strict privacy
practices and policies
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How long does the application
process take?
 Most people will receive immediate eligibility
determinations
• The online application process itself generally takes
45 minutes to 2 hours (average time).
• Some individuals may have to submit additional
information for verification, like proof of identity or
income. This may delay the eligibility determination.
• Marketplace technically has up to 30 days to decide
for pregnant women and children, 45 days for
everyone else.
o Medicaid legal processing timeframes haven’t changed
under the ACA.
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Appeals process
 New appeals process to contest eligibility
determinations
• Marketplace appeal instead of fair hearing
 No change to appeals process for service denials
• Plan appeals/fair hearings for Medicaid consumers
• Plan appeals for CHP and private insurance consumers
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Who is available to help?
 Navigators and In-person assistors
http://info.nystateofhealth.ny.gov/IPANavigatorSiteLocations
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Provide face to face assistance
Compensation from DOH grant program
Training and certification required
Serve Individuals and Small Business Marketplace
 Insurance Brokers/Agents
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Face to face and phone assistance
Commission-based compensation from insurance plans
Training and certification required
Choose to certify in Small Business Marketplace, Individual, or both
 Certified Application Counselors
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Can be care providers, local social service districts, community based organizations
Face to face and phone assistance
No compensation from the state or insurance plans
Training and certification required
 Customer Service Center/Maximus
• Phone assistance only
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How should people prepare for a meeting
with a navigator or other assistor?
 People should call first to make an appointment – there may be a wait
 People should create an email address in advance (if they don’t already
have one)
 People will need to bring certain information to the appointment:
• Social Security Numbers and birthdates for all family members
• Employer and income information for everyone in the household. It is a good
idea to bring wage statements like W-2 forms or letters from employers, as
well as tax statements like last year’s tax return
• If any family members have other health insurance available, people will need
to provide information about the premiums, cost-sharing and benefits.
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Expanded Medicaid
coverage (MAGI)
through the
Marketplace
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New Medicaid Eligibility Categories
MAGI*
(through
Marketplace)
Non-MAGI
(through LDSS)
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Pregnant Women
Children
Parents/Caretaker Relatives
Childless Adults ages 19 to 64 without Medicare
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65+ (age as a condition of eligibility)
Disability (as a condition of eligibility)
TANF, SSI, Foster Care
Spend down, MBI, MSP
Cancer Programs, Former Foster Care
Residents in adult homes, treatment centers,
OMH facilities
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*MAGI = Modified Adjusted Gross Income from tax return
MAGI Medicaid coverage
 Higher income level - up to 138% FPL. No asset test.
• Levels already over 138% FPL have been adjusted upward.
o Pregnant women and infants – 233% FPL; children – 165% FPL
 Under IRS rules for adjusted gross income (AGI), VA income,
Worker’s Compensation and child support are disregarded
 Cannot spenddown to MAGI income level.
• Federal subsidies are available to help pay for private health
insurance, if household income is at/below 400% FPL
• Children over income for Medicaid can get Child Health Plus.
 MAGI Medicaid provides 12 months of continuous coverage
 People can get up to 3 months of retroactive coverage
 Managed care plan enrollment is prospective (following month)
• Fee for service Medicaid will cover in the interim
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MAGI Medicaid
benefit package
 Benefit package in New York State is the same for MAGI
and non-MAGI Medicaid categories, with one exception
(outlined below). Both MAGI and non-MAGI include:
• Community coverage (non-long term care)
• Community-based long term care
• Institutional (nursing home) coverage
o Must be MAGI recipient before needing nursing home care to
be covered under MAGI (medically frail) category
o MAGI applicants who are already in nursing home when they
apply for Medicaid will be treated as non-MAGI.
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Private insurance
options through the
Marketplace and help
with cost sharing
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Qualified health plans (QHPs)
 The Marketplace offers Qualified Health Plans (QHPs).
 QHPs are required to have these essential health benefits:
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including
behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease
management
10. Pediatric services, including oral and vision care
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Qualified health plans (QHP)
network requirements
 QHPs must have adequate network of providers, including essential
community providers (ECPs)
 ECPs have with experience caring for medically underserved populations
or low-income populations, including
• Providers who qualify for 340B drug purchase prices
• Ryan White HIV/AIDS providers
• Federally Qualified Health Centers (FQHCs) and FQHC “Look-Alikes”
• Family Planning Providers (Title X Family Planning Clinics)
• Safety-net hospitals
• STD Clinics
• TB Clinics, Hemophilia Treatment Centers, and Black Lung Clinics
• other entities that serve predominantly low-income, medically-underserved
individuals
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Different levels of QHP
coverage – metal tiers
 Platinum – typically the more expensive plan, but offers
most comprehensive benefits and lower out of pocket
costs
 Gold
 Silver
 Bronze – the least expensive premiums, but pay more
out of pocket
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Help with QHP cost sharing
 Two types of subsidies for Qualified Health Plan enrollees
• Advance Premium Tax Credits (APTC) – helps reduce the
monthly premium of the plan
• Cost Sharing Reductions (CSR) –A discount that lowers the
amount you have to pay out-of-pocket for deductibles,
coinsurance, and copayments. You can get this reduction if
you get health insurance through the Marketplace, your
income is below a certain level, and you choose a health
plan from the Silver plan. If you're a member of a federally
recognized tribe, you may qualify for additional cost-sharing
benefits
• Some households can get both subsidies
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APTC - Who is eligible?
 Those with income between 138% FPL and 400% FPL
• US citizen or lawfully present
• Must not be eligible for other minimum essential coverage
 Immigrants with incomes below 100% FPL can get APTC if
their immigration status makes them ineligible for
Medicaid
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APTC
 Is applied to your monthly premium amount
• Amount of credit is based on the expected income you
report when applying
• Can receive it “up-front” to reduce the monthly amount
you pay
• Or can pay full premium amount each month and receive it
as a credit when you file taxes
 If income increases
• It is important to report to the Marketplace – since tax
credit is based on a lower projected amount, you may have
to pay difference when filing next year’s taxes
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Offers of employer coverage
 An offer of employer coverage will make a person
ineligible for Advance Premium Tax Credits – EVEN IF THE
OFFER OF COVERAGE IS NOT TAKEN
 The exception is if the coverage does not meet the
minimum health benefits, or is more than 9.5% of the
employee’s income for a single plan
• The affordability rule is only considered for the SINGLE plan,
even if the whole family is offered a plan
• If the SINGLE plan is less than 9.5% of the employee’s
income, it is considered affordable under these rules, and if
there is an offer of coverage for the family, they are
INELIGIBLE for tax credits
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Cost Sharing Reductions (CSR)
 Reduces the out-of-pocket charges a person must pay for
medical care covered by the plan
• Deductibles, co-pays, co-insurance
 Income up to 250% Federal Poverty Level (FPL)
 Must choose Silver Level Plan
 3 levels of CSR based on income
• Up to 150%
• 150-200%
• 200-250%
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How is CSR provided?
 Federal government pays the health insurer upfront
 Enrollee cost sharing charges are automatically reduced
when an eligible person or family enrolls in a silver plan
 People do not have to keep track of their spending or get
reimbursed
 Not provided as a tax credit
 Not “reconciled” at the end of the year
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2014 Federal Poverty Levels
Persons in
100% Poverty
family/househ
Guideline
old
138% Poverty
Guideline
200% Poverty
Guideline
250% Poverty
Guideline
400% Poverty
Guideline
1
$11,670
$16,104
$23,340
$29,175
$46,680
2
$15,730
$21,707
$31,460
$39,325
$62,920
3
$19,790
$27,310
$39,580
$49,475
$79,160
4
$23,850
$32,913
$47,700
$59,625
$95,400
5
$27,910
$38,515
$55,820
$69,775
$111,640
6
$31,970
$44,118
$63,940
$79,925
$127,880
7
$36,060
$49,762
$72,120
$90,150
$144,240
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$40,090
$55,324
$80,180
$100,225
$160,360
8+
add $4,060 for
each additional
person
add $5,602
add $8,120
add $10,150
add $16,240
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What if my income has changed?
 If I made a lot more last year than I am making now, will they count
the higher income on my tax return?
• No – the portal will ask for what you expect to make this year.
 Will I have to prove that my salary went down?
• No - the portal will check what you estimate against last year’s return
and then come back and ask you to explain why it has changed. If you
have a reasonable explanation, your information should be accepted.
 What if my income goes up again later?
• You will need to enter the new information into your account as soon
as you get a raise or new job that pays more.
• This is important so that the amount of your tax credit can be
adjusted.
• Remember that Medicaid provides 12 months of continuous
coverage, even if income increases.
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Penalties (Individual mandate)
 The penalty for not getting insurance will not take effect if
people enroll by March 31, 2014
 The penalty is fairly low in 2014 (higher of $95 or 1% of
income per adult), but increases every year. In 2016 it is the
higher of $695 or 2.5% per adult.
• The fee for children is half of the adult amount
• Is assessed at tax filing
 The amount is assessed per person in the household without
insurance
 Exemptions from the penalty:
• individuals who cannot afford coverage
• members of Federally Recognized Tribes
• members of recognized religions with an objection to health
insurance
• individuals who are not required to file tax returns
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This might be the hardest part …
choosing a QHP plan
Each consumer will have different needs
 What medical services do you anticipate needing?
• Dental, vision, possible surgeries
• Provider networks
• Prescription needs – check formularies
 How much can you afford to pay?
• Metal tiers of coverage
o Platinum, Gold, Silver, Bronze – varying levels of cost-sharing
o Only the silver plan will provide cost sharing benefits for individuals
and families up to 250% FPL
 QHP coverage isn’t activated until you pick a plan AND pay your
initial premium
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LGBT in ACA
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LGBT Population Concerns
 Same sex spouse/partner health insurance status
• NY is a marriage-equality state and married same-sex
couples are entitled to apply for family health plans
• Special rules might apply for couples with children
 LGBT knowledgeable health care providers
• Consumers should seek out a provider who offers a
welcoming environment
o Directory of LGBT trained providers:
lgbthealth@health.state.ny.us
• AIDS Institute supports training centers to build LGBT
cultural competency
o http://hivtrainingny.org
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Privacy Concerns
 The Explanation of Benefits (EOB) is mailed to the
residence listed as the primary policyholder.
 EOB identifies who received care, what care was provided,
and includes testing and procedures performed.
 Clients can request that the plan sends the EOB to an
alternate address to protect privacy.
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Transgender Populations
 The Marketplace relies on Social Security Administration
records to confirm name and gender.
 Transgender applicants should list their name and gender
exactly as they appear in Social Security’s records – even
if it does not match the name or gender they are
currently using.
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Immigrant Populations
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All family members are protected
 By law, information about applicants and nonapplicants may
only be used to determine eligibility for health insurance.
 This requirement extends to all involved in the application,
eligibility, and enrollment process.
 Information obtained about applicants or members of their
household used to determine eligibility for insurance will not
be used by U.S. Immigration and Customs Enforcement for
civil immigration enforcement purposes.
(www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf )
 The federal subsidies, tax credits, and cost sharing reductions
will not be considered in the “public charge” decision if and
when a person adjusts status to LPR.
https://www.healthcare.gov/what-do-immigrant-familiesneed-to know/
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Undocumented Individuals
 Definition: individuals born in another county who lost permission
to remain in the U.S., or entered the U.S. without permission
 They CANNOT access regular Medicaid or QHP through the
Individual Marketplace
 They CAN use the Marketplace to obtain:
• Emergency Medicaid for themselves
• CHP for their undocumented children
• Regular Medicaid or QHP for eligible family members (children
and/or spouse)
 They CAN purchase “off exchange” QHPs for themselves (NYS rule)
 They are EXEMPT from the individual mandate
 They CAN continue to access HIV Uninsured Care Programs,
including ADAP
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Households with
Undocumented Members
 For APTC, count a portion of the undocumented person’s
income … do NOT include the person in the household
count
 For Medicaid purposes, income is counted and the
undocumented person is counted (legally responsible
relatives only)
 Other household members could all qualify for different
programs, while some may not qualify for any at all
 By law, applications may not request the citizenship or
immigration status of an individual who is not seeking
coverage for himself or herself.
 Undocumented person can get emergency Medicaid.
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Medicare and the
Marketplace
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Will the Marketplace help
people with Medicare ?
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No – they already have insurance (Medicare)
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People with Medicare cannot use qualified
health plans or get APTC or cost sharing
reductions (unless they have to pay for Part A)
Also, most people with Medicare can’t get
Medicaid through the Marketplace – they have
to go to their local social services district
instead, because they are non-MAGI
But those who are in the two year waiting
period for Medicare CAN use the Marketplace,
and so can their MAGI-related caretakers
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Consumers who
already have Medicaid
– transition to MAGI
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How does Marketplace affect people already
getting Medicaid?
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Non-MAGI only:
 No change. LDSS/HRA will continue to
process changes and renewals.
MAGI only (had obtained under pre-MAGI
rules)
 Should be evaluated under MAGI
budgeting at renewals and when changes
are reported.
Fit into both MAGI and non-MAGI category:
 Ditto. Can apply through Marketplace now
to eliminate spenddown.
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Relationship between
HIV Uninsured
Programs (ADAP) and
the Marketplace
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HIV Uninsured Care
Programs (HUCPs)
 ADAP/HUCP participants may transition to Medicaid, enroll in
comprehensive private insurance via NYS of Health
marketplace, or remain in ADAP/ HUCP program based upon
their eligibility status.
 HIV Uninsured Care Programs assist with the costs of
premiums for a variety of insurance products as a way to
maximize available funds.
 HIV Uninsured Care program is coordinating enrollments with
the NY State of Health Marketplace and facilitating a
streamlined process for cost sharing and premium payments
for eligible clients.
 HIV Uninsured Care assistance will continue to help clients
with cost sharing and premium coverage of Exchange
coverage when those costs are a barrier to care.
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HIV Uninsured Care Programs (HUCPs)
ACA Advice to Participants and Applicants
 When choosing a plan, current program clients can make sure:
 Your doctor accepts the Marketplace health plan.
Your pharmacy participates in the plan and is enrolled with
ADAP.
 If an applicant is eligible for an Advanced Premium Tax Credit
(APTC), the credit is applied directly to the monthly
premiums.
Generally speaking, Silver, Gold and Platinum plans are cost
effective and have lower up-front costs for services not
covered by APIC
For additional information:
www.nyhealth.gov/diseases/aids/resources/adap/index.htm
or call 800.542.2437 8:00am - 5:00pm, Monday through
Friday.
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ADAP continues to play a
critical role
 ADAP can provide wrap-around coverage for out-ofpocket costs of QHP coverage.
 ADAP will continue to assist undocumented immigrants
who can’t access Medicaid or QHP.
 For non-MAGI Medicaid, ADAP can still be used to meet
Medicaid spenddown.
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New York State of Health
 For more information of the Affordable Care Act or New
York’s Marketplace
• NY State of Health
nystateofhealth.ny.gov
1-855-355-5777
 For help finding an assistor
• http://info.nystateofhealth.ny.gov/resource/find-ny-statehealth-certified-broker
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Questions?
 Contact Empire Justice Center
• (800) 724-0490 x 5822
 Amanda Gallipeau, Health Law Paralegal
• (585) 295-5731
• agallipeau@empirejustice.org
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