Medicaid & Marketplace Updates Kyle Fisher Kfisher@phlp.org October 2015 Session Topics 2 Medicaid Traditional Medicaid Expansion Transition from Healthy PA to HealthChoices New Expansion Category Immigrant Coverage Options Marketplace Cost-Sharing Reductions Medicaid 3 TRADITIONAL MEDICAID EXPANSION 4 Phase Out of Healthy PA 5 Gov. Corbett’s alternative Medicaid expansion created new managed care delivery system Effective January 1st, 2015 Called the Healthy PA Private Coverage Option (PCO) Gov. Wolf moved to a simpler, traditional expansion under the “HealthChoices” managed care system: Two phases: PCO -> MCO June 1st - 121,000 enrollees transferred Sept. 1st – 79,000 enrollees transferred Medicaid Expansion 6 PCO to MCO transition completed September 1st Private Coverage Option now defunct “Adult” benefit package implemented 4/27/15 DHS intends to withdraw the Healthy PA 1115 waiver by Sept. 30 Notice given to CMS on March 10, 2015 (6 months req.) None of the other Healthy PA reforms, such as premiums or work incentives, go into effect Delivery Systems 7 What is HealthChoices? Long established Medicaid managed care program Expanded statewide “New West” in fall 2012; “New East” in spring 2013 Separate physical health & behavioral health systems Known as behavioral health “carve-out” Single BH MCO in each county Covers most adults, not dual-eligibles (on PH side) Until, at least, MLTSS proposal implemented 8 Medicaid Eligibility 9 NEW ADULT/EXPANSION CATEGORY 10 Newly Eligible Adults 11 Adults age 19-64 Income under 138% FPL Cannot qualify for Medicare Household of 1 Household of 2 Household of 3 Household of 4 $1,354 $1,832 $2,311 $2,789 138% FPL (2015) monthly No asset test Monthly vs Annual Income 12 Medicaid uses “point-in-time” eligibility Essentially monthly Unlike HealthCare.gov, which uses annual income But, if monthly income is over 138% FPL, and Expected annual income is less than 138% Because income expected to decrease or end Such as unemployment comp. & seasonal employment Then CAO should use expected annual income See policy clarification PMA17446312 (2/2015) Medicaid Eligibility Basics 13 3-step analysis for each person 1) What category does the person fit in? 2) What is the person’s household size? 3) Is the person under the monthly income limit for that category and household size? 4th step for immigrants 1) What is the person’s immigration status and does it meet the relevant Medicaid standard? MAWD 14 Medical Assistance for Workers with Disabilities Underused category High income & resource limits Minimal work requirement Many who do not consider themselves “disabled” meet the MAWD disability standard Age 16-64; requires 5% premium Based on recipient’s income only, after disregards see manual on PHLP website Medicaid Eligibility 15 IMMIGRANT COVERAGE OPTIONS Immigration Status Overview 16 “Lawfully Present” Medicaid standard for: Children Pregnant women “Qualified” Plus five year waiting period, for most immigrants More narrow than “lawfully present” Medicaid standard for: Adults 17 The 5 year bar 18 Waiting period runs from date the person obtains “qualified” status Does not apply to certain immigration categories (generally humanitarian): Refugees & Asylees (even if later become LPR) Persons granted withholding of deportation Cuban/Haitian entrants Iraqi or Afghan special immigration status U.S. veterans or active duty military, spouses, or children GA-related Medical Assistance 19 For very low-income immigrants subject to the ‘5 year bar’ and still in waiting period. This is state-funded MA that covers about 4,000 immigrants. GA/MA has no 5 year bar. Category: 1. Temporary Disability Employability Assessment Form– Box 3 2. Health-Sustaining Medications form, or 3. Age 59+ GA/MA Income Limits 20 GA-related MA (if disability/need for Rx) Household Income Limit (monthly) Resource Limit HH of 1 $205 $250 HH of 2 $316 $1000 Income limits vary slightly by region, see MAEH 368 Appendix A GA-related MA (if age 59+) Household Size Income Limit (6 months) Resource Limit HH of 1 $2,550 $2,400 HH of 2 $2,650 $3,200 HealthCare.gov 21 Special rule for immigrants who do not qualify for Medicaid because of immigration status No income floor for PTC - Income: 0 - 400% FPL To qualify for premium tax credits Normally an income “floor”: Income: 138 - 400% FPL Adults 138% poverty 1 person 2 people 3 people $16,248 $21,984 $27,310 Emergency Medical Assistance 22 What options exist for someone who doesn’t meet the “qualified” or “lawfully present” standards? Emergency Medical Assistance no immigration status required must be otherwise eligible (meet category & income req.) Limited to time period of emergency condition Emergency Medical Assistance 23 Emergency Medical Assistance An emergency medical condition is a medical condition with acute symptoms of such severity including severe pain, that without immediate attention, the result may be: The patient’s health is in serious jeopardy. Serious impairment to bodily functions. Serious dysfunction of any body organ or part. Detailed letter from physician is key (see MAEH 322) Marketplace 24 COST-SHARING REDUCTIONS Cost-Sharing Reductions 25 2.2 million 2015 Marketplace enrollees (under 250% FPL) failed to take advantage of Cost-Sharing Reductions *Avalere Health Analysis Marketplace Basics - Subsidies 26 Who qualifies? Premium Tax Credits Income between 100-400% FPL Cannot be eligible for other “minimum essential coverage” Cannot be offered “affordable” (<9.5%) employer-based coverage Cost-Sharing Reductions Income between 100-250% FPL Eligible for premium tax credits Enroll in Silver-level plan Cost-Sharing Reductions 27 Why would someone forego CSRs? Lower premiums! Essential that they understand the trade-off: Premiums vs Cost-sharing CSR harder to understand than APTC PTC are a concrete number CSR vary by plan, operate in the background Types of Plans – “Metal Levels” 28 Highest Premiums & Lowest Cost Sharing Lowest Premiums & Actuarial Value. The percentage of total average costs that a plan will cover. Highest Cost-Sharing *before CSR Cost Sharing Reductions 29 How do Cost Sharing Reductions work? Three levels of CSR based on income Paid directly to the Silver plan Seamlessly reduces enrollee’s out-of-pocket charges Actuarial Value Standard Silver – no CSR 100-150% FPL 151-200% FPL 201-250% FPL 70% AV 94% AV 87% AV 73% AV Cost Sharing Reductions 30 Average cost-sharing at each CSR tier: Kaiser Family Foundation Types of Plans – “Metal Levels” 31 Resources 32 DHS Medicaid Expansion Website www.HealthChoicesPA.com Medical Assistance Eligibility Handbook http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm Avalere Health Analysis http://avalere.com/expertise/managed-care/insights/more-than-2-million-exchangeenrollees-forgo-cost-sharing-assistance PHLP Helpline: 1-800-274-3258 KFisher@phlp.org PHLP Medicaid Eligibility Manual http://www.phlp.org/wp-content/uploads/2015/02/Eligibility-Manual-2015.pdf