Navigating TennCare
& the Marketplace
Day 2:
Puttin’ it to the Test
10/9/2014
Tennessee Justice Center
301 Charlotte Ave | Nashville, TN, 37201
615-255-0331
Agenda
Day 1
• Pre-Test
• Counting Income
• Counting Household
Size
• TennCare Categories
10/9/2014
Day 2
• Scenarios
• Marketplace Basics
• Scenarios
• Wilson v. Gordon
• Scenarios
• Post-Test
Scenario: Wally “Whitey” White
• Whitey became disabled in his
late 20’s and has no children.
• He used to receive SSI, but
started getting Social Security at
$751/month when he turned 62
in November of 2013.
• He has $500 in a savings
account. He rents his home and
has no other assets.
10/9/2014
What is
Wally
eligible for?
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Whitey is in a household by himself.
What is the household size for each person for Marketplace purposes?
Same household counting as above.
10/9/2014
Step 3: Income
Income for household of 1 is $751/month.
10/9/2014
So who’s eligible for what?
• Whitey?
– Gap
– …or… maybe… could it be…
10/9/2014
Pickle Eligibility
$751 x .985 = $739.74
-$20 unearned income disregard =
$719.74!
Whitey can get TennCare through
Pickle!
10/9/2014
Advocacy Tips
• Apply on the Marketplace and follow-up with
THC.
• Many folks who are on Medicare don’t know
that they are eligible for pickle.
10/9/2014
Scenario: Lamar
• Lamar is a 62 year old widow who retired early.
He gets a Social Security check of $950 per month.
This is his only source of income.
• He has a Qualified Income Trust (QIT) worth
$40,000. Also, he has a burial fund worth $5,500.
• Soon after he retired, he learned that he has
progressive bone cancer. He’s getting some
treatment through a hospital charity program, but
he continues to deteriorate quickly.
• His daughter, Tandy, has moved in with him to
take care of him.
What is he eligible
for?
10/9/2014
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Lamar (poor fella, all on his own!)
What is the household size for each person for Marketplace purposes?
Same household counting as above.
10/9/2014
Step 3: Income
Income for household of 1 is $950/month.
10/9/2014
So who’s eligible for what?
• Lamar?
– Maybe CHOICES – what else do we need to
know?
• Resources?
QIT and burial fund (up to $6000) are noncountable resources.
• Needs help with activities of daily living?
Lamar says he needs help with mobility and
transfer.
10/9/2014
How do you apply for CHOICES?
• Call local Area Agency on Aging and Disability.
• Need to go through an evaluation. Many
times, people “fail” this the first time. If that
happens…
•Appeal!
– Appeal form in back of toolkit.
10/9/2014
Practice Tips
• CHOICES is a common alternative for people who
are in the Gap, because it is a doorway to
Medicaid. If you have a client who needs help
with even 1 activity of daily living and is within
income and resource limits of CHOICES, he/she
could qualify for CHOICES 3.
• If you’re denied the right to an assessment for
CHOICES, you have the right to appeal.
• Counting resources for CHOICES can be tricky.
Sometimes, folks may want to speak to an elder
law lawyer about their resources.
10/9/2014
Marketplace Basics
10/9/2014
What’s my role?
• Unless you are a CAC or Navigator, you cannot
hold yourself out as one.
• You also cannot recommend a specific plan.
• This is training does not provide you with any
type of certification (just tons of helpful info!).
10/9/2014
Premium Tax Credits
10/9/2014
Who is Eligible?
Individuals and families with income between
100% and 400% FPL
• Must be lawfully present in the U.S.
• Must not be eligible for other “minimum essential
coverage”
10/9/2014
FPL and Eligibility
FPL
Affordability
Program
Annual Income by Household Size
1
2
3
4
100% FPL
Medicaid (?)
$
11,670
$
15,730
$
19,790
$
23,850
138% FPL
Medicaid (?)
$
16,105
$
21,707
$
27,310
$
32,913
150% FPL
PTC & CSR1
$
17,505
$
23,505
$
29,685
$
35,775
200% FPL
PTC & CSR2
$
23,340
$
31,460
$
39,580
$
47,700
250% FPL
PTC & CSR3
$
29,175
$
39,325
$
49,475
$
59,625
300% FPL
PTC
$
35,016
$
47,184
$
59,376
$
71,556
400% FPL
PTC
$
46,680
$
62,920
$
79,160
$
95,400
10/9/2014
How is the Amount of the Tax Credit
Determined?
Second-cheapest Silver plan
–– expected contribution
____________________________________________
Premium Tax Credit amount
10/9/2014
How is the Amount of the Tax Credit
Determined?
Your PTC is based on your expected premium
contribution. Everyone in the same FPL has the
same expected premium contribution.
Annual Household Income
% of FPL
Expected Premium Contribution
Income Amount
% of Income
Annual Dollar Amount
100-150%
$11,490 - $16,755
2 - 4%
$230 - $670
150-200%
$16,755 - $22,340
4 - 6.3%
$670 - $1,407
200-250%
$22,340 - $27,925
6.3 – 8.05%
$1,407 - $2,262
250-300%
$27,925 - $33,510
8.05 – 9.5%
$2,262 – $3,183
300-400%
$33,510 - $44,680
9.5%
$3,183 - $4,245
> $44,680
n/a
n/a
10/9/2014
> 400%
Why is this important?
The expected premium contribution doesn’t
change with age, even though the cost of the plan
does.
$16,000
2nd cheapest Silver plan,
$5,000
2nd cheapest Silver plan,
$15,000
$14,000
$12,000
$10,000
$13,552
$8,000
Contribution
$6,000
$4,000
$2,000
$0
10/9/2014
Tax Credit
$3,552
$1,448
$1,448
Gunnar, Age 26
Coleman, Age 62
Offers of Employee Coverage &
Eligibility
An individual is not eligible for
premium tax credits if he is eligible
for other minimum essential
coverage (MEC)
10/9/2014
Minimum Essential Coverage
• Most employer sponsored coverage
is MEC
• An offer of coverage - even if it’s not
taken - can make someone ineligible
for premium tax credits
But wait…
10/9/2014
Exception
An employee may be eligible for premium
tax credits if the employer plan is
unaffordable or inadequate, and if the
employee does not enroll in it
10/9/2014
Jumping the “Firewall” Between Employer
Coverage and Premium Tax Credits
If unaffordable or
inadequate
Offer of Employer
Coverage
10/9/2014
Premium Tax
Credits
Is it Affordable?
• Affordable = employee contribution for selfonly coverage is less than or equal to 9.5% of
household income
• Yes, that’s right! Cost of self-only coverage
used to determine affordability for both
employee and dependents!!??!
10/9/2014
Affordability of Family Coverage (Conrad Family)
Mom works at Edgehill. She earns $35,000. Dad is an
politician and earns about $12,000.
Family Income: $47,000
Premium Cost to Employee for Employee-Only Plan:
$196/mo ($2,350/yr) 5% of income
Premium Cost to Employee for Family Plan: $509/mo
($6,110/yr) 13% of income
15%
10%
9.5% - - - - - - - - - - - - - - - - - - - - 13%
5%
5%
5%
0%
10/9/2014
Employee Only
Family
Bottom Line:
No one is eligible for
premium tax credits
because family coverage
is considered affordable.
Jumping the Firewall:
When is Coverage Adequate?
Coverage is adequate if it has a minimum value
(MV) of 60%
o This generally means that the plan pays
at least 60% of spending for coverage of
essential health benefits for a typical
population, after accounting for costsharing charges required under the plan.
10/9/2014
How Will an Employee Know if his Offer is
Affordable or Adequate?
• Application has an appendix to be completed by the
applicant (with help from his employer to indicate value
and cost of the plan)
• If your employer does not tell you, you can print off the
Employer Coverage Tool from healthcare.gov.
10/9/2014
Cost-Sharing Reductions
10/9/2014
Marketplace Plans – Metal Levels
Plan Level Actuarial
Value
Platinum
90%
Gold
80%
Silver
70%
Bronze
60%
10/9/2014
Lower enrollee cost-sharing
Higher enrollee cost-sharing
Same, but different
SILVER # 1
SILVER # 2
(enrollee pays)
(enrollee pays)
Deductible (individual)
$2,000
$2,500
Maximum OOP Limit
(individual)
$5,500
$6,350
Inpatient hospital
(After deductible)
$1,500/admission
30%
Office visit
(After deductible)
$30
$35
10/9/2014
Sample Cost-Sharing Reduction (CSR) Plans
Standard
Silver
CSR for up to CSR for 151150% FPL
200% FPL
CSR for 201250% FPL
Actuarial
Value
70%
94%
87%
73%
Deductible
(Indiv)
$2,000
$0
$250
$1,750
Max. OOP
limit
(Indiv)
$5,500
$1,000
$2,000
$4,000
Inpatient
hospital
$1,500 per
admiss.
$100 per
admiss.
$250 per
admiss.
$1,500 per
admiss.
Office visit
$30
$10
$15
$30
10/9/2014
Go Silver!
If your client falls between 100-250% of
FPL, she should pick a silver plan.
10/9/2014
Rule:
No reconciliation at end of the year
(for cost-sharing reductions)
10/9/2014
Scenario: Luke and Rayna
What is
everyone
eligible for?
10/9/2014
• Rayna and Luke are married
with three children: ages 12, 7,
and 2.
• Luke makes $3,000/mo.; Rayna
$1500/mo.
• They have savings of $15,000.
• Luke is insured with his
employer, who just announced
that they will be offering
healthcare for employees’
children next month.
• Luke pays $255/mo. for health
insurance.
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Luke
Rayna
Maddie
Daphne
Taylor
Luke
✔
✔
✔
✔
✔
Rayna
✔
✔
✔
✔
✔
Maddie
✔
✔
✔
✔
✔
Daphne
✔
✔
✔
✔
✔
Taylor
✔
✔
✔
✔
✔
What is the household size for each person for Marketplace purposes?
Same household counting as above.
10/9/2014
Step 3: Income: Waylon
Income for household of 5 is $4500/month.
Rayna
Kids
10/9/2014
So who’s eligible for what?
• Luke?
– Not eligible to get PTCs, because he has an offer of
coverage.
• Rayna?
– Eligible for PTCs and CSRs!
• Kids?
– CoverKids!
But, Luke wants to look at all his options… he
doesn’t trust this “CoverKids” deal…
10/9/2014
Luke is skeptical…
• Luke currently pays $255/mo (8.5% in income) for
his healthcare.
• To add his kids, it would be $510 (17% of his
income).
And Rayna is still uninsured…
A silver plan, with PTCs, could cost $167/mo
10/9/2014
The Family Glitch
• Because of the family glitch, Rayna and Luke
would end up spending about $677/mo. (17%
of their income) on healthcare without
CoverKids.
• So… get those girls on CoverKids!
10/9/2014
Take-Aways and Practice Tips
• Family glitch: health insurance that is
“affordable” can still be very expensive for the
family.
• If one spouse has employee coverage, but the
other spouse gets covered on the
Marketplace, the employee coverage
premiums do not count towards expected
contribution.
10/9/2014
Scenario: Juliette
• Juliette is a single mother.
• Her son Garth is 12 years old. Juliette’s 61
year old long-lost father, Waylon, lives
with them.
• Juliette earns $1,900/month. Waylon
makes $100/month working weekends at
a hardware store.
What is
• Juliette claims Waylon as a dependent,
but Garth is claimed by his dad. Garth
everyone
stays with his dad every other weekend.
• Garth has severe intellectual disabilities, eligible for?
and Waylon had diabetes. No one has
insurance right now.
10/9/2014
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Juliette
Juliette
✔
Garth
✔
Waylon
Garth
Waylon
✔
✔
✔
What is the household size for each person for Marketplace purposes?
Juliette and Waylon: Juliette, Waylon
Garth: self, dad
10/9/2014
Step 3: Income: Juliette & Garth
Income for household of 2 is $1900/month.
Juliette
Garth
10/9/2014
Step 3: Income: Waylon
Income for household of 1 is $100/month.
10/9/2014
Step 3: Income: Waylon
What about his income for PTC purposes?
Since he is in Juliette’s household for PTC
purposes, his income is high enough!
10/9/2014
So who’s eligible for what?
• Garth?
– CoverKids
– Maybe Medically Needy Spend Down?
– Get on DIDD waiting list
• Juliette?
– PTCs and CSRs!
• Could get a Silver plan at $35.37/month, with a $141.56
subsidy, and 94% CSRs.
• Waylon?
– CHOICES?
– PTCs and CSRs!
10/9/2014
Practice Tips
• Remember the exceptions for household
sizes!
• Remember to look at someone’s household
for both PTCs and TennCare.
• A quick note about insulin: CoverRx is a
resources for folks under 100% FPL.
10/9/2014
Coffee Break!!!
10/8/2014
TennCare Updates
It took TennCare 8 months to process the application for Rusty
and his family. During that time, Rusty couldn’t get on the list
for a life-saving liver transplant, and his two sons went to the ER
without insurance: one for a broken arm, and one for an illness.
10/9/2014
Wilson v. Gordon
On July 27th, TJC, the Southern Poverty Law
Center, and the National Health Law Program
filed suit against TennCare on behalf of all
Tennesseans who have been waiting for more
than 45 days for TennCare to tell them whether
or not they are eligible.
10/9/2014
“Reasonable Promptness”
Federal law requires TennCare to determine an
applicant’s eligibility “with reasonable
promptness,” defined as no longer than 45 days
(or 90 days for the CHOICES program).
10/9/2014
Applicants’ Right to a Hearing
Federal law requires TennCare to provide an
opportunity for a fair hearing to anyone whose
application is “denied or is not acted upon with
reasonable promptness.”
10/9/2014
Wilson v. Gordon Class
“All individuals who have applied for Medicaid
(TennCare) on or after October 1, 2013, who have
not received a final eligibility determination in 45
days (or in the case of disability, 90 days), and who
have not been given the opportunity for a ‘fair
hearing’ by the State Defendants after these time
periods have run.”
http://www.tnjustice.org/tenncare-suit/class/
10/9/2014
Wilson v. Gordon Order
“The Defendants are ordered to provide the Plaintiff
Class with an opportunity for a fair hearing on any
delayed adjudication. Any fair hearing shall be held
within 45 days after the Class Member requests a
hearing and provides Defendants with proof that an
application was filed.”
If the application is for CHOICES, the hearing must be
held within 90 days of the request.
http://www.tnjustice.org/tenncare-suit/order/
10/9/2014
4 Advocacy Tips from TJC
1. Appeal! Appeal! Appeal!
2. Refer to the Legal Aid Society for
representation at the hearing.
– Refer to TJC for advocacy, if the state says they
are closing the applicant’s appeal.
3. Document the person’s application &
eligibility
4. Be encouraging!
10/9/2014
Advocacy Tip #1
1. Help the class member appeal.
• Call Tennessee Health Connection: 1-855-259-0701 OR
• Fax delayed appeal form to HCFA Eligibility Appeals:
1-844-563-1728 OR
• Certified Mail, Return Receipt Requested, the delayed
appeal request form to:
HCFA Eligibility Appeals:
P.O. Box 23650
Nashville, TN 37202-3650
**Keep the fax/certified mail receipt, or write down date and time of phone
call and who you spoke to.**
10/9/2014
Advocacy Tip #1
• The appeal request form asks for proof of date
of application.
– If the applicant has correspondence from the Marketplace with the
date, send that. If not,
– Call the Marketplace to ask for help with written proof.
• If the consumer applied over the phone and
never received an eligibility notice in the mail:
– Help him/her create an online account.
– Link the application to the online account using the application ID
number.
– Print the eligibility notice.
10/9/2014
Advocacy Tip #2
2. Have the class member call her local Legal
Aid Society if she is in East Tennessee (1-800821-1309) or in Middle Tennessee (1-800238-1443). They may be able to help.
10/9/2014
Advocacy Tip #2
• Refer to TJC if TennCare says they are closing
your client’s appeal because he/she could not
provide the requested information.
• We do not believe this should happen! We will
help advocate for families who have no means
to prove their application date.
10/9/2014
Advocacy Tip #3
3. Help him/her gather documents
•
Other documents that they should bring if they have
them:
–
–
•
10/9/2014
Anything that the Marketplace or TennCare has sent to
him/her
Anything that he/she has sent to the Marketplace or
TennCare
But, at the end of the day, the most important thing is
that they show up.
Advocacy Tip #3
• The state will use an “administrative process”
to adjudicate applications before going to
hearing. TennCare’s goal is to resolve eligibility
without the need for a hearing.
• If you can provide documents to help the state
process the application, then a hearing might
not be necessary.
• This is good news!!!
10/9/2014
Advocacy Tip #4
Be encouraging! We don’t want folks to be
intimidated by this process.
Things are always changing: please check our
website for updates
www.tnjustice.org/tenncare-suit
10/9/2014
Scenario: Dolly & Travis
What is
everyone
eligible for?
10/9/2014
• Dolly and Travis are married with
two kids, Porter (5) and Cash
(11). Dolly has a child from a
previous marriage, Zoey (20),
who is a full-time college student
living at school during the year.
• Dolly and Travis file taxes jointly,
and claim all the kids.
• Travis makes $3400/month, and
that is their only income. He does
not have access to insurance
through work.
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Dolly
Travis
Porter
Cash
Zoey
Dolly
✔
✔
✔
✔
✔
Travis
✔
✔
✔
✔
✔
Porter
✔
✔
✔
✔
✔
Cash
✔
✔
✔
✔
✔
Zoey
✔
✔
✔
✔
✔
What is the household size for each person for Marketplace purposes?
Same as above – 5 people in the household for each member.
10/9/2014
Step 3: Income
Income for household of 5 is $3400/month.
Dolly &
Travis
Cash
Porter
Zooey
Cash
10/9/2014
So who’s eligible for what?
• Porter?
– TennCare
• Cash?
– CoverKids (or Medically Needy Spend Down if the
family has a log of medical bills)
• Zoey?
– Medically Needy Spend Down if the family has a lot
of medical bills, and few resources.
– If not, PTCs and CSRs
• Dolly and Travis?
– PTCs and CSRs
10/9/2014
But then, reality strikes.
• On March 30, 2014, Dolly and Travis applied
on the Marketplace by phone for the whole
family.
• Dolly, Travis, and Zoey are on a silver plan with
PTCs and CSRs!
• …but the kids still haven’t been enrolled in
TennCare or CoverKids.
What should they do now?
10/9/2014
Appeal!
• Call TNHC to ask to file a delay appeal.
• The state may ask for more information:
– If they ask for proof of application, send in any
information that the family has from the Marketplace
with the application date.
• If they have nothing in writing, they can try connecting their
application ID# with an online account.
– If they ask for income verification, send in pay stubs
(month of application, and month before application).
• Go to covertn.gov to apply to CoverKids directly
for Cash.
10/9/2014
Uh-oh… Dolly & Travis Split
What is
everyone
eligible for?
10/9/2014
• Dolly and Travis had one too many
fights about who could eat the last
pickle in the jar, so they got
divorced.
• Travis has custody of Porter and
Cash, and makes their day-to-day
decisions. Zoey is still living at
school, but stays with her mom
when she’s home.
• Dolly claims all three children as tax
dependents.
• Travis’s income is still $3400/month.
• Dolly gets a job making
$1900/month.
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Dolly
Dolly
Travis
✔
Porter
Cash
Zoey
✔
✔
✔
Travis
✔
Porter
✔
✔
✔
Cash
✔
✔
✔
✔
✔
Zoey
✔
✔
What is the household size for each person for Marketplace purposes?
Dolly, Porter, Cash, Zoey: Dolly, Porter, Cash, Zoey
Travis: Travis
10/9/2014
Step 3: Income – Porter & Cash
Income for household of 3 is $3400/month.
Cash &
Porter
10/9/2014
Step 3: Income – Zoey & Dolly
Income for household of 4 is $1900/month.
10/9/2014
Step 3: Income – Travis
Income for household of 1 is $3400/month.
Travis
10/9/2014
So who’s eligible for what?
• Porter?
– CoverKids (or Medically Needy Spend Down if the family has a
lot of medical bills)
• Cash?
– CoverKids (or Medically Needy Spend Down if the family has a
lot of medical bills)
• Zoey?
– Medically Needy Spend Down if the family has a lot of medical
bills.
– If not, Coverage Gap
• Dolly?
– Coverage Gap
• Travis?
– PTCs
10/9/2014
Practice Tips
• If kids are eligible for CoverKids, do a quick screen
to see if they might be Medically Needy Spend
Down (high medical bills? resources?)
• If someone is in the gap:
– If they are close to 100% FPL, see if they can pick up a
few extra hours
– Refer them to Health Assist Tennessee for help getting
care
– Encourage them to share their story: 615-900-GAP3
– If their income has any chance of going up this year,
have them apply on the FFM anyway!
10/9/2014
Scenario: Gunnar & Scarlett
• Gunnar and Scarlett are 22,
graduated college in May,
and just got married in
June!
• In July, Gunnar started working 4 nights a week at the
Bluebird Cafe. He makes about $1800 in wages and tips
each month.
• In July, Scarlett started working a part-time job, making
$580/month.
• Their jobs don’t offer insurance, and neither of their
parents’ have employer insurance.
10/9/2014
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Probably not
eligible for
TennCare!
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Gunnar
Scarlett
Gunnar
✔
✔
Scarlett
✔
✔
What is the household size for each person for Marketplace purposes?
Same household counting as above.
10/9/2014
Step 3: Income
When we count income for TennCare purposes, we want
monthly income. But on the Marketplace, we estimate
yearly income.
Gunnar estimates that his gross income in 2014 will be
$10,800.
Scarlett estimates hers will be $3,480.
Combined income = $14,280: under 100% of FPL
10/9/2014
So who’s eligible for what?
• Gunnar and Scarlett?
– They can buy insurance on the FFM, but they
aren’t eligible for PTCs or CSRs since they are
under 100% FPL.
– The lowest cost silver plan would cost them about
$284/month – they can’t afford this.
Gunnar and Scarlett are in
the Coverage Gap.
10/9/2014
Practice Tips
• For purposes of getting PTCs, the FFM looks at
yearly income.
• TennCare looks at monthly income.
• Remember, for folks in the gap:
–
–
–
–
Can they pick up extra hours if they’re close?
Health Assist Tennessee
615-900-GAP3
Apply anyway!
• Young adults can stay their parents’ employer
insurance – even if they are married.
10/9/2014
Woohoo—Scarlett Gets Preggo!
• Scarlett finds out that
she’s pregnant!
• Income stays the same:
– Combined monthly
income: $2,380
– Income for 2014: $14,280
Now who’s eligible for what?
10/9/2014
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Gunnar
Scarlett
Gunnar
✔
✔
Scarlett
✔
✔
✔
Until the baby is born, Gunnar is in a household of 2, and
is not considered a parent!
What is the household size for each person for Marketplace purposes?
10/9/2014
Gunnar and Scarlett are in a household by themselves.
(Unborn babies don’t count on the FFM!)
Step 3: Income – Scarlett
Income for household of 3 is $2380/month.
Scarlett
10/9/2014
So who’s eligible for what?
• Scarlett?
– TennCare!
• Gunnar?
– Same position he was in before… in the Gap.
What should Scarlett do now?
Go to her local Health Department to get
Presumptive Eligibility, and apply on the FFM.
She must apply to the FFM by the end of the following
month of getting PE, or she will lose her PE.
10/9/2014
Look who’s here…Dierks pops out!
• On March 14, 2015, Gunnar & Scarlett
have their first baby, Dierks!
• Gunnar is still uninsured, and Scarlett
had TennCare when Dierks was born
but will lose it at the end of May.
• Gunnar still makes $1800/month.
• Scarlett worked in January and 2
weeks in February (made $580 in
January, and $290 in February). She
plans to go back to work on June 1,
and will be making $580/month again.
10/9/2014
What is everyone
eligible for?
Step 1: Quick Screen
Quick mental screen: who are we looking at?
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Gunnar
Scarlett
Dierks
Gunnar
✔
✔
✔
Scarlett
✔
✔
✔
Dierks
✔
✔
✔
What is the household size for each person for Marketplace purposes?
Same household counting as above.
10/9/2014
Step 3: Income
Income for household of 3 is currently $1800/month.
10/9/2014
Step 3: Income for the year
• Gunnar will be making $1800/month
($21,600)
• Scarlett made $870 in the beginning of the
year, and will make $580/month from JuneDec ($7,830)
• Combined income for 2014: $29,430 (under
150% FPL)
10/9/2014
So who’s eligible for what?
• Dierks?
– TennCare!
– Call Tennessee Health Connection to get him on.
• Gunnar and Scarlett?
– PTCs and CSRs!
– Gunnar and Scarlett could get a plan that costs
$88/month.
10/9/2014
Practice Tips
• A pregnant woman’s household includes herself and all
her unborn children – but only for her household.
• A pregnant woman must complete her TennCare
application before her PE ends.
• A baby born to a mom on TennCare should get
TennCare for 1 year, even if the family’s income
changes.
• If a family doesn’t know if their income will change,
they should think about taking less APTCs, so they
won’t have to pay back at the end of the year.
10/9/2014
Scenario #5: Layla & Will
• Layla and Will are married with 1 daughter,
Miranda.
• Layla is 3 months pregnant and an undocumented
Canadian immigrant. Will has had his green card
for 3 years and is also a Canadian immigrant.
• Miranda is 2 years old and was born in the U.S.
• Layla is a stay-at-home mother. Will works full-time
as a bartender. He makes around $24,000 (gross) a
year. This is the family’s only source of income.
• Layla and Will are uninsured. Miranda has had
TennCare since birth, and she gets food stamps.
10/9/2014
What are
Layla and
Will eligible
for?
Step 1: Quick Screen
Quick mental screen: who are we looking at?
TennCare is only
available for
folks who have
had legal status
in the US for 5
years. Will is in
the “5-yearbar.”
Children
Pregnant women
Parents/Caretaker Relatives
Folks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Step 2: Household
What is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)
Will
Layla
Miranda
Will
✔
✔
✔
Layla
✔
✔
✔
Miranda
✔
✔
✔
Baby
✔
What is the household size for each person for Marketplace purposes?
Will, Layla, and Miranda are all in each other’s households.
10/9/2014
Step 3: Income
Income for household of 3 is $24,000/year, or $2,000/month.
Will
Layla
10/9/2014
So who’s eligible for what?
• Layla?
– CoverKids!
– She should apply on covertn.gov
• Will?
– PTCs and CSRs!
10/9/2014
Advocacy Tips
• When Layla’s baby is born, she should call
CoverKids to get the newborn on CoverKids for
one year from when Layla got on CoverKids.
– The newborn’s coverage will date back to date of
birth.
– CoverKids will determine whether the child should be
on TennCare or CoverKids, and will facilitate the
enrollment in either category.
• Layla will lose her CoverKids 60 days after
delivery. She should contact HAT for assistance
getting affordable medical services and
prescriptions.
10/9/2014
Y’all are amazing.
Thank you all for joining us.
Post-test time!
Then, stick around for lunch, and to ask any extra
burning questions.
We’re here to help!
Katie: kalexander@tnjustice.org
Rachel: rclifton@tnjustice.org
Chris: ccoleman@tnjustice.org
John: jorzechowski@tnjustice.org
Rob: rwatkins@tnjustice.org
10/9/2014
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