2014
Reference Guide for Indiana Navigators
Version 1.0
October 2014
Published by:
Indiana Primary Health Care
Association
429 N. Pennsylvania Street, Ste 333
Indianapolis, Indiana 46204
www.indianapca.org
With generous support from
The Health Foundation of Greater
Indianapolis
Table of Contents
Becoming an Indiana Navigator and Certified Application Counselor ......................................... 6
Introduction to Consumer Assistants ...................................................................................... 6
Main Types of Consumer Assistants in Indiana .......................................................................... 6
Indiana Navigators.................................................................................................................. 6
Responsibilities ................................................................................................................... 6
Certification Steps ............................................................................................................... 6
Renewal Steps .................................................................................................................... 7
Reporting Requirements ..................................................................................................... 7
Conflict of Interest Policy ..................................................................................................... 7
Privacy, Security and Confidentiality Standards .................................................................. 7
Application Organization (AO) ................................................................................................ 8
Initial Application Steps ....................................................................................................... 8
Annual Renewal Process .................................................................................................... 8
Federal Navigators ................................................................................................................. 8
Certified Application Counselors ............................................................................................. 8
Responsibilities ................................................................................................................... 9
Certification Steps ............................................................................................................... 9
Ethical Standards for Assisters ............................................................................................... 9
Serving Different Cultures and Languages ............................................................................10
Serving Persons with Disabilities ...........................................................................................10
Educating Consumers and Peers about Health Insurance ........................................................11
Health Insurance Literacy Barriers.........................................................................................11
Health Insurance Terms to Know...........................................................................................11
Coinsurance.......................................................................................................................11
Copayment ........................................................................................................................11
Cost Sharing Reduction (CSR) ..........................................................................................11
Deductible ..........................................................................................................................12
Essential Health Benefits (EHBs) .......................................................................................12
Explanation of Benefits (EOB)............................................................................................12
Health Maintenance Organization (HMO)...........................................................................12
Minimum Essential Coverage (MEC) .................................................................................12
Open Enrollment Period .....................................................................................................12
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Out-of-pocket Maximum .....................................................................................................12
Provider Organization (PPO)..............................................................................................12
Premium ............................................................................................................................12
Premium Tax Credit (PTC) .................................................................................................13
Explaining Health Insurance Processes to Consumers..........................................................13
Appealing an Insurance Company’s decision .....................................................................13
Appealing the Marketplace’s Decision ................................................................................13
Reporting Life Changes ......................................................................................................13
Choosing a Health Plan ......................................................................................................14
Educating Our Peers on Assister Roles ....................................................................................14
Explaining Your Role .............................................................................................................14
Educating and Utilizing Your Organization’s Staff ..................................................................14
Assisting Immigrants with Health Coverage Applications ..........................................................16
Eligible Immigration Statuses ................................................................................................16
Lawfully Present Immigrants and Medicaid ............................................................................16
Undocumented Immigrants....................................................................................................17
Disclosure of Immigration Status ...........................................................................................17
Identity Verification on the Marketplace .................................................................................17
Required Documentation for ID Verification .......................................................................17
Mixed-Status Families ...........................................................................................................18
Tips for Assisting Mixed-Status Families ............................................................................18
Individual Taxpayer Identification Numbers (ITINs) ...............................................................18
The Assister’s Guide to Tax Rules ............................................................................................20
Determining Eligibility Based on Income ................................................................................20
Tax-Related Elements of the Marketplace Application ...........................................................20
Who Must File Taxes? ...........................................................................................................20
Tax Elements Defined ...........................................................................................................21
Earned Income ..................................................................................................................21
Head of Household ............................................................................................................21
Gross Income ....................................................................................................................21
Married Filing Jointly ..........................................................................................................21
Married Filing Separately ...................................................................................................21
Modified Adjusted Gross Income (MAGI) ...........................................................................21
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Single.................................................................................................................................21
Unearned Income ..............................................................................................................22
Qualifying Child ..................................................................................................................22
Qualifying Relative .............................................................................................................22
Qualifying Widow(er) with Dependent Children ..................................................................23
Rules for Claiming a Dependent ............................................................................................23
Navigating the Federal Marketplace ..........................................................................................24
Basics of Patient Protection and Affordable Care Act (ACA) ..................................................24
Consolidated Omnibus Budget Reconciliation Act (COBRA) ..............................................24
Catastrophic Coverage ......................................................................................................24
Cost-sharing Reduction Program (CSR) ............................................................................24
Excepted Benefit Plans ......................................................................................................24
Exemptions ........................................................................................................................25
Grandfathered Plans ..........................................................................................................25
Individual Mandate (Individual Shared Responsibility Requirement) ..................................26
Minimum Essential Coverage.............................................................................................26
Metal Levels (Actuarial Value)............................................................................................26
Modified Adjusted Gross Income .......................................................................................26
Open Enrollment Period .....................................................................................................27
Premium Tax Credit (PTC) .................................................................................................27
Qualified Health Plans (QHPs) ...........................................................................................28
Rating Rules ......................................................................................................................28
Shared Responsibility Payment .........................................................................................28
Special Enrollment Period (SEP) .......................................................................................29
Student Health Insurance...................................................................................................30
Assisting Consumers with Marketplace Applications .............................................................30
Screening Consumers........................................................................................................30
Reporting Household Size .................................................................................................31
Estimating Income .............................................................................................................31
Disability Questions ...........................................................................................................31
Employer-Sponsored Coverage Questions ........................................................................31
Coverage Effective Dates ..................................................................................................32
Helping Consumers Maintain Coverage ................................................................................32
3
Choosing a plan .................................................................................................................32
Reporting Life Changes .....................................................................................................32
Paying Premiums ...............................................................................................................33
Annual Redeterminations ...................................................................................................33
Terminating a Health Coverage Plan .................................................................................34
Appealing a Health Coverage Decision ..............................................................................34
Hot Topic: Same-Sex Spouses ..............................................................................................35
Resources for Addressing Consumer Needs .........................................................................35
Small Business Health Options Program (SHOP) .....................................................................36
What is the Small Business Health Options Program (SHOP)? .............................................36
Employer Mandate—Employer Shared Responsibility Provision ...........................................36
How SHOP Will Work in OE2 ................................................................................................36
2014 SHOP Guidelines .........................................................................................................37
2015 SHOP Guidelines .........................................................................................................37
2016 SHOP Guidelines .........................................................................................................37
Calculating Full-time Equivalent Employees ..........................................................................37
Minimum Participation Rate for SHOP ...................................................................................37
Benefits of SHOP ..................................................................................................................37
Appealing a SHOP Decision ..................................................................................................38
Small Business Health Care Tax Credit .................................................................................38
Tips for Assisting SHOP Consumers .....................................................................................38
SHOP Resources for Assisters ..............................................................................................38
Indiana Health Coverage Programs ..........................................................................................40
What is Medicaid? .................................................................................................................40
Federal Poverty Level (FPL) ..................................................................................................40
Indiana’s Health Coverage Programs ....................................................................................40
Hoosier Healthwise ............................................................................................................41
Children’s Health Insurance Program (CHIP) .....................................................................41
Healthy Indiana Plan (HIP) .................................................................................................41
Managed Care Entities.......................................................................................................42
Primary Medical Provider ...................................................................................................43
Care Select ........................................................................................................................43
Traditional Medicaid ...........................................................................................................43
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Medicaid for Employees with Disabilities (M.E.D. Works) ...................................................44
590 Program ......................................................................................................................45
Home and Community Based Waivers ...............................................................................45
Behavioral and Primary Healthcare Coordination Program (BPHC) ...................................46
Medicare Savings Program ................................................................................................46
Family Planning Program ...................................................................................................47
Breast and Cervical Cancer Program (BCCP) ....................................................................47
1634 Transition ..................................................................................................................47
Presumptive Eligibility (PE) ................................................................................................48
Indiana Application for Health Coverage................................................................................49
Authorized Representatives (AR) .......................................................................................49
Eligibility Notices ................................................................................................................49
Eligibility Appeals ...............................................................................................................49
Eligibility Redeterminations ................................................................................................50
Reporting Changes ............................................................................................................50
Application Methods ...........................................................................................................50
Effective Outreach & Enrollment Coverage ...............................................................................52
Strengthen Your Team .......................................................................................................52
Strengthen Your Community ..............................................................................................52
Collaborate and Brainstorm ...............................................................................................52
Strategize and Plan............................................................................................................52
Continue Educating and Assisting Consumers ...................................................................53
Relaying the Important of Health Coverage........................................................................54
Promising Best Practices .......................................................................................................54
5
Becoming an Indiana Navigator and Certified Application Counselor
Introduction to Consumer Assistants
With the launch of the Patient Protection and Affordable Care Act (PPACA),
Consumer Assistants such as Indiana Navigators and Certified Application
Counselors (CACs) were introduced and designed to serve as unbiased,
informed resources for consumers seeking health coverage.
The ACA established basic training guidelines for assisters to follow regarding
addressing the needs of underserved and vulnerable populations, eligibility and
enrollment procedures, the range of public programs and qualified health plan (QHP) options
available, and proper handling of tax data and personal information.
Main Types of Consumer Assistants in Indiana
Indiana Navigators
All individuals doing Medicaid and Marketplace enrollments are required to become an Indiana
Navigator. Indiana Navigators are certified to help consumers complete applications for health
coverage including Medicaid and QHPs, and insurance affordability programs like Premium Tax
Credits (PTCs) and Cost-Sharing Reductions (CSRs) in Indiana.
Responsibilities
Consumer
outreach and
education
Assessing the
level and type of
consumer need
Assisting with
eligibility appeals
Assisting with
enrollment
Checking
consumer
enrollment status
Certification Steps
 Download and review the Training Content Manual, Score Report and Subject Matter
Content Outline.
 Complete Pre-Certification Training from an IDOI-approved Pre-Certification Training
Provider. The cost may vary based on the training source.
o A recommended provider is through IndianaNavigators.org for only $4.95.
 Submit online the New Application for Individual Indiana Navigator Certification
o Pay the non-refundable online application fee and processing fee.
 Review the Conflict of Interest Disclosure Policy and email the signed Conflict of Interest
Statement and Disclosure Form, Privacy & Security Agreement
 Complete a criminal background check ($7-$17 for Indiana Residents)
 Schedule, pay for, and pass the Indiana Navigator Certification Examination
 Email all application materials to: Navigator@idoi.in.gov
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All Navigators receive a unique ID number upon successful completion of all steps. A certificate
may be requested by emailing Navigator@idoi.in.gov.
Renewal Steps
60 days prior to the renewal deadline, Indiana Navigators will receive a notice to renew
no later than the last day of the anniversary month of the original certification date; the
following steps must be completed:
 Complete 2 hours of continuing education through an IDOI-approved Navigator CE
provider annually.
 Complete shorter application and pay filing and processing fees.
 Review the Conflict of Interest Policy and sign and submit new Conflict of Interest
Disclosure Form and Privacy and Security Agreement.
 Submit all materials to Navigator@idoi.in.gov.
Reporting Requirements
Navigators must inform the Indiana Department of Insurance (IDOI) of changes within 30 days:
Legal Name
Address
Criminal
History
Deliquent state
tax and/or child
support
payments
Security breaches or
improper disclosure of
consumer's PII no later
than 5 days following
the discovery
Conflict of Interest Policy
Conflicts of interest include personal or business interests that may influence the advice and
assistance the Indiana Navigator or AO provides to a consumer.
Financial
Receiving direct or indirect financial compensation or incentive for the enrollment of an
individual into a particular health coverage plan.
Loyalty
Having a direct or indirect relationship, through business or family, an
interest or relationship with a third party that forbids or prevents the
individual or organization from exercising unbiased judgment in the
best interest of consumer.
Privacy, Security and Confidentiality Standards
Indiana Navigators and AOs have access to some very personal
Tips for Protecting Personally
Identifiable Information (PII)
information. Due to the sensitivity of this information, Navigators
● Do not leave computer screen
and AO must agree to maintain the confidentiality of and protect
open
any information provided by the consumer in the process of
● Securely destroy and dispose of
applying for and enrolling in a qualified health plan (QHP) or
personal information
public health insurance program like HIP.
● Inform consumer of any security
breach
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Application Organization (AO)
An AO is an organization such as a community health center or FQHC that has employees
and/or volunteers assisting consumers with applications for Marketplace-based health plans,
insurance affordability programs and state-based health coverage programs like HIP and
Hoosier Healthwise.
 Initial Application Steps
 Complete the New Application for Application Organization Registration.
o Pay the online filing and processing fees.
 Multi-location organizations registering as AOs must submit to IDOI the: (1) name, (2)
address, (3) telephone, (4) email, (5) website (if applicable), and (5) contact person;
for each physical location of the Application Organization. Applicants may check the
status of their application online at: www.sircon.com/login.html. (Only one application is
needed for an entity with multiple locations.)
 Review the Conflict of Interest Policy, then complete and submit the Conflict of Interest
Disclosure Form and Privacy and Security Agreement.
 Submit all documents to Navigator@idoi.in.gov
Annual Renewal Process
AOs have a 30-day grace period following the expiration date to complete all steps.
 Complete the Renewal Application for Application Organization Registration.
 Pay the nonrefundable online filing and processing fees.
 Multi-location organizations registering as AOs must submit to IDOI the: (1) name, (2)
address, (3) telephone, (4) email, (5) website (if applicable), and (5) contact person;
for each physical location of the Application Organization.
 Review the Conflict of Interest Policy and submit the Conflict of Interest Disclosure
Form and Privacy and Security Agreement
 Submit all documents to Navigator@idoi.in.gov
Federal Navigators



Selected and funded by the federal government to serve in Federally-Facilitated (FFM)
or Partnership Marketplace states for one year (minimum).
Federal Navigators in Indiana are also required to become Indiana Navigators.
2014 Recipients of the federal grant include:
o Affiliated Services Providers of Indiana, Inc. (ASPIN): $693,444
o Plus One Enterprises, LTD, LLC: $116,342
o Indiana Family Health Council, Inc. (Indiana Department of Health, Indiana
Family and Social Services Administration, and the Department of Children):
$755,304
o Madison County Community Health Centers, Inc.: $110,323
Certified Application Counselors
•
•
Organizations receiving HRSA funding must become a Certified Application Counselor
(CAC) organization and designate staff as CACs.
CAC organizations (usually the AO) apply to and are designated by the Marketplace.
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o
•
•
The organization is responsible for assigning CAC numbers and training their
staff and volunteers as individual CACs.
The federal government provides the training and certification materials but does not
provide any funding for it.
CACs may not impose fees for assistance.
Responsibilities
Assist with
Marketplace
applications
Facilitate enrollment
of eligible individuals
in QHPs and
insurance affordability
programs
Disclose any conflicts
of interests and
comply with privacy
and security
agreements
Act in the best
interest of the
consumer
Abide by federal
standards
Certification Steps
 Complete Marketplace-approved training and pass all examinations.
 Enter into an agreement with the designated CAC organization regarding compliance with
federal standards.
 Disclose to the CAC organization any potential conflicts of interest.
The CAC organization will issue certificates once they have completed these requirements.
Did you
know?
Ethical Standards for Assisters
DO
Be honest regarding personal bias or
conflict of interest
Give complete and accurate
information
Admit when you don’t know the answer
Protect personal information
Be sensitive to different cultures
Use professional language
Empower consumer to make educated
choices
DO NOT
Make up or guess an answer to a
question
Ask anyone for more information than
absolutely necessary
Joke about sensitive physical, social or
cultural difference
Use derogatory or profane language
toward or about a consumer
Disclose personal information to
anyone not assisting with the
enrollment of the individual
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Serving Different Cultures and Languages
In Indiana, there are more than 100 languages spoken, so it is helpful to know what resources
are available for translation.
•
•
As of 2010, there are 262,198 speaking Spanish, 35,439 speaking
German, 16,473 speaking Chinese, 16,120 speaking Pennsylvania
Dutch and 14,063 speaking French in Indiana.
The Marketplace call center (1-800-318-2596) offers immediate
assistance in English and Spanish with a language line for other
options.
Serving Persons with Disabilities
In Indiana, it is most likely that consumer assistants will work with individuals that have a type of
disability. You should be prepared to:
•
•
•
•
•
Ensure consumer education materials, websites, etc. are accessible to all
Provide assistance in a location & in a manner physically accessible
Ensure authorized representatives are able to assist with decisions
Be able to refer people with disabilities to local, state, and federal support
services
Be able to work with individuals regardless of age, disability, or culture
Notes:
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Educating Consumers and Peers about Health Insurance
Health Insurance Literacy Barriers
Only 12 percent of adults have proficient health literacy, according to the National Assessment
of Adult Literacy, and many Americans cannot correctly define common
financial terms related to health insurance like copay or
deductible.i People of all ages, races, incomes and education
levels struggle with limited health literacy, but the groups who
struggle the most are older adults, recent immigrants, people
with low incomes, and those enrolled in Medicare or Medicaid.
Jargon and technical language make it harder for consumers to enroll and retain health
coverage, and many people also face linguistic and cultural barriers. These factors are a recipe
for missed deadlines and appointments, misunderstood instructions, and poor understanding
and management of chronic diseases. Low health literacy is associated with reduced use of
preventive services and management of chronic conditions, unnecessary ER visits, and higher
mortality. This costs the US Economy between $106 billion and $236 billion annually!ii
Health Insurance Terms to Know
Coinsurance
Percentage of allowed charges for covered services that you are required to pay after you have
fulfilled the deductible.
Copayment
A fixed amount you pay for a covered health care service, usually when you receive the service.
The amount can vary by the type of covered health care service.
Cost Sharing Reduction (CSR)
A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance,
and copayments. CSR subsidies are automatically applied on the federal Marketplace for
individuals and families with income between 100 and 250% of the federal poverty level
($11,670-$29,175 for an individual in 2014). A silver plan must be selected for CSR eligibility.
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Deductible
The amount you owe for health care services your health insurance or plan covers before your
health insurance or plan begins to pay.
Essential Health Benefits (EHBs)
Marketplace plans must include health benefits in at least
these 10 categories.
Explanation of Benefits (EOB)
Summary of health care charges that your health plan sends
you after you see a provider or get a service.
Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to
care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network
care except in an emergency. An HMO may require you to live or work in its service area to be
eligible for coverage
Minimum Essential Coverage (MEC)
The type of coverage an individual needs to have to meet the individual responsibility
requirement (individual mandate) under the Affordable Care Act (ACA). A person without
coverage may have to pay the individual shared responsibility fee for each month they are
without coverage or do not have an exemption.
Open Enrollment Period
An annual period of time designated for the purchase of health coverage. The 2014-2015 Open
Enrollment Period is November 15, 2014 - February 15, 2015.
Out-of-pocket Maximum
The most you pay during a policy period (usually a year) before your health insurance or plan
begins to pay 100% of the allowed amount.
Individuals
Families
2015 Out-of-Pocket Maximums
Individual Market
Small Group Market
$6,600
$2,050
$13,200
$4,100
Provider Organization (PPO)
A type of plan that contracts with medical providers, such as hospitals and doctors, to create a
network of participating providers. You pay less if you use providers that belong to the plan’s
network, and you can use doctors, hospitals and providers outside of the network for an
additional cost.
Premium
The amount that must be paid monthly, quarterly or yearly for health insurance. A consumer
must pay the first month’s premium by the insurer’s deadline to avoid plan termination. Monthly
12
premiums are based on several factors including age, tobacco status, location, how many
people are enrolling on the same plan, and the insurance company.
Premium Tax Credit (PTC)
Consumers between 100-400% of the federal poverty level qualify for the Premium Tax Credit
(PTC), which is only available only through the Marketplace. Consumers can elect to have all or
some of the PTC paid directly to the plan on a monthly basis, or they can choose to claim the
full amount on their tax return.
Explaining Health Insurance Processes to Consumers
Appealing an Insurance Company’s decision
Insurers must tell consumers why they’ve denied any claim or ended coverage, and they must
inform about the appeals process. There are two ways to appeal a health plan decision:
1. Internal Appeal: a consumer may ask their insurance company to conduct a full and fair
review of its decision. If the case is urgent, the insurance company must speed up this
process.
2. External Review: a consumer has the right to take their appeal to an independent third
party for review. The insurance company no longer gets the final say over whether to pay
a claim
Appealing the Marketplace’s Decision
A consumer may file an appeal for the following types of Marketplace decisions:
Eligibility to buy a
Marketplace plan
Eligibility for a
special enrollment
period
Eligibility for lower
costs based on
income
The amount of
savings the
consumer is
eligible for
Eligibility for
Medicaid or CHIP
Eligibility for Eligibility
for an exemption from
the individual
responsibility
requirement or CHIP
He or she can write a letter to the Marketplace or use an appeal request form for Indiana;
appeal decisions are made within 90 days.
Reporting Life Changes
It is extremely important to remind consumers that they must report changes such as:




Marriage, divorce or death of a spouse
Birth, adoption or placement of a child
A permanent move outside insurer’s coverage area
Involuntarily losing health coverage from events
such as end of job-based coverage, losing eligibility
for Medicaid or CHIP, aging off a parent’s policy,
COBRA expiration, decertification of a health plan
 A change in income or household status that opens up
eligibility for premium tax credits or CSRs
 Change in citizenship status
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Helping Consumers
Understand Health Coverage
 Use familiar language
 Check for understanding
 Use visuals and keep
the conversation
interactive
 Facilitate healthy
decision-making
Choosing a Health Plan
Encourage consumers to compare
plans based on what is covered and
their needs, preferences (hospitals,
doctors, etc.), costs, and actuarial
value. Someone expecting to have a
lot of health care visits or regular
prescriptions may be better off with
a Gold or Platinum plan that pays a higher percentage of the costs. On the other hand, a
healthy individual who does not expect to have many health care bills may be comfortable
choosing a Bronze or Silver plan.
Educating Our Peers on Assister Roles
Explaining Your Role
Of course you are explaining what a Navigator is to your clients, but both clinical and nonclinical staff in your health center can benefit from knowing more about your position and
responsibilities as a Navigator and CAC. Tell everyone that you are:
 A trained and certified professional through the Indiana Department of Insurance (and
Centers for Medicare and Medicaid Services if applicable)
 Prepared and capable to determine coverage eligibility, assist with coverage
applications, answer questions about health insurance, and plan or participate in
outreach events
 Willing to connect individuals to different resources and information in the healthcare
system and your community
Educating and Utilizing Your Organization’s Staff
It is important to let your colleagues know how low health literacy impacts your community and
how you can work together to improve access to affordable health care. Capitalize on individual
staff expertise by building an internal referral system for consumer questions and concerns—
know who to ask! Advocate for health insurance literacy in your organization by incorporating
health literacy in staff training and orientation, posting and sharing relevant resources, or by
creating a presentation on health literacy at your next staff meeting.
Other ideas include: hosting a workshop or panel discussion about
health insurance literacy, creating flashy, informative bulletin boards
in an area with a lot of foot traffic, promoting a contest for developing
a catchy phrase for encouraging consumers to enroll in coverage,
and involving the entire organization in planning a health literacy
outreach event.
Did you know October is Health Literacy Month? Use this month to
build awareness about the November open enrollment period, educate about health coverage
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options, and encourage consumers to commit to enrolling! There are many community festivals
and events during October as well as other health-related holidays to partner with such as
National Breast Cancer Awareness month, National Disability Employment Awareness Month,
National School Lunch Week (11-15th), Mental Illness Awareness Week (4-10th), and National
Child Health Day (4th).
Remember that consumers who understand health care information may:
•
•
•
•
•
•
Follow more fully instructions on medications
Call back less often
Visit less often
Have fewer hospitalizations
Have better health outcomes
Have increased patient satisfaction
Notes:
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Assisting Immigrants with Health Coverage Applications
Eligible Immigration Statuses
Lawful Permanent Resident
(LPR)
Paroled into U.S.
Asylee
Refugee
Conditional Entrant
granted before 1980
Temporary Protected
Status (TPS)
Lawful Temporary Resident
Resident of American
Samoa
Granted Withholding of
Deportation or Withholding of
Removal, under the
immigration laws or under the
Convention against Torture
(CAT)
Member of a federallyrecognized Indian tribe or
American Indian born in
Canada
Administrative order
staying removal issued
by the DHS
Individual with Nonimmigrant Status
(includes worker visas,
student visas, and
citizens of Micronesia,
the Marshall Islands,
and Palau)
Cuban/Haitian
Entrant
Deferred
Enforced
Departure
(DED)
Deferred Action
Status
Victim of
trafficking and
his/her spouse,
child, sibling,
or parent
Applicant for any of these statuses:
 Temporary Protected Status with Employment Authorization
 Special Immigrant Juvenile Status
 Victim of Trafficking Visa
 Adjustment to LPR Status
 Asylum
 Withholding of Deportation or Withholding of Removal, under the immigration laws or under the
Convention against Torture (CAT)
With Employment Authorization:
• Registry Applicants
• Order of Supervision
• Applicant for Cancellation of Removal or Suspension of Deportation
• Applicant for Legalization under IRCA
• Legalization under the LIFE Act
Lawfully Present Immigrants and Medicaid
Immigrants who entered the U.S. on or after August 22, 1996 must
meet the 5-year waiting period for Medicaid or CHIP coverage after
receiving a “qualified immigrant status.” People who don’t have eligible
immigration status and therefore aren’t eligible for Medicaid may get
Medicaid coverage for limited emergency services if they meet all other
Medicaid eligibility criteria.
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Undocumented Immigrants
The estimated 11 million immigrants living in the U.S. illegally are not eligible for federal
public benefits through the Affordable Care Act or Medicaid, and subsequently cannot buy
coverage through the Marketplace. They may continue to buy coverage on their own outside the
Marketplace and get limited services for an emergency medical condition through Medicaid, if
they are otherwise eligible for Medicaid in Indiana. In addition, they are not subject to the
individual shared responsibility requirement.
Citizens or lawfully present children of undocumented parents are eligible to purchase from the
Marketplace with advanced premium tax credits and cost-sharing reductions as well as
Medicaid and CHIP.
Disclosure of Immigration Status
The Marketplace and state Medicaid and CHIP agencies can’t require applicants to provide
information about the citizenship or immigration status of any family or household members who
are not applying for coverage. Only those applying are required to provide their SSN and
immigration/citizenship status, and states can’t deny benefits to an applicant because a family
or household member who isn't applying hasn’t disclosed his or her citizenship or immigration
status. People who aren’t seeking coverage for themselves won’t be asked about their
immigration status.
A Social Security number of a non-applicant may be requested to electronically verify household
income. If unavailable, other proof of income can be provided. Information about immigration
status may be used only to determine an individual’s eligibility.
Identity Verification on the Marketplace
When ID verification cannot be completed online a unique reference ID is provided.
Consumers may call the Experian Help Desk directly or with the Marketplace on a three-way
call. If language assistance is needed, then consumers can call the call center first and request
language assistance to call the Experian Help Desk.
When ID verification cannot be completed over the phone
consumers are required to mail or upload documents to their
Healthcare.gov account (manual process) to be verified by the
Marketplace in order to have access to and use their online
account. Be sure to include the reference ID number when
mailing to: Health Insurance Marketplace, 465 Industrial Blvd.,
London, KY 40750.
Required Documentation for ID Verification
Consumers can mail or upload copies of documents from the chart on the next page to verify
their identity on the Marketplace.
17
•
•
•
•
•
•
•
•
•
•
One of these:
Driver’s license
School ID card
Voter Registration Card
U.S. Military Card
U.S. Military Draft Record
Military Dependent ID Card
Tribal Card
Authentic Document from a Tribe
U.S.C.G Merchant Mariner Card
ID card issued by the federal, state,
or local government
• Including immigration
document and US passport
•
•
•
•
•
•
•
OR two of these:
U.S. Public Birth Record
Social Security Card
Marriage Certificate
Divorce Decree
Employee Identification Card
High School or College Diploma
Property Deed or Title
Mixed-Status Families
Mixed-status families are households made up of individuals with different citizenship or
immigration statuses such as an undocumented mom, a “lawfully present” dad, an adolescent
granted deferred action through DACA, and a child who is a U.S. citizen because he or she was
born in the United States. According to the National Immigration Law Center, “As of 2010,
nearly one in four children younger than eight years old had at least one immigrant parent.”
Mixed-status families are less likely to enroll because eligibility rules divide them. Remember
that the Marketplace can’t require applicants to provide information about citizenship or
immigration status of any household members who are not applying for coverage.
Tips for Assisting Mixed-Status Families
 Inform consumers that information obtained on the Marketplace application cannot be
used by the Immigration and Customs Enforcement (ICE) Department of Homeland
Security (DHS) for immigration enforcement purposes.
 Agencies can collect, use and disclose only the information strictly necessary for
enrollment in health coverage.
 Medicaid and Marketplace subsidies are not considered in screening green card
applicants for public charge.
 The Call Center can connect language lines for immediate interpretation into 150
languages.
Individual Taxpayer Identification Numbers (ITINs)
ITINs (Individual Taxpayer Identification Numbers) are issued by the IRS to people who are
ineligible for SSNs but who need to file tax returns. Other lawfully present immigrants who are
ineligible for or who may not have an SSN include people in “nonimmigrant” categories whose
visas do not permit them to work, some children under 14 years old whose application for
asylum or withholding of deportation/removal has been pending for 180 days, and some
children who have applied for Special Immigrant Juvenile status.
18
Notes:
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19
The Assister’s Guide to Tax Rules
Determining Eligibility Based on Income
Marketplace
•Premium tax credits follow tax rules in determining
households
•A premium tax credit household is the same as the tax unit
•Considers projected annual income
Indiana Health Coverage
Programs/Medicaid
•Uses a person’s status as a tax filer, tax dependent, or nonfiler to determine who is in the individual’s household and
whose income is counted
•Considers current monthly income
Tax-Related Elements of the Marketplace Application
Whether the applicant files
taxes:
People receiving the premium
tax credit (PTC) must agree to
file taxes for the year after they
receive advanced payments.
Who is in the applicant’s
household:
Determining who is in a
household requires knowledge
of the filing status used on the
applicant’s tax return and how
many dependents can be
claimed.
What the applicant’s
household income is:
A household’s total income is
the MAGI of everyone in the
household with a tax filing
requirement, including any
dependents required to file.
Who Must File Taxes?
Minimum Income Requirements to File a Federal Tax Return
If filing status is…
And age at the end of the
year was…
Then Required to file a return if gross
income was at least…
Single
Under 65
$10,000
65 or older
$11,500
Under 65
$12,850
65 or older
$14,350
Under 65 (both spouses)
$20,000
65 or older (one spouse)
$21,200
65 or older (both spouses)
$22,400
Married, Filing Separately
Any age
$3,900
Qualifying Widow(er) with
Dependent Child(ren)
Under 65
$16,100
65 or older
$17,300
Head of Household
Married, Filing Jointly
20
Tax Elements Defined
Earned Income
Includes salaries, wages, tips, professional fees and taxable scholarship and fellowship grants.
Head of Household
Unmarried or considered unmarried for tax purposes and pays more than half the costs of
keeping up home for a qualifying dependent. A married person can file as Head of Household if
he or she can answer YES to each of the following questions:
1.
2.
3.
4.
Will you file taxes separate from your spouse in the year which the PTC is received?
Will you live separately from your spouse from July 1 to December 31 in that year?
Will you pay more than half of the cost of keeping up your home in that year?
Do you have a child, stepchild, or foster child (of any age) who lives with you more than
half the year?
5. Will either you or the child’s other parent claim the child as a dependent?
Gross Income
All income received in the form of money, goods, property and services that is NOT exempt
from tax. It includes earned income, unearned income, and gains but not losses. It does not
include Social Security benefits unless the person is married and filing a separate return and
lived with the spouse at any time during 2014 OR half of the person’s Social Security benefits
plus other gross income and any tax-exempt interest is more than $25,000 ($32,000 if married
filing jointly).
Married Filing Jointly
Legally married, living together or apart. This may occur because one spouse is not available to
sign the return, the couple is separated and unwilling to file taxes jointly, or the couple is
together but they don’t want to be held jointly liable for each other’s taxes. These individuals
cannot claim the premium tax credit, but there are two exceptions: survivors of domestic
violence and abandoned spouses.
Married Filing Separately
Legally married, living together or apart. There is joint responsibility for any tax, interest or
penalty due on the return, including responsibility for the premium tax credits, even if only one
spouse qualifies for the credits.
Modified Adjusted Gross Income (MAGI)
The universal method used for calculating income eligibility for all insurance affordability
program. It is adjusted gross income + tax excluded foreign earned income + tax exempt
interest + tax exempt Title II Social Security Income.
Single
Unmarried, or legally separated or divorced on the last day of the tax year.
21
Unearned Income
Includes interest, ordinary dividends, capital gain distributions, unemployment compensation,
taxable Social Security benefits, pensions, annuities, cancellation of debt, and distributions of
unearned income from a trust.
Qualifying Child
In general, a child can be claimed as a qualifying child if he or she is:
 A U.S. Citizen or resident of the U.S., Canada, or Mexico
 Lives with the tax filer for more than half the year
 Is under the age of 19 at the end of the year (of 24 if a full-time student or any age if
disabled
 Doesn’t provide more than half of his or her own support
Rules for Claiming a Qualifying Child
Relationship—child must be:
 Biological, adopted, foster, or stepchild of the taxpayer
 Brother or sister (including half- and step-siblings of the taxpayer;
 OR niece, nephew, or grandchild of the taxpayer
Age—at the end of the tax year, the child must be:
 Under age 19 and younger than the taxpayer
 Under age 24, if a full-time student for at least five months of the year and younger than
the taxpayer
 Any age if permanently and totally disabled
Residence—child must live with the taxpayer for more than half the year
 Temporary absences, such as a child who attends college and is living away from home,
are considered time in the parents’ home
 There are exemptions for children of divorced or separated parents or parents who live
apart:
o Parents may agree that the noncustodial parent will claim the child, even if the
child lived with the custodial parent for the majority of the year
o The custodial parent must agree and sign a tax form to allow the noncustodial
parent to claim the child
Support—child must not provide more than half of his or her own support
 Total support includes rent or fair rental value of the home, food, utilities and home
repairs, with costs equally divided between family members to decide the child’s portion.
o Expenses related to the child’s clothing, education, medical, travel and other
expenses are included
o State benefits such as TANF or food support are not included
 Includes all of the child’s taxable and nontaxable income such as wages, Social Security
benefits, student loans, and other income
Qualifying Relative
In general, a person can be claimed as a Qualifying Relative if he or she is:




A U.S. Citizen or resident of the U.S., Canada, or Mexico
Receives more than 50% of his support from the tax filer
Cannot be claimed as a Qualifying Child
Is related to the tax filer or lives in the tax filer’s home all year
22
 Makes less than $3,900 (in 2014). Generally doesn’t include Social Security.
Rules for Claiming a Qualifying Relative
 NOT a Qualifying Child
 Relationship—prospective dependent must either be related to the taxpayer or live in the
taxpayer’s home for the entire year
 Income—The prospective dependent must not have gross income greater than $3,900
 Support—The taxpayer must pay more than half the support of the prospective
dependent.
Qualifying Widow(er) with Dependent Children
Has a spouse that passed away in the previous two tax years with a qualifying child. If a spouse
dies during the tax year, the surviving spouse is considered married for the entire tax year. He
or she can file jointly or separately from their deceased spouse.
What should an assister tell a consumer whose marital status will change
during the year?
A person’s marital status is determined by whether he or she is single, married, legally
separated or divorced on the last day of the calendar year for which the person is filing a
tax return. Applicants for premium tax credits should provide their current filing status on
their application.
Rules for Claiming a Dependent
 The person claiming the dependent cannot be a dependent of another taxpayer
 If the prospective dependent is married, he or she can still be claimed as a dependent.
However, if the married dependent files a joint return with his or her spouse, the return
must be filed only to claim a refund of taxes paid during the year through wage
withholding
 The prospective dependent must be a U.S. citizen, resident or national or must be a
resident of Mexico or Canada
Notes:
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23
Navigating the Federal Marketplace
Basics of Patient Protection and Affordable Care Act (ACA)
The Patient Protection and Affordable Care Act (ACA) was passed on March 23, 2010 under the
Obama administration. This created a new avenue to purchase health insurance coverage—the
Marketplace, or Exchange which is managed by the U.S. Centers for Medicare & Medicaid
Service (CMS) and accessed through www.healthcare.gov. In addition, the law allows for tax
subsidies to help individuals afford coverage, enacted tax penalties associated with not having
health insurance, and restricted the time coverage is available for purchase. Other benefits of
the ACA include:
Eligible young adults
can be covered
under a parent’s plan
until age 26
Individuals with preexisting conditions
are no longer
excluded from
coverage offers
Lifetime and annual
maximums are
eliminated
Preventive and
wellness services are
mandated benefits
without any costsharing requirements
Common Terms Defined
Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA gives workers and their families who lose their health benefits the right to choose to
continue group health benefits provided by their group health plan for limited periods of time
under certain circumstances such as voluntary or involuntary job loss, reduction in the hours
worked, transition between jobs, or death, divorce, and other life events. Qualified individuals
may be required to pay the entire premium for coverage up to 102% of the cost to the plan.
Catastrophic Coverage
What is it?
Plans with high deductibles and lower
premiums
Consumer pays all medical costs up to a
certain amount
Includes 3 primary care visits per year and
preventive services with no out-of-pocket costs
Who is eligible?
Young adults under 30
Those who qualify for a hardship exemption
Those whose plan was cancelled and believe
Marketplace plans are unaffordable
Cost-sharing Reduction Program (CSR)
 Reduces out-of-pocket costs for consumers
 Increases the Actuarial Value (AV) of health coverage plans for low-income
consumers (below 250% FPL)
 Consumer must select at least a Silver plan
Excepted Benefit Plans
Plans that cover a specific service or condition and do not provide comprehensive health
coverage. They are not subject to many of the ACA market reforms. The most common is
stand-alone vision. Stand-alone dental plans are the only excepted benefit plans offered on the
Marketplace. They are:
24
x Not offered in the metal tier levels of QHP
 Subject to a $700 maximum out of pocket amount for a single individual and
$1,400 for family
 May be purchased using the APTC
x Not eligible for cost-sharing reductions
Exemptions
Individuals may seek an exemption from the shared responsibility requirement by applying for
one or more of the exemption types. To be eligible for an exemption in any month, the individual
must meet the criteria for the exemption for at least one day in that month.
Exemption
Method
Details
Exemption length
Recognized religious
sect member
Marketplace
Apply anytime within
the year
Continuous until reportable
change (e.g. turn 21)
Indian Tribe member
Marketplace or IRS
Tax Filing
Apply anytime within
the year
Continuous unless
reportable change
Health Care Sharing
Ministry
Marketplace or IRS
Tax Filing
Apply anytime within
the year
Months during membership
Incarceration
Marketplace or IRS
Tax Filing
Apply anytime within
the year
Month(s) in which in prison
or jail after conviction
Household income
below filing limit
IRS Tax Filing
Automatically
exempt if tax return
not filed
Calendar year
Inability to afford
coverage
IRS Tax Filing
Cost is ≥ 8% of
household income
Calendar year
Not lawfully present
IRS Tax Filing
Short coverage gaps
IRS Tax Filing
Until 1st full month that
immigration status has
changed
No coverage for less
than 3 months in a
row
The months without
coverage (up to 3)
Grandfathered Plans
Health plans in existence prior to the passage of the ACA that do not have to comply with some
provisions related to benefits, cost-sharing, pre-existing condition exclusions and annual
maximums. Plans may only maintain grandfathered status if they do not make substantial
changes to their policies. Individuals offered grandfathered coverage through an employer may
25
choose to not accept the coverage and purchase coverage that meets ACA requirements
instead.
Individual Mandate (Individual Shared Responsibility Requirement)
Affordable Care Act (ACA) condition requiring individuals to maintain health coverage for
themselves and their dependents; health coverage must be considered Minimum Essential
Coverage (MEC) as determined by the federal government. All Qualified Health Plans (QHPs)
on the Marketplace must cover certain the 10 Essential Health Benefits (EHBs) set for 20142015.
Minimum Essential Coverage
Coverage for one day in the month is considered to be coverage for the entire month.
Types of MEC
Coverage under a government sponsored program including:
 The Medicare Program
 The Medicaid Program
 The Children’s Health Insurance Program (CHIP)
 Veteran’s Administration programs including TriCare and CHAMP VA
 Coverage for Peace Corps Volunteers
 Coverage under an employer-sponsored health plan
 Coverage under a health plan offered in the individual market within a state
 Coverage under a grandfathered health plan
 Additional coverage as specified such as Refugee medical assistance and Medicare
advantage plans
Metal Levels (Actuarial Value)
The Marketplace offers four categories of Qualified Health Plans (QHPs), known as “Metal
Levels” which are distinguished by the share of health care costs QHP are expected to cover.
These four levels are indexed to actuarial value, or the percentage that insurance companies
will pay on average for the health services consumers use.
Metal Level
AV target
AV Band
Bronze
60%
58-62%
Silver
70%
68-72%
Gold
80%
78-82%
Platinum
90%
88-92%
Modified Adjusted Gross Income
Modified Adjusted Gross Income or MAGI is the figure used to determine eligibility for lower
costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income
is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income
you have.
26
Items NOT Counted for MAGI Income Eligibility
American Indian and Alaskan Native tribal income
Child support
Educational income (used for tuition and books)
SSI
Nominal cash support for dependents
Veterans’ benefits
Assets such as homes, stocks or retirement
accounts
Workers’ compensation
Income disregards (except tax deductions
and non-taxable income
Open Enrollment Period
Annual timeframe when consumers can purchase health coverage on the Marketplace. The
open enrollment period for 2014-2015 is November 15, 2014—February 15, 2015.
Premium Tax Credit (PTC)
 Lowers the monthly premium amount
 Can be used to purchase any plan on the federal Marketplace
 Can be paid directly to insurer (Advanced Payment)
 Available to consumers 100-400% of the Federal Poverty Level (FPL).
The amount of the premium tax credit (PTC) and the level of cost-sharing reductions (CSR) is
based on the applicant’s income. Income is expressed as a percentage of the federal poverty
level (FPL), which is updated each year and published by HHS.
PTC Eligibility
Must be a citizen, national,
or legal resident of the U.S.
Household income between
100% and 400% of FPL
No other Minimum Essential
Coverage is available or
available coverage has an
individual premium more
than 9.5% of household
income or does not provide
minimum value
Individuals can have the full amount of the PTC sent directly to the insurer as an advanced
payment option, elect to have partial payment with the potential of a tax credit at filing time, or
claim the entire amount later on their tax return. The amount that an individual may owe the IRS
due to an over payment of the APTC is capped, so individuals between 100% and 400% FPL
may owe no more than the amounts due to excess APTC payments (see next page).
27
APTC Repayment Caps
Household income
Single Individual
Family
< 200% FPL
$300
$600
200% to 300% FPL
$750
$1,500
300% to 400%
$1,250
$2,500
Qualified Health Plans (QHPs)
Plans sold on the Marketplace must be certified and accredited as QHPs and provide Minimum
Essential Coverage (MEC), cover Essential Health Benefits (EHBs), and meet Actuarial Value
(AV) and provider network standards. QHPs are the only plans that an individual can purchase
that are eligible for the Premium Tax Credit (PTC) or Cost-Sharing Reductions (CSRs).
Rating Rules
The ACA limits the factors that major medical plans can base the price of their plan on to age,
location and tobacco use.
Rating for Age
Limited to a 3 to 1 ratio—older adults may be charged no more than 3 times the
premium as younger adults.
3x
Rating for Location
The ACA allows insurers to adjust their premiums depending on enrollee’s location; there are 17
rating areas in Indiana.
Rating for Tobacco
Up to 1.5 times the premium for individuals that use tobacco. Tobacco use is
defined as use of any tobacco product on average four or more times per week
over the past six months. At no point may a rate increase for tobacco based on
age contradict the 3 to 1 age rating limit.
1.5x
Shared Responsibility Payment
Those who do not have MEC or an exemption will be required to pay a shared-responsibility
payment to the IRS upon tax filing. It is calculated on a monthly basis = 1/12 of the annual
penalty amounts, for each month without coverage. See the chart on the next page for more
details on the Shared Responsibility Payment.
28
Year
Penalty is the greater of:
Dollar Penalty, assessed for every
household member without MEC
2014
Maximum
Penalty
Percent Penalty
Adult: $95
1% of annual
household income
Under age 18: $48
Maximum: $285
2015
Adult: $325
2% of annual
household income
Under age 18: $163
Maximum: $975
2016
Adult: $695
3% of annual
household income
Maximum Shared
Responsibility
Payment:
National Average
Premium for a
QHP Bronze Plan
that would cover
the applicable
individual(s).
Under age 18: $348
Maximum: $2,085
Special Enrollment Period (SEP)
A time outside of the open enrollment period when a consumer can sign-up for health coverage.
In the Marketplace, an individual qualifies for a special enrollment period 60 days following
certain life events that involve a change in family status.
SEP Event
QHP Effective Date
Loss of coverage
If loss of coverage is in the past, 1st of the month
following QHP selection. If loss is in the future, 1st
of the month following loss of coverage
Marriage
1st of the next month following plan selection
Denial of Medicaid or CHIP
Birth, Adoption, Foster Care
Date of birth, adoption, placement of adoption or
placement in foster care
Gaining lawfully present status
Within first 15 days of the month: 1st of the
following month
Newly eligible or ineligible for APTC, change in CSRs
Moving & Incarceration Release
Native American status
29
On or after the 16th of the month: 1st of the month
after next
Other Types of Special Enrollment Periods
 Material contract violations by qualified health plan
 Gaining or losing eligibility for PTC or change in eligibility for cost-sharing reductions
 Enrollment Errors of the Marketplace
o Consumer chose plan, but enrollment wasn’t processed on time, or insurance
carrier doesn’t have record of enrollment
 Exceptional circumstances
o Serious medical emergencies—unexpected hospitalization or cognitive
incapacitation or disability
 Misrepresentation
o Misconduct or misinformation by person(s) providing enrollment assistance
and/or failure to enroll; e.g. enrolled in wrong plan or found ineligible for
PTC or CSR due to error
 Married and victim of domestic violence
Student Health Insurance
Only self-funded student health coverage qualifies as MEC. Effective May 12, 2014, student
health plans are not required to be offered as a calendar year plan. Student health insurance is
exempt from the requirement to establish open enrollment period and coverage effective dates
based on a calendar policy year.
Assisting Consumers with Marketplace Applications
Screening Consumers
First of all, make sure you do these three things:
Introduce
yourself as a
Navigator
Explain your
role and how
you can help
Reveal any
potential
conflicts of
interest
Then you can proceed to determine their coverage options by:
Assessing knowledge:
Are the familiar with
ACA? Tax penalty?
PTCs?
Asking about:
- Household size
- Household income
- Plan to file taxes
- Coverage preferences
Answering questions:
Direct consumer to
additional resources
while keeping the focus
on the application
To purchase coverage on the
Marketplace, individuals must:
Remember!
- Be U.S. citizen or legal
resident
- Reside in the state they are
applying in
- Not be incarcerated
30
Reporting Household Size
Include
Do NOT Include

Consumer
x

Consumer’s spouse
x

Children who live with the consumer, even
if they make enough money to file a tax
return themselves
Unmarried partner needing health
coverage
Anyone claimed as a dependent on a tax
return, even if they don’t live with the
consumer
Anyone else under 21 who the consumer
lives with and takes care of
x



x
Unmarried partner who does not need
health coverage
Unmarried partner’s children, if they are not
consumer’s dependents
Parents living with the consumer, but file
their own tax return and are not
consumer’s dependents
Other relatives who file their own tax return
and are not the consumer’s dependents
Estimating Income
Include









Do NOT Include
Consumer’s and their spouse’s gross
income, if they are married and will file a
joint tax return
Any dependent’s gross income who is
required to file a tax return
Wages
Salaries
Tips
Net income from any self-employment or
business
Unemployment compensation
Social security payments, including
disability payments—but not SSI
Alimony
x
Child support
x
Gifts
x
x
x
x
Supplemental Security Income (SSI)
Veterans’ disability payments
Workers’ compensation
Proceeds from loans (like student loans,
home equity loans or bank loans)
Disability Questions
The consumer should answer “yes” to the Marketplace disability question if he or she and/or
other household members is blind, aged, or hard of hearing;
Activities of daily living
receives SSDI or SSI; has a physical, intellectual or mental health
Bending
Eating
condition causing: serious difficult completing activities of daily
Hearing
Lifting
living, difficulty doing errands, serious difficulty concentrating,
Thinking
Breathing
Sleeping
Standing
remembering or making decisions, and/or difficulty walking or
Seeing
Walking
climbing stairs.
Employer-Sponsored Coverage Questions
The Marketplace may require consumers who are currently employed with access to employersponsored coverage to enter additional information about who (with employer) to contact about
employee health coverage (usually HR); amount employee pays for premium cost; any known
changes in future employer coverage; and whether employer-sponsored coverage meets
31
minimum value (whether the policy covers at least 60% of healthcare costs for the covered pool,
on average, after premiums).
Coverage Effective Dates
The start date for federal Marketplace coverage is based on the date a consumer completes
enrollment in a QHP. A consumer is not considered enrolled in a QHP until they pay their
portion of the first month’s premium. In general coverage purchased by the 15th of the month is
effective the 1st of the next month, and coverage purchased after the 15th is effective the 1st of
the following month.
Helping Consumers Maintain Coverage
There are many reasons adults and children lose coverage despite their eligibility such as
administrative barriers, cost, or not knowing how to navigate the health coverage system. As an
asssister, you should help consumers understand their responsibilities as insured.
As an assister, you might help consumers with the following tasks:
Choosing a
health
coverage plan
How and when
to pay
premiums
How the annual
redetermination
process works
How and when
to report life
changes
Terminating a
plan
Appealing a
decision
Choosing a plan
Individuals can select a plan based on quality, covered benefits, covered providers, and
expected cost-sharing level. Remember to remain neutral as your help the consumer compare
plans and weigh their options for health coverage.
Reporting Life Changes
Once a consumer has Marketplace coverage, they are responsible for reporting certain life
changes which may change the coverage or savings they’re eligible for. These changes include:
Marriage or divorce
Having or adopting child or
placing child for adoption
Change in income
Changing place of
residence
Change in disability status
Gaining or losing a
dependent
Changes in tax filing status
Change in citizenship or
immigration status
Incarceration or release
Correction to name, date
or Social Security number
Other changes affecting income or household size
32
Getting health coverage
through Medicare or
Medicaid
Becoming pregnant
Change in status of
America Indian, Alaska
Native or tribal status
Reporting a change can occur through two methods:
Online
Log-in to account. Select the
application and report the life
change.
A new eligibility notice will be
generated that will explain
eligibility for a SEP.
By phone
Contact the Marketplace Call
Center, and a representative will
authorize the SEP.
Paying Premiums
If consumers do not pay their premiums, qualified health plans (QHPs) can cancel their
coverage. Consumers receiving the advanced premium tax credit (APTC) have a three-month
grace period before their coverage can be cancelled (as long as they have paid their premiums
for at least one month). Consumer must repay all outstanding premiums by end of grace period,
or QHP may cancel the coverage. Consumer may have to pay for all health care services
received during the second and third months of the grace period.
Annual Redeterminations
Historically, coverage loss at renewal is all too common in public health coverage programs like
Medicaid and CHIP. Some 8 million consumers will experience the Marketplace renewal
process this fall for the first time. Consumers should be strongly encouraged to use the open
enrollment period as an opportunity to update their information and reevaluate their health
coverage needs for the coming year.
2014 coverage ends
December 31, 2014 for
all Marketplace plans!
Remember!
The consumer’s insurer will send information prior to November 15th about updated premiums
and benefits. If consumer is happy with current plan and income or household size HAVE NOT
changed, she or he doesn’t need to do anything. The Marketplace will auto-enroll the
consumer in the same plan for 2015.
If a consumer wants to change plans, he or she can:
1. Choose any other Marketplace plan within the same insurer and service area if
she or he wants to stay with same company.
2. Choose a new health plan from a different insurance company through the
Marketplace.
3. Buy a new private plan outside the Marketplace. (Will not be eligible for PTC or
CSR)
In some cases, 2014 plans won’t be offered in 2015. These individuals will be automatically
enrolled in a similar plan unless he or she chooses another plan and enrolls. These individuals
will also be eligible for an SEP because their plan is ending.
33
For an enrollee who did not authorize the Marketplace to request updated tax return
information for use in the annual redetermination process (reportedly about 100,000
individuals):


For those receiving APTC and CSR, a notice will be mailed that unless the
individual contacts the Marketplace to obtain an updated eligibility determination
by December 15th for coverage effective January 1, 2015, APTC and CSR will
end on December 31, 2014.
The Marketplace will renew the enrollee’s coverage in a QHP for 2015 without
APTC and CSR if coverage is otherwise renewable.
For individuals found in excess of 500% FPL:
Individuals who are enrolled in a Marketplace QHP with APTC or CSR who authorized the
Marketplace to request updated tax information will receive the standard notice, and they will be
told that if they do not contact the Marketplace to update their information they will be
terminated from PTC and CSR and reenrolled in their QHP without assistance if the plan is
renewable. Individuals must report eligibility changes by December 15, 2014 to receive an
updated eligibility determination.
Tips for Educating Consumers about the Renewal Process
Establish a systematic way for staff to remind consumers about their coverage renewal
date and/or the open enrollment period
Add an alert to medical records that staff can see when patients come in for appointments
Use social media to promote messages that inform about reporting life changes and
renewal processes
Use appointment cards, posters and mailings to communicate with patients at time of
renewal
Develop materials geared toward your clients that highlight the key aspects of the renewal
process
Terminating a Health Coverage Plan
Individuals may terminate their enrollment in a Qualified Health Plan (QHP) at any time. To
terminate enrollment in a QHP the individual should contact their qualified health plan directly.
QHPs may terminate enrollees for non-payment of premiums, enrollment in another QHP, or
fraud.
Appealing a Health Coverage Decision
Individuals that believe their eligibility determination for a QHP, or eligibility for APTC or CSR is
incorrect should contact the federal Marketplace to file an appeal. Individuals may file appeals
for up to three years after they experienced the triggering event.
Individuals that believe they have been denied a provider or service they should have had
access to through their QHP, should contact the plan administrator as soon as possible.
Individuals who do not feel their situation is resolved through the QHP grievance procedure may
request an appeal from the QHP issuer.
34
Hot Topic: Same-Sex Spouses
Beginning January 1, 2015, a health insurance issuer cannot deny coverage options to samesex spouses under the same terms and conditions as coverage offered to opposite sex-spouses
if the marriage was legitimately entered into in a jurisdiction where the laws permit the marriage
of two individuals of the same sex, regardless of the jurisdiction in which the insurance policy is
issued or where the policyholder resides. Same-sex spouses will also receive premium tax
credits and cost-sharing reductions, as applicable.
Resources for Addressing Consumer Needs
Need or Concern
Resource(s)
The Affordable Care Act
Federal Marketplace call center: 1-800-318-2596
Health plan details
Health plan summary of benefits, insurance carrier, Employer’s Human
Resources of Benefits Manager
Plan recommendations
IDOI—research “Find agent/broker”
Plan quality
Federal Marketplace researching, “Consumer Experience”
Complaints about a Consumer
Assistant
IDOI
Complaints about Health
Insurance Plan
Find another Navigator
1st : Contact health insurance company
2nd: If unable to resolve the issue with health insurance company, contact IDOI
•
•
IDOI—”Find an Indiana Navigator or AO in Your County”
Enroll America locator tool
Notes:
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35
Small Business Health Options Program (SHOP)
_________________________________________________________________________
What is the Small Business Health Options Program (SHOP)?
The SHOP Marketplace is an avenue on the federal Marketplace for small businesses to
purchase health insurance coverage for employees. SHOP:
• Simplifies the process of buying health insurance
• Helps curb premium growth and spurs competition based on price and quality
• Provides access to a small business tax credit
Certified enrollment specialists are permitted to assist employers with SHOP. Federal
Navigators are required to assist with SHOP, but CACs are not.
Employer Mandate—Employer Shared Responsibility Provision
Starting in 2015, employers with over 50 full-time equivalent employees or a combination of fulltime and part-time equivalent employees will be subject to the employer shared responsibility
provision, or employer mandate. These employers will be subject to a fine collected by the IRS
for each month they have one or more full-time employees receiving a Premium Tax Credit
(PTC).
• Employees can only get PTC if employer-sponsored coverage is not offered or it is
considered unaffordable (greater than 9.5% of the employees’ household income)
• Employers will not be subject to the shared-responsibility payment if employees that
work on average less than 30 hours a week receive a PTC.
Employers offering coverage to at least
95% of full-time employees
Employers not offering coverage to
at least 95% of full-time employees
Penalty is the lesser of:


$250 per month or $3,000 per year
for each full-time employee
receiving a Premium Tax Credit, or
$167 per month or $2,000 per year
for every full-time employee and
full-time equivalent employee,
excluding the first 30 employees

$167 per month or $2,000 per year
for every full-time employee and fulltime equivalent employee, excluding
the first 30 employees
How SHOP Will Work in OE2
The SHOP Marketplace is open to employers that meet the following requirements:
Have at least 1
common-law employee
on payroll (cannot be a
spouse)
Offer coverage to all
full-time employees
working more than 30
hours a week
Meet the 70%
participation rate of fulltime employees offered
coverage (does not
include spouses or
dependents, if offered)*
* The requirement is waived between November 15th and December 15th of each year
36
2014 SHOP Guidelines
The employer must set a contribution level and select a plan for their employees. Employers will
pay their portion and their employee’s portion of premiums for their group coverage directly to
the insurer that issues the coverage.
2015 SHOP Guidelines
Beginning in 2015, the employer will select a metal coverage level (bronze, silver, gold, or
platinum), as well as a reference plan within that coverage level. The employer and employees
portions of the premium will go directly to the SHOP Marketplace.
2016 SHOP Guidelines
Beginning in 2016, SHOP will be open to employers with up to 100 FTEs. Employers that enroll
in SHOP coverage and then grow past the small group limit for employees may continue with
their SHOP coverage, and renew their SHOP coverage.
Calculating Full-time Equivalent Employees
To calculate full-time equivalent employees (FTEs):
• Use the most recent year
• Exclude seasonal employees (those working <120 day a year)
• Count the number of people who worked an average of 30+ hours a week
• Add this amount to the number of hours worked per week by non-full time employees
divided by 30
Minimum Participation Rate for SHOP
What if a business does not reach the minimum participation rate?
1. Change offer of coverage
 e.g. Increase the amount the employer contributes to the employees’ insurance
premiums to encourage more participation
 Change of offer cancels current offer, and the process starts over with a new
enrollment period
2. Enroll between November 15th and December 15th. The minimum participation
requirement does NOT apply during this annual enrollment period.
3. Completely withdraw offer of coverage.
An employer can reapply at any time during the same calendar year if minimum participation
was not met. Mid-year changes in participation do not affect ability to maintain coverage.
Benefits of SHOP
 Apply year-round.
 Control the coverage offered and how much is paid toward employee premiums.
 Choose from the four tiers of coverage to find a plan that meets the needs of the
business and employees.
 Start coverage any time.
 Establish own open enrollment period of at least 30 days.
 Same coverage start dates on the individual Marketplace apply in SHOP.
 SHOP coverage for businesses with fewer than 25 employees may qualify for a
small business health care tax credit.
37
Appealing a SHOP Decision
SHOP eligibility is determined within 3-5 days of receiving a completed application. Employers
have 90 days from the date of the notice to request an appeal and can appeal SHOP decisions
in 2 cases:
1. Receiving a notice that denies SHOP eligibility
2. The SHOP Marketplace hasn’t made a SHOP eligibility determination in a timely
manner
Appeal request form should be mailed, or a letter should be written including name, address,
phone number and explanation. If the appeal determines eligibility for SHOP, the decision must
be retroactive to the date the incorrect determination was made.
Small Business Health Care Tax Credit
Business must have an official eligibility determination from the SHOP Marketplace before the
end of 2014. Employer claims the tax credit when submitting federal income tax returns for 2015
using form 8941. To qualify, 50% of the full-time employees’ premium costs must be paid by the
employer. The tax credit is worth up to 50% of the employer’s premium contribution (up to 35%
for tax-exempt employers). Businesses with < 25 employees making an average of ≤ $50,000
may qualify for tax credits if purchasing through SHOP.
Tips for Assisting SHOP Consumers
Prescreen employers
based on number of fulltime employees or fulltime equivalent
employees and average
incomes
Use the Healthcare.gov
Premium Estimator Tool
with employers which will
show a list of available
plans in their area
Use the Healthcare.gov
Full-time Equivalent
(FTE) Employee
Calculator
Encourage consumers to
keep a copy of SHOP
eligibility determinations
for tax filing purposes
SHOP Resources for Assisters
SHOP Small Employer
Call Center
General Inquiries: 1-800-706-7893
TTY: 1-800-706-7915
Hours: Monday – Friday, 9 AM – 7 PM
Small employers and
those helping small
employers
Health Insurance
Marketplace Call
Center
General Inquiries: 1-800-318-2596
TTY: 1-855-889-4325
Hours: 24 hours a day, 7 days a week
Employees and those
helping employees
38
Notes:
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39
Indiana Health Coverage Programs
What is Medicaid?
Medicaid is a public health insurance program enacted in 1965 by Title XIX of the Social
Security Act which provides free or low-cost health insurance coverage to low-income children,
pregnant women, and parents and caretakers, former foster children under age 26 receiving
Indiana Medicaid when aged out of the system, and blind, disabled, and aged individuals.
Indiana Medicaid programs are collectively referred to as Indiana Health Coverage Programs
which are administered by the Office of Policy Planning (OMPP) and Family and Social Services
Administration (FSSA). The federal government matches Indiana spending on Medicaid. The
Department of Family Resources (DFR) is the division of FSSA responsible for processing
applications and making eligibility decisions. The County Offices of the DFR administer IHCP at
the local level. Online applications for Medicaid are located on the DFR’s Benefit Portal.
Federal Poverty Level (FPL)
Medicaid uses the Federal Poverty Level (FPL) issued by the Department of Health and Human
Services (HHS) as a measure of pre-tax income to determine what is considered poverty in the
United States. Anyone living at 100% or below the FPL is considered living in poverty. In 2014,
an individual with a pre-tax income of $11,670 or less is living in poverty, and so is a family of 4
with pre-tax income at or below $23,850.
Indiana’s Health Coverage Programs
Indiana has a variety of programs with varying criteria.
40
Hoosier Healthwise
Provides health care coverage for low-income parents/caretakers of children under age 18,
pregnant women, children up to age 19, and former foster children up to age 26 at little or no
cost.
HHW PACKAGE
A—Standard
C– Children’s
Health Insurance
Program (CHIP)
P—Presumptive
Eligibility
DESCRIPTION
 Full-service plan for children,
pregnant women and
families
 No premiums
 Full service plan for children
only (under age 19)
 Small monthly premium
payment & co-pay for some
services based on income
 Ambulatory prenatal
coverage for pregnant
women who are determined
“presumptively eligible” while
their Indiana Application for
Health Coverage is being
processed
Monthly Income Limits for HHW
Family Parents & Children Pregnan
Caretaker
Size
t Women
Relatives
1
n/a
$2,432
n/a
2
$247
$3,278
$2,727
3
$310
$4,123
$3,431
4
$373
$4,969
$4,134
5
$435
$5,815
$4,838
Children’s Health Insurance Program (CHIP)
Child cannot be covered by other comprehensive health insurance. Individuals in CHIP are
responsible for monthly premiums and must pay the first premium prior to coverage becoming
effectuated (there is a 60-day grace period). A child whose coverage was dropped voluntarily
may not receive CHIP coverage for 90 days following the month of termination with some
exceptions.
Family FPL
Monthly Premium for 1
Child
Monthly Premium for 2 or
More Children
158% up to 175%
$22
$33
175% up to 200%
$33
$50
200% up to 225%
$42
$53
225% up to 250%
$53
$70
Healthy Indiana Plan (HIP)
HIP is Indiana’s unique health coverage program for adults between the
ages of 19-64 with a household income at or less than the FPL who are
otherwise ineligible for Medicaid. The program provides full health benefits
41
including free preventative services ($500), hospital services, mental health care, physician
services, prescriptions and diagnostic exams but does not currently include vision, dental, or
maternity services.
Monthly
Income
Power Account
Family Size
Threshold
The program provides a Personal Wellness and Responsibility
1
$973
(POWER) Account valued at $1,100 per adult to pay for
medical costs. Enrollee contributes 2-5% of gross income, and
2
$1,311
employers and non-profits can also contribute. Individuals who
3
$1,649
fail to make their monthly POWER Account contribution after a
4
$1,988
60-day grace period are disenrolled for 12 months.
5
$2,326
HIP Expansion
6
$2,665
On May 15, 2014, Indiana Governor Mike Pence announced a
7
$3,003
plan to expand HIP from 100% to 138% of the FPL. As of
8
$3,441
October 2014, Indiana and the federal government are in
negotiations after the federal comment period closed in
September of 2014.
Proposed Programs include:
HIP Link
Provides financial support
to members who wish to
purchase employersponsored coverage
HIP Plus
For members who
consistently make
contributions to their POWER
account
Enhanced benefits such as
dental and vision coverage
HIP Basic
More limited benefit plan
Requires co-payments for all
services but not POWER
account contributions
HIP Gateway to Work
HIP participants referred
to the State’s workforce
training programs and
work search resources
Managed Care Entities
Hoosier Healthwise & HIP enrollees select one of the three MCEs, or they are auto-assigned 14
days after enrollment. In 2014, the MCEs are Anthem, MDwise, and MHS.
Some factors for beneficiaries to consider when selecting an MCE include:
 Provider network
o Is the individual’s doctor available in the MCE network?
o Are the locations of network providers easily accessible for the enrollee?
o Are the locations convenient to the individual’s work, home or school?
 Special programs and enhanced services
o Is there a service or program offered by the MCE that is particularly important or
attractive to the enrollee?
42
Changing MCEs
Hoosier Healthwise enrollees can change
MCES…
Anytime during the first 90 days with a health plan
Annually during an open enrollment period
Anytime when there is a “just cause”
 Lack of access to medically necessary
services covered under the MCE’s contract
with State
 The MCE does not, for moral or religious
objections, cover the service the enrollee
seeks
 Lack of access to experienced providers
 Poor quality of care
 Enrollee needs related services performed
that are not all available under the MCE
network
Healthy Indiana Plan enrollees can change
MCES…
In the first 60 days or until they make the first
POWER account contribution
Annually at eligibility redetermination
Anytime there is a “just cause” as outlined for
Hoosier Healthwise enrollees
Primary Medical Provider
Once a beneficiary is enrolled in an MCE, he or she must select a Primary Medical Provider
(PMP). Enrollees must see their PMP for all medical care; if specialty services are required the
PMP will provide a referral. Provider types eligible to serve as a PMP include Indiana Health
Coverage Program enrolled providers with the following specialties:
Family
Practice
General
Practice
Internal
Medicine
Ostetrics/
Gynecology
General
Pediatrics
Care Select
Program for aged, blind, disabled, ward of the court or foster child, or a child receiving adoptive
services or adoption assistance. Enrollees must have one of the following conditions: Asthma,
Diabetes, Congestive, Heart Failure Coronary Artery Disease, Chronic Obstructive Pulmonary
Disease, Hypertension, Severe Mental Illness, Serious Emotional Disturbance (SED)
Depression, Chronic Kidney Disease w/o dialysis, co-morbidity of Diabetes and Hypertension or
other combinations, or other approved serious or chronic conditions.
This program will phase-out January 1, 2015 due to a new coordinated care program.
Traditional Medicaid
The following individuals who meet income and resource requirements are eligible:
•
•
Blind, Disabled, and Aged persons
Persons in nursing homes & other long-term care institutions
43
•
•
•
•
•
•
Undocumented aliens who do not meet a specified qualified status; lawful permanent
residents who have lived in the USA less than five years; or those whose alien status
remains unverified receiving Emergency Services only
Persons receiving home and community-based waiver or hospice services
Dual eligibles (individuals receiving Medicaid & Medicare)
Persons eligible on the basis of having breast or cervical cancer
Refugees who do not qualify for another aid category
Former Independent Foster Children up to age 18, IV-E Foster Care Children, IV-E
Adoption Assistance Children, and Former foster children under the age of 26 who were
enrolled in Indiana Medicaid as of their 18th birthday
In Traditional Medicaid, beneficiaries are not enrolled in a Managed Care Entity (MCE) or Care
Management Organization (CMO) and can see any Indiana Health Coverage Program enrolled
provider.
TRADITIONAL MEDICAID
BENEFIT PACKAGE
Standard Plan
Medicare Savings Program
DESCRIPTION
 Full Medicaid coverage
QMB: Medicare Part A & B premiums, deductibles, & coinsurance
SLMB/QI: Medicare Part B premiums
QDWI: Medicare Part A premiums
Package E
Emergency Services only– for certain immigrants who do not qualify
for full Medicaid coverage
Family Planning
Family planning services only
Medicaid for Employees with Disabilities (M.E.D. Works)
Provides full Medicaid for working people ages 16-64 with disabilities and below 350% FPL.
Enrollees must be disabled according to Indiana’s definition of disability and not exceed the
asset limit (Single: $2,000 or Couple: $3,000). Members pay a small monthly premium and may
also have employer insurance (see chart on next page).
44
MED WORKS PREMIUMS
Monthly Income
Premium
$1,459 - $1,702
$48
$1,703 – $1,945
$69
$1,946 - $2,432
$107
$2,433 - $2,918
$134
$2,919 - $3,404
$161
$3,405
$187
$1,967 - $2,294
$65
$2,295 - $2,622
$93
$2,623 - $3,278
$145
$3,279 - $3,933
$182
$3,934 - $4,588
$218
$4,589
$254
Single
Married
590 Program
This program provides coverage for residents of state-owned facilities. It does not cover
incarcerated individuals residing in Department of Corrections (DOC) facilities. Enrollees are
eligible for Package A benefits with the exception of transportation.
Home and Community Based Waivers
These waivers allow provision of long-term care services in home and community based
settings under the Medicaid program.
WAIVER
ELIGIBILITY
SPECIFICS
Aged and
Disabled
 Income: Up to 300% Supplemental
Security Income (SSI) benefit
 Complex medical condition
which required direct assistance
Traumatic
Brain Injury
•
 Diagnosis of Traumatic Brain
Injury
Community
Integration &
Habilitation
 Meets ANSA “Level of Care”
Family
Supports
Parental income & resources
disregarded for children under 18
 Would otherwise be place in
institution such as nursing home
without waiver or other home-based
services
45
 Diagnosis of intellectual disability
which originates before age 22
 Individual requires 24 hours
supervision
To apply for the Aged and Disabled waiver or the Traumatic Brain Injury Waiver, individuals can
go the local Area Agencies on Aging (AAA) or call 1-800-986-3505 for more information.
To apply for the Community Integration & Habilitation or Family Supports waiver, individuals can
go the local Bureau of Developmental Disabilities Services (BDDS) office or call 1-800-5457763 for more information.
There are currently waiting lists for the Family Supports waiver and the Traumatic Brain Injury
waiver.
Behavioral and Primary Healthcare Coordination Program (BPHC)
BPHC assists individuals with serious mental illness (SMI) who otherwise won’t qualify for
Medicaid or other third party reimbursement Individuals meet the following eligibility criteria:
 Age 19+
 MRO-eligible primary mental health diagnosis (e.g. schizophrenia, bipolar
disorder, major depressive disorder)
 Demonstrated need related to management of behavioral and physical health
and need for assistance in coordinating physical and behavioral healthcare
 ANSA Level of Need 3+
 Income below 300% FPL
o Single: $2,918/month
o Married: $3,933/month
Individuals may apply for the BPHC program through a Community Mental Health Center
(CMHC) approved by the FSSA Division of Mental Health and Addiction (DMHA) as a BPHC
provider. A list of approved CMHCs can be found at
http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.aspx.
Medicare Savings Program
This program covers low-income Medicare beneficiaries and helps pay for out-of-pocket costs.
Individuals must be eligible for Medicare Part A.
Program
Qualified Medicare
Beneficiary (QMB)
Income Threshold
100% FPL
Resource Limit
Single: $7,080
Couple: $10,620
(Specified Low
Income) SLMB
120% FPL
Single: $7,080
Benefits
 Medicare Part A & B
Premiums
 Co-pays, deductibles,
coinsurance
 Part B Premiums
Couple: $10,620
Qualified Individual
(QI)
135% FPL
Single: $7,080
 Part B Premiums
Couple: $10,620
Qualified Disabled
Worker (QDW)
200% FPL
Single: $7,080
Couple: $10,620
46
 Part A Premiums
Family Planning Program
The Family Planning Program is for individuals wishing to prevent or delay pregnancy who do
not qualify for any other category of Medicaid, meet citizenship or immigration status
requirements, are not pregnant, have not had a hysterectomy or sterilization procedure, and
have income at or below 141% FPL. This program includes, but not limited to:






Annual family planning visits
Pap smears
Tubal ligation
Vasectomies
Hysteroscopic sterilization with an implant device
Laboratory tests, if medically indicated as part of the decision-making process regarding
contraceptive methods
 FDA approved anti-infective agents for initial treatment of STD/STI
Individuals must request to be considered for this program on their Indiana Application for
Health Coverage if not eligible for full Medicaid benefits.
Breast and Cervical Cancer Program (BCCP)
BCCP provides Medicaid coverage to women with breast and cervical cancer diagnosed
through the Indiana State Department of Health (ISDH). Enrollees must have the ISDH
diagnosis or be of age 19-64, need treatment for breast or cervical cancer, ineligible for
Medicaid under any other program, and have no other access to health insurance that covers
the treatment.
Uninsured or underinsured Indiana residents below 200% FPL (age 40+) may qualify for free
breast and cervical cancer screenings and tests.
Age
Eligible Services
40-49
Free office visit & Pap test
50-64
Free office visit, Pap test, and mammogram
65 and older
Free office visit, Pap test, and mammogram only if not enrolled in Medicare
1634 Transition
In June 2014, Indiana transitioned to a 1634 state. Indiana implemented changes to disability
eligibility to the aged, blind and disabled (ABD) Medicaid program. This entails a simplified
disability eligibility process requiring consumers to submit an application to the Social Security
Administration (SSA) for disability benefits as part of the Medicaid for the Disabled application.
Individuals deemed eligible for Supplemental Security Income (SSI) and Social Security
Disability Insurance (SSDI) are automatically enrolled in Medicaid. The State gives precedence
to SSA disability determinations for SSI.
47
Presumptive Eligibility (PE)
Hospitals are permitted to determine PE for children under 19 (not including CHIP), low-income
parents/caretakers and pregnant women, individuals seeking family planning services only, and
former foster care children up to age 26. This allows individuals meeting eligibility requirements
access to services covered and paid for by Medicaid as they wait for their application
determination for full Medicaid. Applicants must know gross family income and citizenship; selfattestation is accepted for information.
The PE period extends from the date an individual is determined presumptively eligible until…
 When an Indiana Application for Health Coverage is filed:
o Day on which a decision is made on that application
 When an Indiana Application for Health Coverage is not filed:
o Last day of the month following the month in which the PE determination was
made
Presumptive Eligibility for Pregnant Women (PEPW)
Qualified Providers may provide PE for pregnant women only. QPs must meet the following
criteria:






Be enrolled as an Indiana Health Coverage Program (IHCP) provider
Attend a provider training
Provide outpatient hospital, rural health clinic or clinic services
Be able to access HP Web interchange, internet, printer & fax machine
Allow PE applicants to use an office phone to facilitate the PE and Hoosier Healthwise
enrollment process
May include hospitals, pediatricians, family/general practitioner, internist, medical clinic,
rural health clinic among others
Eligible women are pregnant, Indiana residents, and U.S. citizens or qualified immigrants
with a household income of less than 208% FPL. PEPW does not pay for hospital stays,
48
hospice, long term care, abortion, postpartum services, labor and delivery, or services
unrelated to pregnancy.
Hospital PE
•
•
•
•
•
Pregnant Women
Medicaid Eligible Children
Low Income Parents and Caretakers
Family Planning Eligibility Program
Former Foster Care Children up to Age 26
QP PE
• Pregnant Women
Indiana Application for Health Coverage
The Indiana Application for Assistance includes SNAP, cash assistance and health coverage.
Application methods:
• Online (Recommended)
• Telephone
• Fax
• Mail
• In Person at Division of Family Resources (DFR) office
Medicaid eligibility determinations are made within 45 days or 90 days for determination based
on disability. Applicants can check status of online application using:
• Case number
• Case name
• Date of birth
• Last four digits of SSN
Authorized Representatives (AR)
An AR is an individual or organization which acts on a Medicaid applicant or beneficiary’s behalf
in assisting with the application, redetermination process and ongoing communications with the
state. An AR is commonly a trusted family member, but can also be a third party entity.
Designation must be in writing and signed by the applicant or beneficiary and the authorized
representative—State Form 55366 can be used.
Eligibility Notices
The DFR provides written notice, via mail, to applications and beneficiaries regarding any
decision affecting eligibility. Types of notices include, but not limited to approvals, denials,
terminations, suspensions of eligibility, and changes in benefit packages or aid categories.
The State sends notice within 24 hours + mailing time. Individuals can be determined Medicaid
eligible for up to 3 months of retroactive eligibility from the date of application.
Eligibility Appeals
Individuals wishing to challenge disability eligibility decisions appeal to the Social Security
Administration (SSA) or Indiana Medicaid depending on the reason for the denial.
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•
•
Regarding an SSA disability on file: appeal to SSA
Indiana Medical Review Team (MRT) decision: appeal to Indiana Medicaid
Eligibility Redeterminations
Eligibility redeterminations are conducted every 12 months for MAGI categories. The State
renews if there is sufficient information, effective December 2014. If there is not sufficient
information, a pre-populated renewal form will be sent beginning in 2015. Eligibility is terminated
if the form is not submitted in a timely manner; if eligibility is terminated but the documents are
submitted within 90 days of the original due date, the documents will be reviewed without the
need to submit a new application
Reporting Changes
Enrollees are required to report changes to the state (FSSA). Examples of changes include:
• Change in address
• Income
• Family composition
• Babies born to Medicaid enrollees receive coverage for the first year of life without the
need for a separate application
o They will be covered under Hoosier Healthwise and enrolled in the mother’s
Managed Care Entity (MCE)
Application Methods
Program
Application Process
Aged & Disabled Waiver
Apply at Area Agencies on Aging (AAA) or call 1-800-986-3505
Breast & Cervical Cancer
Program (BCCP)
Apply for Medicaid coverage, option 3; Family Helpline: 1-855-435-7178
Care Select
Contact Enrollment Broker: MAXIMUS:1-866-963-7383
Community Integration &
Habilitation or Family
Supports Waiver
Apply at Bureau of Developmental Disabilities Services (BDDS) office or
call 1-800-545-7763
Family Planning Eligibility
Program
Division of Family Resources (DFR) Toll-Free at 1-800-403-0864 OR
online
Healthy Indiana Plan (HIP)
Print or pick-up application at a DFR office
Hoosier Healthwise (HHW)
Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in
person at DFR office
Traditional Medicaid
Apply at DFR office, online/phone, Community Enrollment Centers
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Notes:
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Effective Outreach & Enrollment
What Can You Do Outside of Open Enrollment?
Strengthen Your Team
 Reflect and debrief on what worked and what didn’t work in 2014
 Recruit volunteers
 Utilize receptionists and other staff to assist with setting up
appointments and answering questions
 Attend trainings, conferences and networking events
 Involve the entire health center staff in ACA awareness and inreach strategies
 Assign a lead Navigator
 Recruit, hire and train bilingual Navigators
Strengthen Your Community
 Form community partnerships with local organizations and coalitions such as:
o Faith-based organizations
o Refugee organizations and Indiana Minority Health Coalition
o Local universities, community colleges and technical schools
o Food pantries and shelters
o School districts and school nurse workgroups
o Head Start programs
o WIC
o Unemployment offices
o Hospitals and hospital associations
 Develop relationships and build a referral network with other consumer assister
organizations
Collaborate and Brainstorm
 Hold weekly meetings
o Share new resources, tools and updates
o Dispel myths and miscommunication
o Reveal best practices and strategies
 Identify and capitalize on your strengths
 Support staff with time-management
o Prioritization and data can help
 Help others develop individual work plans
Strategize and Plan
 Prepare for logistics of next open enrollment period
o How will you address high demand?
o What population gaps do you need to reach,
and how will you reach them?
 Research and implement new strategies:
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o Host a phone-a-thon
o Lease storefront space
o Use signage and buttons
 Develop an outreach work plan
Continue Educating and Assisting Consumers
 Educate about the benefits of the ACA
 Help consumers navigate the health insurance and health care system, including:
 Understand, maintain and use their coverage
 Understand their rights as health care consumers
 Appeal eligibility and coverage decisions
 Report a change in circumstance and navigate subsequent eligibility redeterminations
o How these changes may affect APTC and eligibility for coverage
 How and when to pay premiums (if applicable)
 The annual redetermination and open enrollment process
 Assist American Indians, Native Alaskans and other members
o Documented members of federally-recognized tribes can enroll for the 1st time
any time during the year and may change plans once per month throughout the
year through an SEP
 Help small business owners wanting to enroll employees in SHOP
o SHOP is open all year
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Relaying the Important of Health Coverage
Key Messages for Consumers:
• Consumers should apply for insurance because plans available in the Marketplace and
IHCP provide free preventive care like vaccines, screenings and check-ups. They also
cover some costs for prescription drugs.
• Having insurance is having peace of mind knowing that if a serious medical situation
arises, they are covered.
• Health care without insurance is expensive—in Indiana the average cost per inpatient
day is $2,025.iii
Promising Best Practices
Track those who
would be eligible
for HIP postexpansion
Look at the patient
list for the next day
and identify
possible clients
Take advantage of
free advertising like
school newsletters
and IN-211
Prescreen your
clients
Partner with
schools and
libraries
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i
HHS, Kaiser Health News
Center for Health Care Strategies, Inc.
iii
KFF
Other resources include: The Indiana Navigator Training Content Manual, Centers for Medicare and Medicaid, and Enroll America.
ii
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