March 2014

03/21/2014

The Affordable Care Act establishes a new Health Insurance Marketplace. People who need health insurance can go to the Marketplace, find out what they’re eligible for and apply for the plan that’s right for them. They can apply through a web-site, by phone, by mail, or with personal assistance. There are four kinds of coverage.

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Medicaid

Children’s Health Insurance Program (CHIP)

Private Health Insurance Plans (The Exchange)

Small Business Health Options Program (SHOP) Marketplace

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The timeline to begin enrolling in the Market-place will be Oct. 1, 2013 with eligibility start date Jan. 1, 2014. After January 1, 2014. Medicaid will be effective same month of enrollment.

CHIPS policy is being looked at to begin the same month of enrollment also.

Private Insurance will be Jan 1, 2014 to March 31, 2014. The Insurance will begin the next month after enrollment. There are special circumstances to be enrolled in private insurance such as birth, death of spouse, etc.

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Medicaid will cover everyone who lives in West Virginia, is a US citizen, is under the age of 65, and earns less than 138 percent of the federal poverty level (FPL).

Medicaid coverage for pregnant women is 155% FPL.

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Children’s Health Insurance Program (CHIP) will continue to be available for income eligible children, but current enrollees who are in families with income below 138% of FPL will be transferred to Medicaid.

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Private Insurance is for individuals/families whose income is above 138% FPL level.

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Federal poverty level is the amount of money that an individual or family earns and is used to determined eligibility for Medicaid, CHIP and subsidized private insurance plans. The federal poverty level varies by income and family size.

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Eligibility is determined based on access to the “federal hub” which includes information from databases from IRS, the Social Security Administration, etc.

All three of the insurance options will be determine using the modified adjusted gross income (MAGI). ◦ Medicaid and CHIP will use a family’s current

earnings in the month they apply. ◦ The Marketplace will use what a family is

expected to earn.

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Modified Adjusted Gross Income (MAGI). ◦ This method adopts the income tax definition of

what counts as income. In general, income that is taxable will be counted for the purpose of determining Medicaid eligibility.

◦ Examples of non-taxable income:Child support, VA benefits

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All taxable income for adults, parents, spouses, and for a child that filed income taxes. The only exception is grants or scholarships.

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No

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The ACA expanded Medicaid eligibility for MAGI populations to include all children and adults who meet income and other guidelines. ACA leaves current eligibility intact for traditional Medicaid programs such as people who are blind or disabled, or in need of long-term care services.

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No, The Marketplace will make the eligibility decisions based on access to the “federal hub” which includes information from databases for the IRS, the Social Security Administration, Homeland Security, and other state and federal agencies.

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The Smith family consists of Roger, who is a mechanic; Sally, who works at a local restaurant; and Amy, their three-year old daughter. Neither Roger’s nor Sally’s employer offers health insurance coverage. Sally goes to the Marketplace, enters her social security number, and other personal information. The marketplace pulls up the recent tax return. Then the Social Security Administration will verify that all members of the Smith family are US citizens. The family’s income is $27,500. Sally reports she is pregnant. Given these circumstances, the Marketplace determines that Sally is eligible for Medicaid (pregnant and in a family earning less than 155% of FPL), and her information is forwarded to WV for enrollment. Amy, their three year old is, eligible for CHIP, and her information is forwarded to CHIP. Roger qualifies for a private insurance policy. He will be given a list of private insurances to select from.

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Sally will not be asked about family resources, nor can the Marketplace require a face to face interview. Sally will need to “attest” that her family’s current month income is $2,292. Since this amount is “reasonably compatible” with the IRS’s data base, the Marketplace accepts this. The Marketplace must also accept Sally’s attestation that she is pregnant. Sally cannot solely attest regarding whether she, Roger and Amy are US citizens. This must be checked electronically with the Social Security Administration or other data bases.

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Self attestation is what a person states is his or her income, family size, where he or she lives, and other eligibility criteria.

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To be eligible for a QHP (Qualified Health Plan), an applicant must be a US citizen or an immigrant who is lawfully present in the US, be a resident or intend to be a resident of West Virginia and not be incarcerated.

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Bronze: 60% paid by insurance company, 40% co-pay

Silver: 70% paid by insurance company, 30% co-pay

Gold: 80% paid by insurance company, 20% co-pay

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Ambulatory patient services Inpatient and outpatient hospital services Maternity and newborn care Mental health and substance use disorder

services Prescription drugs Laboratory Services Clinically effective preventative services without

payment of deductibles, co-payments or coinsurance

Chronic disease management Pediatric services, including vision health

benefits Rehabilitative and habilitative services

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Yes

Premium tax credit: Assist in the form of advanceable tax credit. “Advanceable” means that the federal government will pay the credits directly to the applicant’s insurance company on a monthly basis. Also, if you are married, you must file a joint tax return

Cost Sharing: Is only available with the silver plan. Individual or families with incomes 250% or below the FPL who select a silver plan will have reductions in their deductibles, copayments and co-insurance. The reduction depends on what level the applicants fall in the FPL.

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CAMC became a Certified Application Organization with CMS.

This allowed us to train our eligibility specialists, that included ten Financial Counselors, two Medicaid Eligibility workers, four state workers and four CEA workers to become Certified Application Counselors (CAC).

Presumptive Eligibility Certified.

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Consents Conflict of interest Certificates displayed Policy and procedures written

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Before ACA After ACA

Only screened Inpatients and high dollar outpatients

Screening all self pay

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Tablets

Each Financial Counselor received a tablet having all systems loaded on the tablet to have a mobile office. This allows us to reach the clinics, ER, etc..

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Created a 1-800 number to have a centralized phone number to have patients call with questions and appointments.

Created a brochure to hand out at all Points of service that has our 1-800 number on it with information about the program.

03/21/2014

Working with CAMC Physicians group that have 27 locations to ensure compliance.

Handed out brochures.

Developed scripts for an uninsured patient to be referred for a financial screening.

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Worked with Human Resources to help employees that needed assistance with the Marketplace or Medicaid application.

Financial Counselor attended CAMC Benefit Fair to answers employee questions.

Attended several internal staff meeting. Financial Counselor will be attending our

annual community Healthfest Event.

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