Eligibility Categories
To achieve simplified and integrated systems, states need to develop, adopt and implement consistent policies for new eligibility categories across state health subsidy programs.
*Milestone details:
*Full name: Adopt state policies necessary to implement new eligibility categories for Medicaid, the basic health program, if adopted, CHIP, and federal tax credits through the Exchange.
*Relevance to the ACA:
The ACA establishes new eligibility categories or determination methods for Medicaid and CHIP, and also creates a basic health program option and Exchange tax credits. Consistent with federal guidance and state policy making rules, States will need to develop policies to implement these new categories and methods. States also may need to review policies for categorical eligibility determinations to promote as much consistency with the new income based methodologies as possible. Provisions relevant to new eligibility categories include:
§1331 – Requirements for the establishment of a basic health program.
§1401 – Premium tax credits eligibility guidelines.
§1411 – Eligibility determination procedures for the Exchange and federal tax credits.
§2001 – Medicaid expansion to cover individuals with income below 133% of the federal poverty level.
§2002 – Eligibility determination for Medicaid using MAGI.
§2101 – Eligibility standards for children through September 30, 2019.
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California
Has any guidance from HHS been provided as to whether the dependents of an employee offered an affordable group plan are eligible for the tax credits through the state exchange? In other words, can the employee enroll in the qualified group plan but have his or her family insured through exchange and will they receive the tax credit if they meet the income test.
Maryland
Kevin - I believe the basic answer to your question is No, based on my reading of the IRS regs. A dependent who has access to a ESI (say though a spouse) can not collect a premium assistance tax credit if they turn down coverage. This would hold true even if the family coverage goes above the 9.5% income threshold, so long as the self-only coverage is below 9.5%.
From the regs:
(3) Employer-sponsored minimum essential coverage --(i) In general. For purposes of section 36B, an employee who may enroll in an eligible employer-sponsored plan (as defined in section 5000A(f)(2
)) and an individual who may enroll in the plan because of a relationship to the employee (a related
individual) are eligible for minimum essential coverage under the plan for any month only if the plan is affordable and provides minimum value.
(v) Affordable coverage--(A) In general
--(1) Affordability for employee. Except as provided in paragraph (c)(3)(v)(A)(3) of this section, an eligible employer-sponsored plan is affordable for an employee if the portion of the annual premium the employee must pay, whether by salary reduction or otherwise (required contribution), for self-only coverage does not exceed the required contribution percentage
HealthReform GPS discusses this issue a bit here:
http://www.healthreformgps.org/resources/update-when-should-uninsured-fa...
California
That seems like it might be problematic for some families. A minimum wage employee is going to be in a difficult situation.
How are other states handling or finding the resources along with the health exchange going to help people who are homeless and adult pass the age of 26 who don’t have children?
District of Columbia
My colleagues at the National Health Care for the Homeless Council are more knowledgable on this topic than I am, to be sure. But we believe this is a critical population to cover under any expanded Medicaid program.
Maryland
States are not specifically required to make plans for outreach to the homeless, but are required to make plans for many populations that overlap, like those with HIV, serious mental illness, and substance abuse conditions. No funding is provided specifically for this outreach, although the Navigator program could be helpful if Medicaid and the Exchange are combined in a State. Traditional sources of outreach for homeless persons and community based organizations already working with the homeless are probably the best routes to help the homeless learn about the ACA and assist them in enrolling into coverage.
Indiana
Curious if anyone knows what might be behind the re-release of the TN bid for eligibility?
Illinois
Illinois Health Matters released its interactive map tool, "Visualization Health Care Reform," last week. It specifically shows how two provisions – expansion of Medicaid eligibility and the creation of new insurance marketplaces – could expand coverage to the state’s residents, some 13 percent of whom are currently uninsured. You can look at data statewide, by region, Cook County only and community area. You can view on your computer or iPad, or print a PDF of your community area to share with legislators and constituents.
Feel free to contact me with questions.
Stephani Becker
Illinois Health Matters Project Director
sbecker@hdadvocates.org
New Jersey
The State Health Reform Assistance Network through the team at Manatt Health solutions developed this brief titled "Federal Requirements and State Flexibilities for Verifying Eligibility Criteria." It summarizes some of the key requirements and state flexibilities with regards to Medicaid and Advance Premium Tax Credit eligibility verification.
District of Columbia
California's "Bridge to Reform" 1115 waiver allows California counties to implement reforms in advance of 2014, including expanding Medi-Cal eligibility to childless adults. The following documents summarize the details of the waiver.
Minnesota
SHADAC recently hosted a webinar on issues related to FMAP claiming and converting income eligibility requirements to MAGI-based standards. An archived version of the webinar and transcript are available at http://www.shadac.org/FMAPMethodologyWebinar.
Massachusetts
ACA Implementation Workgroup Advisory Council Presentations from Consultants analyzing potential implementation models.
Minnesota
Minnesota's Early Medicaid Adult Expansion
Oregon
Oregon, Arizona and Illinois have developed a list of questions for the Federal government relating to eligibility and implementation of the ACA in 2014 - questions that we plan to pose through the ETAGS and perhaps through a joint letter to CMS. We invite other states to join us in seeking answers to these questions, plus other questions our colleagues may have to add.
California
This issue brief draws on lessons from New York’s experience in covering childless adults, which other states may find helpful as they extend eligibility to this population as outlined in the Affordable Care Act. Access the brief here: http://www.statereforum.org/sites/default/files/ny_enrollingchildlessadu...
California
This report, produced by the New York Department of Health, describes the state’s plan to transition the current locally-based administration of its Medicaid program, to a state-based administration system. The report broadly outlines how the state plans to accomplish this transition by the April 1, 2016 target date set by state legislation enacted in June. Access the report here: http://www.statereforum.org/sites/default/files/ny_adminreport2010.pdf
District of Columbia
The Iowa Legislative Health Care Coverage Commission presented 18 recommendations to General Assembly regarding implementation of the ACA. Highlights include planning for a new eligibility system to support Medicaid, CHIP, implementing a number of cost-containment strategies, and establishing an operational insurance information exchange by July 1, 2011.
Access the presentation here:
http://www.statereforum.org/sites/default/files/final_2010_comm_recommen...
District of Columbia
This report details the activities of the Converage Expansions for Iowa Care, Medicaid, and High Risk Pools Workgroup of the Legislative Health Care Comission to date, including the meetings held over the course of the year. It also includes recommendations made by the group, including many on Medicaid eligibility, IT systems, and the integration between the exchange and Medicaid.
Access the report here:
http://www.statereforum.org/sites/default/files/ia_care_expansion_workgr...