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    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.


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    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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    Vendors & Presumptive Eligibility
    Hello, Can anyone tell me if it is possible for a hospital VENDOR to become a presumptive eligibility organization? If I understand correctly, only hospitals can process presumptive eligibility, so while a hospital may contract with a vendor to provide... read more

    Hello, Can anyone tell me if it is possible for a hospital VENDOR to become a presumptive eligibility organization? If I understand correctly, only hospitals can process presumptive eligibility, so while a hospital may contract with a vendor to provide a worker to process presumptive applications, it is still the hospital that holds the Presumptive Eligibility "contract" with the state. Is that correct? Any information you can provide is appreciated. Thank you!

    replyDecember 27th, '13
    Dan Ridge
    Michigan
    Re: Vendors & Presumptive Eligibility

    The regulations state that the agency must ensure that qualified entities "do not delegate the authority to determine presumptive eligibility to another entity."

    Medically Frail Exempt Group
    Has any state developed a process to identify Medically Frail in the Newly Eligible - in particular recipients with serious mental illness or chronic substance abuse? What eligibility requirements? What process to give the option of ABP or Regular... read more

    Has any state developed a process to identify Medically Frail in the Newly Eligible - in particular recipients with serious mental illness or chronic substance abuse? What eligibility requirements? What process to give the option of ABP or Regular Medicaid?

    replyAugust 23rd, '13
    Kaitlin Sheedy
    District of Columbia
    Re: Medically Frail Exempt Group
    Hi Cynthia, thank you for your question. On a recent State Refor(u)m webinar, one of our speakers, Suzanne Bierman from Arkansas, said:... read more

    Hi Cynthia, thank you for your question. On a recent State Refor(u)m webinar, one of our speakers, Suzanne Bierman from Arkansas, said:

    "To determine whether someone would be better served under traditional Medicaid in Arkansas, we worked with disability research experts and the Agency for Healthcare Research and Quality (AHRQ) to develop a 12-question questionnaire. The purpose of the questionnaire is to identify individuals who are medically frail (we used the federal definition of medically frail as the starting point), or individuals for whom coverage through the marketplace has been determined to be impractical, overly complex or undermining continuity or effectiveness of care. Basically two types of questions are in this questionnaire. One type of questions focuses on activities of daily living (ADL) needs, and those who need assistance with ADL. ADL needs are what we refer to as auto qualifiers. The second set of questions are from the Medicaid Expenditure Panel Survey (MEPS), and are targeted at identifying individuals with predictable high levels of service needs throughout the year, suggesting they will have exceptional needs.

    It’s an online automated questionnaire. If you are deemed by the questionnaire to be medically frail you may not receive services through the private option, and you are instead put into FFS Medicaid, where you have a choice of traditional FFS or the ABP in FFS. Once an individual has been identified as an exempt individual, we provide notice and choice counseling, which explains the differences between standard Medicaid and the ABP in FFS."

    To follow this thread, you can visit our Medicaid discussion page: https://www.statereforum.org/discussions/medicaid#comment-13194

    February 10th, '14
    Kaitlin Sheedy
    District of Columbia
    Re: Medically Frail Exempt Group
    Additionally, MA is proposing that individuals self-identify as Medically Frail. The Massachusetts Executive Office of Health and Human Services (EOHHS) notifies members how to self-identify as medically frail. Self-identification instructions are... read more

    Additionally, MA is proposing that individuals self-identify as Medically Frail. The Massachusetts Executive Office of Health and Human Services (EOHHS) notifies members how to self-identify as medically frail. Self-identification instructions are included in MassHealth CarePlus eligibility notices, which are sent out at initial enrollment and whenever a member is re-determined eligible. These instructions are also in the MassHealth Member Booklet and the MassHealth CarePlus enrollment guide, which MassHealth provides to help members choose a health plan. Members may self-identify as medically frail at any time after their MassHealth CarePlus eligibility determination. If a member believes he or she is medically frail, the member can call MassHealth to self-identify. If the member chooses, MassHealth will immediately enroll the individual in the MassHealth Standard ABP.

    You can see more information in this "Notice of Intent to Submit State Plan Amendments for MassHealth Alternative Benefit Plans Summary" document available at: http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/alternate-benefit....

    February 10th, '14
    Zach Rioux
    West Virginia
    Hospital Based Presumptive Eligibility
    We are currently working with a number of states on implementing ACA changes in Medicaid and CHIP and we were wondering how other states were handling Hospital Based Presumptive Eligibility. Specifically: ... read more

    We are currently working with a number of states on implementing ACA changes in Medicaid and CHIP and we were wondering how other states were handling Hospital Based Presumptive Eligibility. Specifically:

    1: What standards are you using to measure Hospital Based Presumptive Eligibility programs?
    2: What actions are you planning on taking when a hopsital does not comply with PE standards/rules?

    Thank you.

    replyJuly 9th, '13
    Medicaid Funds for Student Health Insurance/Benefit Programs
    Hello all,... read more

    Hello all,

    The American College Health Association (www.acha.org) recently issued a position paper on the permissibility of using Medicaid funds to pay for the cost of student health insurance/benefit programs.

    Thought you might find this to be of interest.

    Qualifying Event -- Access to Insuarance Exchanges Outside of Open Enrollment
    Are there regulations that allow for someone who has involuntarily lost access to a health insurance plan (i.e., a qualifying event) to have access to the insurance exchange outside of the annual open enrollment period? ... read more

    Are there regulations that allow for someone who has involuntarily lost access to a health insurance plan (i.e., a qualifying event) to have access to the insurance exchange outside of the annual open enrollment period?

    For example, could a college student who is covered by a university-sponsored student health insurance plan have access to the insurance exchange upon graduation and loss of eligibility for the student insurance plan? This may be a bit tricky as fully insured student health insurance plans are not regulated as group health insurance -- they are a form of individual health insurance.

    replyMay 24th, '13
    Re: Qualifying Event -- Access to Insuarance Exchanges Outside of Open Enrollment
    Hi Stephen--Loss of minimum essential coverage triggers eligibility for a special enrollment period - regs can be found at 45 CFR 155.420(d)(1). The most up-to-date language can be found in the January NPRM on Exchange eligibility. You can also check 26... read more

    Hi Stephen--Loss of minimum essential coverage triggers eligibility for a special enrollment period - regs can be found at 45 CFR 155.420(d)(1). The most up-to-date language can be found in the January NPRM on Exchange eligibility. You can also check 26 CFR 54.9801 for additional info on circusmtances that qualify as loss of MEC. MEC is defined at 26 CFR 1.5000A-2--it includes insurance in the individual market.

    Kevin Knauss
    California
    Group insurance eligibility with state exchange
    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... read more

    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.

    Ken Zipin
    Maryland
    Re: Group insurance eligibility with state exchange
    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... read more

    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...

    Kevin Knauss
    California
    Re: Group insurance eligibility with state exchange

    That seems like it might be problematic for some families. A minimum wage employee is going to be in a difficult situation.

    St. Thomas USVI

    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?

    replyNov 14th, '12
    Jeremy Rosen
    District of Columbia
    Re: St. Thomas USVI

    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.

    Nov 20th, '12
    Dan Rabbitt
    Maryland
    Re: St. Thomas USVI
    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... read more

    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.

    Nov 20th, '12
    Tennessee

    Curious if anyone knows what might be behind the re-release of the TN bid for eligibility?

    replyAug 3rd, '12
    Illinois - Eligibility Categories
    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... read more

    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

    Chad Shearer
    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... read more

    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.

    replyFeb 8th, '12
    Julie Sonier
    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. read more

    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.

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