Reference Guide for Indiana Navigators
Transcription
Reference Guide for Indiana Navigators
2015 Reference Guide for Indiana Navigators Version 2.0 July 2015 Developed 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 About IPHCA………………………………………………………………………………….…2 In-Person Assistant Certification Procedures……………………………….…………....4 Data Management & Personally Identifiable Information (PII)…………………………10 Health Insurance Literacy…………………………………………………………………….16 Outreach Best Practices………………………………………………………………………22 Assisting Immigrants and Refugees………………………………………………………..26 Guide to Tax Rules……………………………………………………………………………..34 The Federally-Facilitated Marketplace……………………………………………………...40 The Small Business Health Options Program (SHOP Marketplace) ……………….....57 Indiana Health Coverage Programs (Medicaid)…………………………………………...62 1 About IPHCA Organized in 1982, Indiana Primary Health Care Association (IPHCA) advocates for quality health care for all persons residing in Indiana and supports the development of communityoriented primary care initiatives (including Community Health Centers, or CHCs) that are: Affordable (based on income), Available (services delivered when needed), Accessible (services delivered where needed), Appropriate (emphasizing continuous, comprehensive, prevention-oriented primary care), and Acceptable (to everyone residing in the community regardless of cultural heritage, financial status, or personal circumstances). Included in IPHCA’s comprehensive definition of primary care are medical, dental, and behavioral health services. IPHCA has a diverse membership that includes CHCs, interested individuals, and organizations that support IPHCA's important mission. State-based Primary Care Associations exist in every state and U.S. territory. IPHCA receives funding from a number of sources, including the Health Resources and Services Administration's Bureau of Primary Health Care (part of the US Department of Health and Human Services) to monitor and advocate for access to primary care services throughout Indiana and to provide technical assistance to Federally Qualified Health Centers in the state. IPHCA also receives funding from The Indiana State Department of Health and other organizations such as The Health Foundation of Greater Indianapolis. Outreach & Enrollment Department IPHCA’s Outreach & Enrollment (O/E) department consists of two full-time employees who both work with FQHCs, state-funded health centers, and other organizations across Indiana to expand access to health care through application assistance, patient education, and community outreach. IPHCA strengthens the statewide O/E network by providing technical assistance, guidance, and training to Indiana Navigators, Certified Application Counselors (CACs) and other O&E professionals. Please consider checking out the IPHCA website (www.indianapca.org) for more information! Here’s what you can find online: “HIP 2.0 Hub”—news & updates, resources for consumers and enrollment professionals, a listing of key documents and information from each Managed Care Entity (MCE), FAQs about HIP coverage, and more “How to Apply” section—Step-by-step Marketplace and Medicaid enrollment procedures for consumers “Resources for Assisters”—two-page fact sheets about each Marketplace Qualified Health Plan (QHP) issuer, toolkits, manuals, educational trainings and resources, free outreach tools, consent forms, contact cards, certification and recertification steps, Marketplace topic-specific pages, privacy and security information, and more “Trainings”—listing of upcoming webinars and face-to-face trainings and archived IPHCA webinars and presentations “Updates and News”—the latest news and updates in O/E 2 How We Can Help You Technical assistance—IPHCA staff are available to help members with troubleshooting issues, resolving casework, and answering questions about health coverage enrollment on the Marketplace and Indiana Health Coverage Programs. Event support—Need an extra set of hands at a large enrollment event you have planned? IPHCA can assist in planning events, advertising efforts, and even enrollment services. Training—IPHCA hosts periodic webinars about all things O/E, can speak at coalition or group meetings, and offer face-to-face instruction. Meet the IPHCA Outreach and Enrollment Staff Jessica Ellis received her Bachelor of Science degree in Retail Management and an associate degree in Organizational Leadership and Supervision from Purdue University. Since joining IPHCA in Mid-2009, Jessica has been a part of many aspects of IPHCA and has enjoyed working with our members. As the Outreach and Enrollment Program Director, Jessica works with Community Health Centers on growing, educating, and developing their Outreach and Enrollment staff. Email: [email protected] Phone: (317) 630-0845, ext. 120 Emily Daw received her Bachelor of Liberal Arts from Indiana University at Indianapolis with a concentration in English Arts and Humanities and is currently pursuing an MBA. Since joining IPHCA in January 2014, Emily has played a role in assisting with all Outreach and Enrollment initiatives--most importantly serving as support to health centers as they work diligently to ensure all Hoosiers have access to quality, affordable health insurance. Email: [email protected] Phone: (317) 630-0845, ext. 116 About This Guide This guide was created, developed, and distributed through generous funding from The Health Foundation of Greater Indianapolis (THFGI). THFGI is a private foundation that serves the community's most vulnerable citizens by funding health-related projects and organizations not easily supported by other means. Download a hyperlinked copy of this guide online: https://indianapca.site-ym.com/?page=OEResources 3 Becoming an Indiana Navigator and Certified Application Counselor Introduction to Consumer Assistants With the launch of the Patient Protection and Affordable Care Act (PPACA, or ACA), 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 1. Complete online New Application for Indiana Navigator Certification. ($50 and $14.40 processing fee for Indiana residents) *Licensed insurance producers and consultants are excluded from this requirement and must submit the Designation Form for Licensed Producers and Consultants.* Applicants may check the status of their application online at: www.sircon.com/login.html. Application submissions will remain "Pending"/"Under State Review" until all 6 Steps are complete. Application submissions still pending/incomplete after 90 days from the submission date will be withdrawn. 2. Complete and submit a Background Check ($7-17 for Indiana residents) *Licensed insurance producers and consultants are excluded from this requirement.* 3. Review the Conflict of Interest Policy, then complete and submit the Conflict of Interest Disclosure Form. 4. Review, sign, and submit the Privacy and Security Agreement. 5. Complete Precertification Training and Continuing Education from an IDOI-approved Navigator precertification education (PE) provider. *IPHCA recommends www.IndianaNavigators.org for only $4.95.* 6. Pass certification exam. Follow the Certification Examination Procedure and Guidelines. *Licensed insurance producers and consultants are excluded from this requirement.* 4 All forms/documents may be attached electronically to the end of the online application. They may also be submitted to IDOI by either: o Email: [email protected] o Fax: 317-232-5251 ("attn: Navigator Director"), or o Mail: Indiana Department of Insurance, c/o Navigator Director, 311 W. Washington St., Ste. 300, Indianapolis, IN 46204. Applicants may check the status of their application online at: www.sircon.com/login.html. o Application submissions will remain "Pending"/"Under State Review" until all six steps are complete. Application submissions still pending/incomplete after 90 days from the submission date will be withdrawn. All Navigators receive a unique ID number upon successful completion of all steps. A certificate may be requested by emailing [email protected]. Renewal Steps Sixty (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 [email protected]. 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. Tips for Protecting Personally Identifiable Information (PII) ● Do not leave computer screen open ● Securely destroy and dispose of personal information ● Inform consumer of any security breach Privacy, Security and Confidentiality Standards Indiana Navigators and AOs have access to some very personal information. Due to the sensitivity of this information, Navigators 5 and AO must agree to maintain the confidentiality of and protect any information provided by the consumer in the process of applying for and enrolling in a qualified health plan (QHP) or public health insurance program like HIP. Please see page 10 for more information about complying with privacy and security requirements. Application Organization (AO) An AO is an organization such as a Community Health Center (CHC) or Federally Qualified Health Center (FQHC) that has employees and/or volunteers assisting consumers with applications for Marketplace-based health plans, insurance affordability programs and statebased health coverage programs like HIP and Hoosier Healthwise. Initial Application Steps 1. Complete the New Application for Application Organization Registration. Pay the online filing ($50) and processing fees ($14.40). 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.) 2. 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. 3. Review the Conflict of Interest Policy, then complete and submit the Conflict of Interest Disclosure Form and Privacy and Security Agreement. 4. Submit all documents online at end of online application or to [email protected] Annual Renewal Process AOs have a 30-day grace period following the expiration date to complete all steps. 1. Complete the Renewal Application for Application Organization Registration. 2. Pay the nonrefundable online filing ($50) and processing fees ($7.23). 3. 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. 4. Review the Conflict of Interest Policy and submit the Conflict of Interest Disclosure Form and Privacy and Security Agreement 5. Submit all documents at end of online application or to [email protected] Please view the Indiana Department of Insurance’s (IDOI) website for more information about becoming an Indiana Navigator and/or Application Organization and the recertification process: www.in.gov/idoi/2823.htm. Federal Navigators Federal Navigators are selected and funded by the federal government to serve in Federally-Facilitated (FFM) or Partnership Marketplace states for one year (minimum). In April 2015, CMS announced the new funding period will be 36 months; recipients will be announced in early September 2015. Federal Navigators in Indiana are also required to become Indiana Navigators. 6 Certified Application Counselors Certified Application Counselors (CACs) provide free, unbiased assistance to consumers applying for and enrolling in health coverage. There is no cost associated with becoming a CAC. The federal government provides the training and certification materials but does not provide any funding for it. The training is administrated through the Medicare Learning Networks and is expected to take between 5-8 hours to complete. Many CACs spread the training over the course of a few days in order to keep up with other assigned duties. Individuals who want to become CACs must be affiliated with a CAC Designated Organization (CDO), an organization designated by the Marketplace to oversee individual CACs. Key Points • Organizations (FQHCs) receiving HRSA funding must become a Certified Application Counselor (CAC) Designated Organization and appoint enrollment staff as CACs to complete any health coverage application. • CAC organizations (usually the AO) apply to1 and are designated by the Marketplace. o The organization is responsible for assigning CAC numbers and training their staff and volunteers as individual CACs. • 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 Annual Training CMS recommends that individual CACs complete their CAC training prior to the beginning of the Open Enrollment Period, even if this is prior to the expiration date of their certification. This ensures that they have received the most up-to-date training to provide application and enrollment assistance to consumers. CAC Designated Organization (CDO) Registration Steps Complete the application to be a Certified Application Counselor Organization: https://marketplace.cms.gov/technical-assistance-resources/assister-programs/cac-apply.html o The individual identified as the authorized representative on the application should hear back from CMS within a few weeks by email. The email will contain a contract. Sign contract and return to CMS Once approved, help staff or volunteers become certified as individual CACs. o The authorized representative must assign each CAC a unique number which will consist of the organization’s number (e.g. INCACA9401) CAC organizations must have these two agreements in place before assisting consumers: o An agreement between the CAC organization and the Centers for Medicare and Medicaid Services (CMS) o Agreement(s) between the CAC organization and individual CAC(s) (staff and/or volunteers) 1 https://marketplace.cms.gov/technical-assistance-resources/assister-programs/cac-apply.html 7 CAC Certification Steps Complete Marketplace-approved training (Available on https://marketplace.medicarelearningnetworklms.com/Default.aspx) 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. Upon completion of the training, the CAC organization will issue certificates once they have completed these requirements. CAC Recertification Steps Complete the new training via the Medicare Learning Network. (https://marketplace.medicarelearningnetworklms.com/Default.aspx) Complete the Recertification Request Form (https://marketplace.cms.gov/technical-assistanceresources/recertification-request-form.PDF). If necessary, enter into a new CDO-CAC Agreement with your CAC organization. Your CAC organization will issue a new certificate which should be displayed when assisting consumers. Helpful Tool Enroll America’s CAC Organization Toolkit: https://www.enrollamerica.org/resources/toolkits/cac/ Ethical Standards for Assisters DO Be honest regarding personal bias or conflict of interest Give complete and accurate information Admit when you do not 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 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. 8 • • The Marketplace call center (1-800-318-2596) offers immediate assistance in English and Spanish with a language line for other options. It’s suggested to have oral and written notice of language assistance services at Navigator appointments such as the call center number, existing staff members that serve as translators, and/or an outside service providing language assistance services. Serving Persons with Disabilities In Indiana, it is most likely that consumer assistants will work with individuals that have a type of disability—approximately 13.1% of Indiana’s population has some type of disability. You should be prepared to: • Ensure consumer education materials, websites, etc. are accessible to all (e.g. providing TTY services) • Provide assistance in a location & in a manner physically accessible (e.g. wheel chair access) • 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: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 9 Data Management Protecting Consumer Information Tracking Consumer Data Use contact cards and authorization forms like CMS’ “Appendix E.” Download this “IPHCA Contact Card” here: http://www.indianapca.org/?page=OETools Use password-protected and/or encrypted computer files, data management. websites, or locked storage cabinets. Limit who has access to the data. Helpful Tips Track only what you care about (age, language, income, etc.). Re-evaluate your strategies and data tracking on a regular basis. Always have benchmark goals. o Monthly, weekly, daily o By geography o By staff Set goals that will be met about ½ the time. o (e.g. “enrolling 25 people per week”) Connect each person’s goal to the big picture –understanding consumers based on the metrics you track to ensure Hoosiers get enrolled and stay enrolled in health coverage. Establish who enters the data. Where to get Data about Your Community Small Area Health Insurance Estimates (SAHIE): www.census.gov/did/www/sahie/ Public Use Microdata Areas (PUMAs): www.census.gov/geo/reference/puma.html State Health Access Data and Assistance Center (SHADAC): www.shadac.org/ Enroll America—Marketplace data by zip codes: www.enrollamerica.org/researchmaps/maps/changes-in-uninsured-rates-by-county/ STATS Indiana—Public Data Utility: www.stats.indiana.edu/index.asp The State of Indiana Monthly Medicaid enrollment data: www.in.gov/fssa/ompp/4881.htm 10 Privacy and Security Standards Compliance with Personally Identifiable Information (PII) Standards Inform consumers of your assister role and the application process; ensure they understand. Obtain documented authorization prior to accessing personally identifiable information (PII) and assisting with eligibility and enrollment—you can do this in-person, over the phone, in writing, or electronically. Maintain a record of the authorization. Inform Obtain Assist Maintain What is PII? Information that can be used to distinguish or trace an individual’s identity, whether alone or combined with other information linkable to the individual: Name Address Income Social Security Number Email address Photographic images Date and place of birth Mother’s maiden name Payment information Informing Consumers Explain to the consumer: Your assister duties as a Navigator/CAC Their privacy rights How the information will be used and stored Have client sign the Certified Application Counselor (CAC) Authorization Form (“Appendix E”) or the authorization form created and approved by your organization. Make sure you are providing space that is secure and comfortable for the consumer. Obtaining Authorization Your authorization should include at least the following: Acknowledgement that you informed the consumer of your responsibilities as a Navigator or CAC Consent for you to access and use the consumer’s PII to carry out your assister functions and responsibilities Acknowledgment that the consumer may withdraw any part of the authorization at any time Description of any limitations the consumer wants to place on your access or use of PII It is recommended to include the following in your standard authorizations: Explanation of what PII includes and examples of PII you might request Acknowledgment that the consumer is not required to provide you with any PII Explanation that the help you provide is based only on the information the consumer provides 11 Acknowledgement that you will only ask for the minimum amount of PII necessary for enrollment purposes and assister responsibilities IPHCA encourages assisters to utilize CMS’s Model Authorization Form for CACs, or “Appendix E”. Download it here: http://www.indianapca.org/?page=OESecurityStandards Maintaining a Record of Authorization At minimum, the record of the authorization should include the following: Consumer’s name (and the name of the authorized representative if applicable) The date of authorization Your name, or the name of the assister to whom authorization was given (you can include multiple names) Notes regarding any limitations placed by the consumer Notes recording all acknowledgments as previously discussed Notes of any changes made to the authorization later Maintaining Post-Enrollment PII You can store PII in a format and process that works best for your organization. You must maintain record of consumer authorization for at least six years. CMS expects your organization to establish policies for keeping records of authorization secure, organized, and accessible if a consumer needs to update or correct their information or consent 6 years De-identify information used in presentations or for reporting purposes if it is not necessary. If confidential information is used for a success story, commercial, etc., obtain consent from the client. Only provide or compile data which is required to fulfill its purpose. Password protect and/or encrypt all data files containing sensitive information. Methods of Storing PII Paper Use locked file cabinet. Shred any unnecessary information. Only individuals who need access to files to complete job duties should have access. 12 Electronic Keep authorization in a passwordprotected and/or encrypted computer and/or file. Do not access PII on an unsecure network. Scheduling Appointments Receive and document client permission to collect and put PII on outlook calendar or scheduling system o CMS permits you to use technology tools to schedule appointments. Tips to remember before buying or using scheduling tools: o Carefully review the software tool’s terms regarding how a consumer’s information will be used Check that the terms do not claim to provide a service on behalf of CMS or the Marketplace. o Be sure to inform consumers how the tool will use their data by updating your organization's Privacy Notice Statement. o If the tool reports to a third party, you should ensure the consumer permits the third party to collect, use and store information. CMS encourages you to have a separate consent form if this is the case. Assisting Over the Telephone • Read your organization’s standard written authorization form or a script that contains required elements. • Record in writing that the consumer’s authorization was obtained. • Read back the content of the record to the consumer. • Provide a copy of the record to the consumer at earliest available opportunity. Assisting Via Email • ONLY email PII through a secure email. • It is risky to use personal email systems such as: Yahoo, Gmail, MobileMe, etc. • Identify suspicious emails. • Do not open suspicious email attachments or respond/forward the message. • Never save PII on a cell phone device unless it is encrypted. • Before emailing a consumer, ensure a valid consent is on record. Tips for Protecting PII Be aware of your surroundings and who’s listening. Speak softly. Close doors whenever possible. Lock computer screen when left unattended. Password protect any program or document with PII. Turn or block computer screens from public view as much as possible. Lock-up contact cards. Shred documents when necessary and dispose of appropriately when finished. When leaving voice messages, only provide your name, contact information, and a message for callback. Try to avoid faxing sensitive PII—scan, encrypt and email. If you must fax, arrange transmission with the recipient and use cover sheets. Obtain authorization from your supervisor to remove PII from the workplace, and ensure it is appropriately secured. 13 Password Tips Don’t tell anyone your password or permit your computer to remember. Don’t reuse old passwords. Don’t use personal information (SSN, Birth dates). Memorize! Change on a regular basis. Use 6-8 characters (mix of upper and lower case, alpha and numeric). Security Breaches • When there is a breach or potential breach (i.e. when equipment or data is lost or stolen), prompt action is critical Notify management immediately. Notify IDOI no later than 5 days after discovery. Notify the consumer no later than 10 days after discovery. 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____________________________________________________________________________ 15 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.2 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!i Health Insurance Terms to Know Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law. Authorized Representative (AR): Someone chosen to act on behalf on an individual with the Marketplace or Medicaid programs. Some ARs may have legal authority to act on behalf of an individual. Catastrophic Health Plan: Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but do not cover any benefits other than three primary care visits per year before the plan’s deductible is met. The premium amount paid each month is generally lower than for other QHPs, but the out-of-pocket costs are generally higher. To qualify for a catastrophic plan, an individual must be under 30 years old or get a hardship exemption because the Marketplace determined that he or she is unable to afford health coverage. COBRA: A federal law that may allow an individual to temporarily keep health coverage after employment ends, coverage as a dependent is lost, or another qualifying event. If an individual elects COBRA coverage, he or she pays 100% of the premiums, including the share the employer used to pay, plus a small administrative fee. 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. 2 Source: HHS, Kaiser Health News 16 Cost Sharing Reduction (CSR): A discount that lowers the amount you have to pay out-ofpocket for deductibles, coinsurance, and copayments. CSR subsidies are automatically applied on the federal Marketplace for individuals and families with income below 250% of the federal poverty level (FPL). A consumer must select ad enroll in a silver plan for CSR eligibility. Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. Employer Shared Responsibility Payment (ESRP): The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to its full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP. Essential Health Benefits (EHBs): Marketplace plans must include health benefits in at least 10 categories (see image on right). Exemption: If an individual does not have qualifying health coverage, he or she can apply for one of the many exemptions to avoid paying the “penalty” or “individual share responsibility payment.” Exclusive Provider Organization (EPO): A lot like HMOs; They generally do not cover care outside the plan’s provider network. Members, however, may not need a referral to see a specialist. Explanation of Benefits (EOB): Summary of health care charges that your health plan sends you after you see a provider or get a service. Federal Poverty Level: A measure of income level issued annually by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine eligibility for certain programs and benefits. Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list. Grandfathered Plan: A health plan exempt from certain provisions of the Affordable Care Act. Health Insurance Marketplace: Also known as just “Marketplace” or “Exchange,” The Health Insurance Marketplace is a resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace encourages competition among private health plans, and is accessible through www.healthcare.gov, the CMS call center, and in-person assistance. 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 will not 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. 17 Health Savings Account (HSA): An HSA is a tax-exempt or custodial account set up with a qualified HSA trustee (such as bank or insurance company) to pay or reimburse certain medical expenses. Individual Shared Responsibility Payment: Also known as the “penalty” for not having health coverage or an exemption. This is a fee that is collected through the IRS when an individual files his or her tax return. Modified Adjusted Gross Income (MAGI): The figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP. Generally, MAGI is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income. 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 2015-2016 Open Enrollment Period is November 1, 2015 - January 30, 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. 2016 Out-of-Pocket Maximums Individuals $6,850 Families $13,700 Point of Service (POS): Plans vary, but POS plan are often a sort of hybrid HMO/PPO. Members may need a referral to see a specialist, but they may also have coverage for out-ofnetwork care, though with higher cost-sharing. Preventive Services: Most health plans cover a set of preventive services like shots and screening tests with no cost-sharing—including copayments and coinsurance even if the deductible has not been met for the year. This includes Marketplace private insurance plans. 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 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 133-400% of the federal poverty level qualify for the Premium Tax Credit (PTC), which is a subsidy available only through the Marketplace to help pay for a Qualified Health Plan (QHP). 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. 18 Qualifying Life Event: A change in life that can make and individual eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in family size (marriage, divorce, or having a baby) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder. Special Enrollment Period (SEP): A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Jobbased plans must provide a special enrollment period of 30 days. TRICARE: A health care program for active-duty and retired uniformed services members and their families. 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 Indiana3; appeal decisions are made within 90 days. Appeals can be mailed to: Helping Consumers Health Insurance Marketplace Understand Health Coverage 465 Industrial Blvd. London, KY 40750-0061 Use familiar language Reporting Life Changes It is extremely important to remind consumers that they must report changes such as: Marriage, divorce or death of a spouse Becoming pregnant Birth, adoption or placement of a child A permanent move outside insurer’s coverage area 3 https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf 19 Check for understanding Use visuals and keep the conversation interactive Facilitate healthy decisionmaking 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 Change in filing status Incarceration or release from incarceration Corrections to name, date of birth, or Social Security number 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. You can tell both colleagues and partners 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 Involving the entire organization in planning a health literacy outreach event. 20 Did you know October is Health Literacy Month? You can use this month to build awareness about the open enrollment period, educate about health coverage options, and encourage consumers to commit to enrolling! There are many community festivals and events during October as well as other health-related events and awareness weeks to partner with such as: National Breast Cancer Awareness Month National Health Education Week: October 19-24, 2015 National School Lunch Week: October 12-16, 2015 National Child Health Day: October 6, 2015 Red Ribbon Week: October 10-21, 2015 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 Helpful Resource: Enroll America’s Health Insurance Literacy Resource Hub: https://www.enrollamerica.org/hil/ NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 21 Effective Outreach & Enrollment Tips for Providing Effective Outreach & Enrollment Strengthen Your Team Reflect and debrief on what worked and what did not work in 2015. 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 Immigrant and refugee organizations o Indiana Minority Health Coalition o Local universities, community colleges and technical schools o Food pantries and shelters o Child care centers o School districts and school nurse workgroups o Head Start programs o WIC o Unemployment offices o Health departments o Tax preparation sites like VITA o Hospitals and hospital associations Attend community events like health expos, county fairs, job fairs, ethnic and multicultural fairs, parades, and holiday celebrations. 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? 22 o What population gaps do you need to reach, and how will you reach them? Research and implement new strategies: 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: o Understand, maintain and use their coverage o Understand their rights as health care consumers o Appeal eligibility and coverage decisions o Report a change in circumstance and navigate subsequent eligibility redeterminations How these changes may affect APTC and eligibility for coverage o How and when to pay premiums (if applicable) o The annual redetermination and open enrollment process Assist American Indians, Native Alaskans and other members of tribal organizations. o Documented members of federally-recognized tribes can enroll for the first 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. 23 Relaying the Important of Health Coverage Key Messages for Consumers: • Consumers should apply for insurance because plans available in the Marketplace and Indiana Health Coverage Programs (Medicaid) 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 stay is $2,025.ii • “Apply before the deadline!” • “You may be eligible for financial assistance to help pay for your health insurance.” • “If you do not enroll in health coverage, you may be fined when you file your taxes.” Promising Best Practices Look at the patient list for the next day and identify possible clients Prescreen your clients Take advantage of free advertising like school newsletters and IN-211 Partner with schools, libraries and other community resources NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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25 Assisting Immigrants & Refugees with Health ____________________________________________________________________________ Coverage Applications Coverage for Lawfully Present Immigrants Lawfully present immigrants are eligible for coverage through the Health Insurance Marketplace. The term “lawfully present” includes immigrants who have: “Qualified non-citizen” immigration status without a waiting period (see details below) Humanitarian statuses or circumstances (including Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking) Valid non-immigrant visas Legal status conferred by other laws (temporary resident status, LIFE Act, Family Unity individuals) Lawfully Present Immigrants and Marketplace Savings Lawfully present immigrants can buy health insurance on the Marketplace. If their annual income is 400% of the federal poverty level or below: They may be eligible for premium tax credits and other savings on Marketplace insurance. If their annual household income is below 100% federal poverty level: If they’re not otherwise eligible for Medicaid, they’ll be eligible for premium tax credits and other savings on Marketplace insurance, if they meet all other eligibility requirements. 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) 26 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 Types of Immigration Documentation Immigrants applying on the Marketplace may need to have one or more of the following documents when applying for and enrolling in coverage. The documents they need depend on their immigration status. The following is a list of immigration documentation types and examples for some of the most common types. Administrative order staying removal issued by the Department of Homeland Security Alien number (also called alien registration number or USCIS number) or 1-94 number Arrival/Departure Record (I-94/I-94A) Arrival/Departure Record in foreign passport (I-94) Certificate of Eligibility for Exchange Visitor Status (DS2019) 27 Certificate of Eligibility for Nonimmigrant Student Status (I-20) Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR) Document indicating membership in a federally recognized Indian tribe or American Indian born in Canada Document indicating withholding of removal Employment Authorization Card (I-766) Foreign Passport Machine Readable Immigrant Visa (with temporary I-551 language) Notice of Action (I-797) 28 Office of Refugee Resettlement (ORR) eligibility letter (if under 18) Permanent Resident Card, “Green Card” (I551) Reentry Permit (I-327) Refugee Travel Document (I-571) Temporary I-551 Stamp (on passport or I94/I-94A) Lawfully Present Immigrants and Medicaid Immigrants who entered the U.S. on or after August 22, 1996 must meet the five-year waiting period for Medicaid or CHIP coverage after receiving a “qualified immigrant status.” People who do not have eligible immigration status are therefore not eligible for full Medicaid coverage, but they may get coverage for limited emergency services through Medicaid “Package E” if they meet all other Medicaid eligibility criteria. 29 Medicaid & CHIP Coverage for Lawfully Residing Children and Pregnant Women States have the option to remove the 5-year waiting period and cover lawfully residing children and/or pregnant women in Medicaid or CHIP. Twenty-nine states, plus the District of Columbia and the Commonwealth of the Northern Mariana Islands, have chosen to provide Medicaid coverage to lawfully residing children and/or pregnant women without a 5-year waiting period. Twenty-one of these states also cover lawfully residing children or pregnant women in CHIP. Indiana has chosen not to provide coverage to either of these groups. Getting Emergency Care Medicaid provides payment for treatment of an emergency medical condition for people who meet all Medicaid eligibility criteria in the state (such as income and state residency), but don’t have an eligible immigration status. 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. 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 cannot 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 Social Security Number (SSN) and immigration/citizenship status. States cannot deny benefits to an applicant because a family or household member who is not applying has not disclosed his or her citizenship or immigration status. People who are not seeking coverage for themselves will not 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 (1-866-5785409) 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. 30 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. One of these: OR two of these: • Driver’s license • U.S. Public Birth Record • School ID card • Social Security Card • Voter Registration Card • Marriage Certificate • U.S. Military Card • Divorce Decree • U.S. Military Draft Record • Employee Identification Card • Military Dependent ID Card • High School or College • Tribal Card Diploma • Authentic Document from a Tribe • Property Deed or Title • U.S.C.G Merchant Mariner Card • ID card issued by the federal, state, or local government • Including immigration document and US passport 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 cannot 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. 31 NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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____________________________________________________________________________ ____________________________________________________________________________ 33 Guide to Tax Rules Determining Eligibility Based on Income •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 Marketplace 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… Single Head of Household Married, Filing Jointly Married, Filing Separately Qualifying Widow(er) with Dependent Child(ren) And age at the end of 2014 was… Under 65 65 or older Under 65 65 or older Under 65 (both spouses) 65 or older (one spouse) 65 or older (both spouses) Any age Then Required to file a return if gross income was at least… $10,150 $11,700 $13,050 $14,600 $20,300 $21,500 $22,700 $3,950 Under 65 $16,350 65 or older $17,550 Please note that at the time of this publication, the 2015 numbers were unavailable. Please refer to IRS.gov for updates. Tax Elements Defined Deductions An expense from gross income that can be deducted from one’s taxable income. Examples include: 34 Moving expenses (can only be deducted if the taxpayer moved due to a change of employment or business location or to start a new business.) IRA contributions (not Roth IRA)—The maximum IRA deduction is $5,500 ($6,500 if over age 50), or twice that amount if Married Filing Jointly. Student loan interest—The deduction of student loan interest is capped at $2,500 per year. Tuition and fees—The maximum amount of the tuition and fees deduction that can be claimed is $4,000 per year. This deduction is not available for married couples who file separate tax returns. 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 2015 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). 35 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 do not 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. Non-resident aliens: In general, a couple cannot file jointly if one spouse is a nonresident for any portion of the year. However, they can choose to file jointly if one spouse is a U.S. citizen or resident and the non-resident spouse agrees to be treated as a U.S. resident for the year; in that case, both spouses would be taxed on worldwide income. Same-sex marriage: As of June 2015, same-sex couple is considered married for federal and state tax purposes. 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. Abandoned Spouses: A taxpayer is still eligible for premium tax credits if he or she has been abandoned by a spouse and certifies on the tax return that they are unable to locate the spouse after “reasonable diligence.” Victims of Domestic Abuse: A married individual who is living apart from his or her spouse at the time of filing an income tax return, and is unable to file a joint return as a result of domestic abuse, will be permitted to claim a premium tax credit while filing a tax return with a filing status of married filing separately. 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. Living apart: Married people cannot claim to be “Single” if they are still married, even if they have been living apart from their spouse for a long time or their spouse is in another country. Legal separation: Indiana residents who are legally separated must still file as married (either jointly or separately) until their divorce is finalized. Indiana Code 31-15-3-9 specifies that a legal separation cannot last longer than one year. Divorce: A divorce decree must be final in order for the tax filer to be considered “Single”. An interlocutory decree — a temporary court judgment — is not final and does not qualify a person to be “Single.” 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. 36 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 (or 24 if a full-time student or any age if disabled) Does not 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, 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 Makes less than $3,900 (in 2014). Generally does not 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. 37 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. Counting a Dependent’s Income Premium tax credit and Medicaid rules require a tax dependent’s income to be included in the household income if the tax dependent is required to file a tax return. In general, individuals claimed as dependents on someone else’s tax return must file taxes if they receive at least $6,200 in earned or $1,000 in unearned income (for 2014 tax year). Medicaid Rules for Determining Household 38 Rules for All Dependents—To be a dependent, three tests must be met: 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. Helpful Resources CBPP’s The Assister’s Guide to Tax Rules In The Loop’s Tax Resource Center IRS Tax Tips Newsletters Health Coverage and Federal Income Taxes Most tax filers, about 75%, just need to check a box on their tax return to indicate that they had coverage all year. Marketplace consumers receive a Form 1095-A that includes all the information they need about their coverage to file their return. Consumers will use the information included on Form 1095-A to complete Form 8962, which they will file with their tax returns to claim the premium tax credit or to declare premium assistance they received through advanced payments made to their insurance provider. Read more about the Form 1095-A online: https://marketplace.cms.gov/technical-assistance-resources/1095a-faqs.PDF. Exemptions Consumers who obtained a coverage exemption from the Marketplace or qualify for an exemption that can be claimed on the tax return will file Form 8965. NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 39 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 President Barack 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 Members of federally recognized tribes may qualify for additional cost-sharing benefits. 40 Quick Facts about American Indians and Alaska Natives Members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders: Can enroll in the Marketplace any time Can change plans up to once a month Can be exempt from the penalty for not having health coverage Do not have any out-of-pocket costs for Indian health programs Do not have any out-of-pocket costs if their income is below 300% FPL 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: x Not offered in the metal tier levels of QHP Subject to a maximum out of pocket amount 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. Reason for Exemption Where to apply When to apply Length of exemption No health insurance for less than 3 months in a row (short coverage gap) No application needed; this will be handled on tax return Tax return or automatically exempt if not required to file a tax return Tax return 2015 Application Tax filing The months without coverage, up to 3 months N/A Calendar year Tax filing Calendar year IRS will provide guidance IRS will provide guidance Marketplace application, tax return, or this form Marketplace application, tax return, or this form Anytime within the year Until the first full month that immigration status has changed Month(s) in prison or jail after a conviction Anytime within the year Months of membership Income below tax filing threshold Insurance is more than 8% of household income (income from all members of household listed on taxes) Not lawfully living in the US, do not have permanent residency, or considered a “nonresident alien” In jail or prison after a conviction Member of a recognized health care sharing ministry that pays the health expenses of its 41 members Member of a federally recognized Indian tribe or ANCSA corporation Marketplace application, tax return, or this form Anytime within the year; documentation must be submitted Anytime within the year Member of a religious sect that is opposed to insurance, such as the Amish Marketplace application or this form Eligible for services through an Indian health care provider Marketplace Anytime within the application or this year form Hardship Exemptions Marketplace Right away when application or this hardship begins application for exemption form Unexpected increase in basic expenses that prevents purchase of coverage Cost of coverage would deprive individual of food, shelter, clothing or other necessities Homelessness, eviction, foreclosure, damage from natural disaster In a plan that cannot be renewed and cannot afford other plans (See complete list here) Insurance would cost more than 8% of household income for the upcoming year Income is below 100% of poverty, but cannot get Medicaid (Hoosier Healthwise, HIP, etc. Marketplace application Marketplace application Before February 15, during a special enrollment period, or when eligible for a jobbased plan Anytime within the year Continues unless a change is reported For adults, continues until a change is reported For children, continues until age 21, at which time a separate application is required Until ineligibility for services is reported At least three months; might need to be renewed The rest of the year after an exemption is granted Calendar year 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 choose to not accept the coverage and purchase coverage that meets ACA requirements instead. Grandfathered plans may be renewed up until October 1, 2016. 42 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 20152016. 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 Bronze Silver Gold Platinum AV target AV Band 60% 70% 80% 90% 58-62% 68-72% 78-82% 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. 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 43 Open Enrollment Period Annual timeframe when consumers can purchase health coverage on the Marketplace. The open enrollment period for 2015-2016 is November 1, 2015—January 30, 2016. 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 138-400% 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 138% and 400% of FPL No other MEC is available; or available coverage has individual premium ≥ 9.5% 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 overpayment of the APTC is capped, so individuals between 100% and 400% FPL for the 2015 tax year may owe no more than the amounts due to excess APTC payments 2014 APTC Repayment Caps Household income Single Individual Family < 200% FPL $300 $600 200% to 300% FPL $750 $1,500 300% to 400% $1,250 $2,500 400% and above Full Amount Full Amount Please note that at the time of this publication, the 2015 numbers were unavailable. Please refer to IRS.gov for updates. 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. 44 Rating for Age Limited to a 3 to 1 ratio—older adults may be charged no more than three 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 three-to-one 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, or one-twelfth (1/12) of the annual penalty amounts, for each month without coverage. 45 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 Details/Examples Loss of Minimum Essential Coverage (MEC) Loss of eligibility for employer coverage (e.g., loss of a job, Voluntarily quitting a job, or a reduction in work hours that causes Loss of availability of employer-sponsored plan Loss of Medicaid or CHIP eligibility (including loss of pregnancy-related and medically needy Medicaid) Expiration of COBRA Cancellation of non-group plan Loss of eligibility for student health plan Divorce or legal separation resulting in loss of coverage Cessation of dependent status Death (i.e., of another person in the family) resulting in loss of coverage Decertification of current Marketplace coverage No longer living, working, or residing in the area of the plan Termination of employer contributions to employee’s health coverage Newly eligible for the premium tax credit due to discontinuation or change to employer-sponsored plan resulting in plan no longer being considered MEC IF PLAN SELECTED AFTER DATE OF LOSS OF COVERAGE: 1st day of the month following plan selection The plan year ends for a non-calendar year plan in the individual (non-group) or group market (i.e., the plan year ends in a month other than December) Applies even if there is an option to renew the non-calendar year plan 1 of the next month following plan selection IF PLAN SELECTED BEFORE OR ON DATE OF LOSS OF COVERAGE: 1st day of month following loss of previous coverage Death: Enrollee or enrollee’s dependent dies Divorce IF PLAN SELECTED AFTER DATE OF LOSS OF COVERAGE: 1st day of the month following plan selection Date of birth, adoption, placement of adoption or placement in foster care 1st day of month following plan selection Birth, Adoption, Foster Care Losing a dependent or no longer considered a dependent IF PLAN SELECTED BEFORE OR ON DATE OF LOSS OF COVERAGE: 1st day of month following loss of previous coverage st Marriage Expiration of noncalendar year plan QHP Effective Date 46 Loses a dependent due to divorce No longer considered a dependent due to divorce Includes losing dependent through a child support order or other court order Gaining lawfully present status Newly eligible or ineligible for APTC, change in CSRs Permanent Move Regular coverage effective dates Change in income or household size leads to determination that enrollee or dependent is newly eligible or ineligible for premium tax credits Change in income or household size changes eligibility for cost-sharing reductions Includes moving between cost-sharing reduction levels and losing or gaining eligibility Move within the same city, county, or state as long as there is a different set of qualified health plans available Move to another state Return to the U.S. after living outside the country A child or other dependent moves back to parent’s home Released from incarceration Native American or Alaska Native status Is or becomes a member of a federally recognized Native American or Native Alaskan tribe Exceptional Circumstances Demonstrate to the Marketplace that an individual meets exceptional circumstances Serious medical condition or natural disaster kept person from enrolling during open enrollment (e.g., unexpected hospitalization or temporary cognitive disability; an earthquake, hurricane, or massive flooding) Survivors of domestic violence or abuse or spousal abandonment Medicaid/Marketplace transfers that kept a person from enrolling in coverage during open enrollment System errors related to immigration status Unresolved casework that kept a person from enrolling in coverage during open enrollment NOTE: Many complex situations may trigger an SEP under exceptional circumstances. For more information on this SEP and how to access it, see Healthcare.gov: www.healthcare.gov/sep-list 47 Regular coverage effective dates IF PLAN SELECTED BEFORE DATE OF MOVE: 1st day of month following permanent move IF PLAN SELECTED AFTER DATE OF MOVE: Regular coverage effective dates Regular coverage effective dates (May enroll in or change QHPs one time per month) Effective date appropriate to circumstances Error/Inaction/Misconduct Error, misrepresentation, or inaction by the Marketplace or HHS, its instrumentalities, or other entity providing enrollment assistance (e.g., assisters, navigators, insurers, brokers) resulted in the person not being enrolled in a plan, being enrolled in the wrong plan, or not receiving advance payments of premium tax credits or costsharing reductions for which the person was eligible NOTE: For more information on this SEP and how to access it, see Healthcare.gov: www.healthcare.gov/sep-list Effective date appropriate to circumstances Health plan violation Demonstrate to the Marketplace that QHP substantially violated a material provision of its contract Effective date appropriate to circumstances 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: Be U.S. citizen or legal resident Reside in the state they are applying in Not be incarcerated 48 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 do not 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 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 Do NOT Include 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 remembering or making decisions, and/or difficulty walking or Sleeping Standing climbing stairs. Seeing Walking 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 minimum value (whether the policy covers at least 60% of healthcare costs for the covered pool, on average, after premiums). 49 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 assister, 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 Getting health coverage through Medicare or Medicaid Becoming pregnant Change in status of America Indian, Alaska Native or tribal status Other changes affecting income or household size 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 (1-800-318-2596), 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 50 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 2015 coverage ends December 31, 2015 for all Marketplace plans! Historically, coverage loss at renewal is all too common in public health coverage programs like Medicaid and CHIP. Millions of consumers will experience the Marketplace renewal process this fall for the second 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. The consumer’s insurer will send information prior to November 1st about updated premiums and benefits. If a consumer is happy with his or her current plan, and income or household size HAVE NOT changed, then he or she does not need to do anything. The Marketplace will auto-enroll the consumer in the same plan for 2016. 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, 2015 plans will not be offered in 2016 (e.g Assurant enrollees). 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. For an enrollee who did not authorize the Marketplace to request updated tax return information for use in the annual redetermination process: • For those receiving APTC and CSR, a notice will be mailed that states something like: Unless the individual contacts the Marketplace to obtain an updated eligibility determination by December 15th for coverage effective January 1, 2016, then APTC and CSR will end on December 31, 2015. • The Marketplace will renew the enrollee’s coverage in a QHP for 2016 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, 2015 to receive an updated eligibility determination. 51 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 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. Same-Sex Spouses Effective January 1, 2015, a health insurance issuer cannot deny coverage options to same-sex 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. As of June 2015, same-sex marriage is legally recognized on both state and federal levels. 2016 Qualified Health Plan (QHP) Issuers Ambetter (CeltiCare; formerly MHS—both of Centene Corporation) Ambetter is an HMO network which services 28 counties in Indiana. Member Benefits: My Health Pays program—members who stay up-to-date with preventive care services can earn rewards, wellness program reimbursement, discounts on gym memberships, and special health management and pregnancy programs. Ambetter Phone Number Member Services: 1-877-687-1182 Website: www.ambetter.mhsindiana.com 52 Anthem Anthem is Indiana’s largest health insurance company with approximately four million enrolled Hoosiers as of November 2014. Anthem services all counties in Indiana and contracts with over 1,500 primary care providers and over 9,000 specialty care providers. As an open access HMO Network, Anthem Marketplace members Anthem Phone Numbers do not need to select a Primary Care Broker Service Center (helps Navigators): 1-800-742-8199 Physician (PCP) and do not need a Customer Service: 1-855-330-1095 referral to access services that are in Provider Service: 1-855-854-1438 network. Website: www.anthem.com Member Benefits: Special member-only savings on fitness center memberships, hearing aids, LASIK eye surgery, vitamins, health and beauty products, and massage therapy. CareSource CareSource is an HMO that does not require referrals for in-network services. All Indiana University (IU) Health providers are in-network (4,000 as of November 2014) for a total of 10,000 in-network providers in 23 counties. Member Benefits: Free generic prescriptions with Silver and Ultra Gold plans, healthy living programs, and optional dental coverage. CareSource Phone Numbers Customer Service: 1-877-806-9284 or 1-800-429-9502 Provider Service: 1-866-286-9949 Nurse Advice Line: 1-866-206-4240 Website: www.CareSourceJust4Me.com Indiana University (IU) Health Plans IU Health is Indiana’s largest healthcare system which will service 45 counties in 2016. The HMO provider network includes all IU Health physicians and other non-employed physicians at all Indiana Health Hospitals, including Riley Hospital for Children. Referrals are needed for a specialist provider. IU Health Phone Numbers Member Benefits: Local customer solutions center and personal case and disease management MDwise MDwise is an Indiana-based, not-for-profit company that will service all 92 counties in 2016. Members select a Primary Medical Provider (PMP) by calling the MDwise customer service line; PMPs provide referrals to specialists. Direct enrollment: 1-888-820-1275 Member Service: 1-855-413-2432 o Existing member service: #1 o Enrollment information: #2 Website: www.iuhealthplans.org MDwise Phone Numbers Customer Service: 1-855-417-5615 o Provider Service: #1 o Member Service #2 NURSEon-call: 1-855-417-5615 Website: www.mdwise.org Member Benefits: Rewards program for receiving preventive care, completing health risk screening, maintaining healthy weight, etc. (MDwise Rewards—earn points to receive free gift cards). 53 Physicians Health Plan of Northern Indiana (PHP) PHP is an Indiana-based health insurance company headquartered in Fort Wayne. PHP is available in 28 counties in northern Indiana with approximately 12,000 providers to choose from. Plans offered are HMO open-access with HSA options available. Member Benefits: Health clubs (e.g. YMCA and Anytime Fitness and health class (e.g. CPR) discounts, game and activity discounts (e.g. Fort Wayne Children’s Zoo) PHP Phone Numbers Customer Service: 1-800-982-6257 o Pharmacy: #14 o Billing: #16 o All other calls: #11 MyNurse 24/7: 1-800-931-4714 Website: www.phpni.com Southeastern Indiana Health Organization (SIHO) SIHO is an HMO network that services six counties in southern Indiana (Bartholomew, Brown, Decatur, Jackson, Jennings, and Scott). SIHO Phone Numbers Member Services: 1-812-378-7070 or 1-800-443-2980 o Provider: #1 o Member: #2 Marketplace Enrollment Support: 1-844-378-7103 Website: www.siho.org UnitedHealthcare (UHC) UHC is licensed under All Savers Insurance Company (ASIC) on FFM and covers all 92 counties with all Indiana hospitals in-network. Member Benefits: myHealthcare costs calculator to estimate prices of doctor visits, inpatient procedures, and medications and a variety of other digital and mobile tools. UHC Helpful Phone Numbers Navigator Hotline: 1-866-698-1739 Member Services: 1-877-512-9947 Website: www.uhc.com/ Key Changes From 2015 MDwise is expanding from 71 counties to statewide coverage of all 92 counties. Time (Assurant) is discontinuing its plans and will not be a QHP issuer in 2016 54 IU Health Plans will expand coverage from 17 to 45 counties Resources for Addressing Consumer Needs Need or Concern The Affordable Care Act Health plan details Plan recommendations Plan quality Complaints about a Consumer Assistant Complaints about Health Insurance Plan Find another Navigator Resource(s) Federal Marketplace call center: 1-800-318-2596 Health plan summary of benefits, insurance carrier, Employer’s Human Resources of Benefits Manager IDOI—research “Find agent/broker” Federal Marketplace researching, “Consumer Experience” IDOI: On-line Form (click here) Printable Fillable Form (PDF) 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 Filing Complaints with Indiana Department of Insurance (IDOI) IDOI accepts complaints and compiles reports so you and other members of the public can evaluate the companies and agents who conduct insurance business in Indiana. Once the complaint information has been collected, IDOI thoroughly investigates all circumstances and take any appropriate action to prosecute or fine the company or person if found to be at fault. If the insurance company has not followed the terms and conditions of your policy, you may submit a consumer complaint form. Examples of appropriate issues include: Coverage Concerns Claim Disputes Premium Issues Policy Cancellations Refunds You may submit a consumer complaint online using the on-line forms below or via the mail. Mail all complaints to: Indiana Department of Insurance Consumer Service Department 311 West Washington Street, Suite 300 Indianapolis IN 46204-2787 Fax to: 317-234-2103 Types of Issues Handled by IDOI Improper denial or delay in settlement of a claim Alleged illegal cancellation or termination of an insurance policy Alleged misrepresentation by an agent broker or solicitor Alleged theft of premiums paid to an agent, broker, or solicitor Problems concerning insurance premiums and rates Alleged improper handling of an insurance claim by a company or agent What IDOI Can Do: Forward a copy of your complaint to the insurance company, if appropriate 55 Obtain information or explanations on your behalf from the insurance company or their representatives. This may involve written and verbal contact with such companies or persons Review in detail the information obtained from the company for compliance with statues, regulations and policy contracts Explain the provisions of your insurance policy, as appropriate Suggest to you actions or procedures that you may take which could aid in resolving your insurance problems If it is determined that the actions of an insurance company are in violation of a statute, regulation or policy that the Division enforces we may take corrective action against that company. See more information about filing complaints with IDOI here: http://www.in.gov/idoi/2547.htm. NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 56 ____________________________________________________________________________ __________________________________________________________________________ ____________________________________________________________________________ Small Business Health Options Program (SHOP) What is the Small Business Health Options Program (SHOP)? The SHOP Marketplace (www.healthcare.gov/small-businesses) 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 are 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 Penalty is the lesser of: $250 per month or $3,000 per year for each fulltime 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 Employers not offering coverage to at least 95% of full-time employees $167 per month or $2,000 per year for every full-time employee and full-time equivalent employee, excluding the first 30 employees How SHOP Will Work in OE3 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 th th Meet the 70% participation rate of fulltime employees offered coverage (does not include spouses or dependents, if offered)* * The requirement is waived between November 15 and December 15 of each year 57 Employers interested in SHOP coverage should contact their agent or broker or the Marketplace directly at http://www.healthcare.gov or 1-800-706-7893. 2015 SHOP Guidelines In 2015, the employer selects 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. The SHOP Marketplace will also offer small employers an Employee Choice option. 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. Metal Level Bronze Silver Gold Platinum Plan Pays (average) Employee Pays 60% 70% 80% 90% 40% 30% 20% 10% 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 Helpful Tool SHOP FTE Calculator: https://www.healthcare.gov/shop-calculatorsfte/ Guide to Enrolling in the SHOP Marketplace 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. 58 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. 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 has not 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 2015. Employer claims the tax credit when submitting federal income tax returns for 2016 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 Encourage consumers to keep a copy of SHOP eligibility determinations for tax filing purposes 59 Use the HealthCare.gov Full-time Equivalent (FTE) Employee Calculator Use the HealthCare.gov SHOP Tax Credit Estimator The Role of Agents, Brokers, and Producers in SHOP The SHOP Marketplace on HealthCare.gov has an Agent/Broker Portal with online enrollment functions. To work with the SHOP Marketplace, all agents and brokers must keep an active SHOP registration, an active state insurance license, and National Producer Number (NPN). Brokers act on behalf of the consumer. They can be compensated by the consumer or receive compensation from an insurance company. Agents are loyal to an insurance company and sell, solicit, or negotiate insurance on behalf of the insurer. They are compensated by the company (or companies) only. An “independent agent” is affiliated with more than one company. A “captive agent” works for or on behalf of one insurance company. (When you buy a policy directly from an insurance company, you are probably going through an in-house agent.) Producer is a broader term that encompasses both agents and brokers. A producer is defined as someone who sells, solicits, or negotiates insurance. SHOP Resources for Assisters SHOP Small Employer Call Center Health Insurance Marketplace Call Center General Inquiries: 1-800-706-7893 TTY: 1-800-706-7915 Hours: Monday – Friday, 9 AM – 7 PM General Inquiries: 1-800-318-2596 TTY: 1-855-889-4325 Hours: 24 hours a day, 7 days a week Small employers and those helping small employers Employees and those helping employees NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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61 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) Household Size 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. FPL Guidelines are typically released in January each year. The Marketplace will use 2015 guidelines for 2016 coverage. Indiana Health Coverage Programs (IHCP) begins using new guidelines in March or April of each year. In 2015, an individual with a pre-tax income of $11,770 or less is living in poverty, and so is a family of 4 with pre-tax income at or below $24,250. 2015 Federal Poverty Level for The 48 Contiguous States and D.C. 100% 133% 150% 200% 250% 300% 1 2 3 4 5 6 7 8 400% $11,770 $15,654.10 $17,655 $23,540 $29,425 $35,310 $47,080 15,930 21,186.90 23,895 31,860 39,825 47,790 63,720 20,090 26,719.70 30,135 40,180 50,225 60,270 80,360 24,250 32,252.50 36,375 48,500 60,625 72,750 97,000 28,510 37,785.30 42,615 56,820 71,025 85,230 113,640 32,570 43,318.10 48,855 65,140 81,425 97,710 130,280 36,730 48,850.90 55,095 73,460 91,825 110,190 146,290 40,890 54,383.70 61,335 81,780 102,225 122,670 163,560 For family units of more than 8 members, add $4,160 for each additional member. Indiana’s Health Coverage Programs Indiana has a variety of programs with varying criteria with year-round enrollment. The state’s website, www.indianamedicaid.com, is a great resource that provides information about each program, eligibility, and more. The following descriptions are brief overviews of the programs. Hoosier Healthwise Provides health care coverage for pregnant women (up to 213% FPL), children up to age 19 (up to 250% FPL), and former foster children up to age 26 at little or no cost. There are three benefit packages in Hoosier Healthwise. The state determines eligibility and selects the coverage right for the applicant. 62 HHW PACKAGE A—Standard C– Children’s Health Insurance Program (CHIP) P—Presumptive Eligibility for Pregnant Women (PEPW) DESCRIPTION Full-service plan for children and pregnant women No premiums May have small copays for pharmacy, transportation, and emergency services 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 individuals who are determined “presumptively eligible” while their Indiana Application for Health Coverage is being processed Children’s Health Insurance Program (CHIP) CHIP is a part of Hoosier Healthwise (Package C) for children up to age 19 with household income between 158%-250% FPL. A child cannot be CHIP (HHW Package C) Income Limits covered by other comprehensive health insurance to Family Size Monthly Income Limit be eligible for this program. Individuals in CHIP are 1 $2,453 responsible for monthly premiums and must pay the 2 $3,319 first premium prior to coverage becoming effectuated 3 $4,186 (there is a 60-day grace period). A child whose 4 $5,053 coverage was dropped voluntarily may not receive 5 $5,919 CHIP coverage for 90 days following the month of termination with some exceptions. Enrollees of CHIP receive standard HHW benefits like hospital care, doctor visits, check-ups, lab and x-ray services, mental health care, substance abuse services, home health care, dental care, vision care, therapies, emergency transportation, and prescription drugs. There is a three dollar ($3) copayment for generic, compound, and sole-source drugs and a ten dollar ($10) copayment for brand-name drugs; over-the-counter drugs are not covered. Monthly Premiums Family FPL 158% up to 175% 175% up to 200% 200% up to 225% Premium for 1 Child $22 $33 $42 Premium for 2+ Children $33 $50 $53 225% up to 250% $53 $70 Healthy Indiana Plan (HIP) HIP was created in 2008 and is Indiana’s unique health coverage program for adults between the ages of 19-64. On January 27, 2015, Indiana Governor Mike Pence announced that Indiana and the federal government had reached an agreement on HIP 2.0 expansion. HIP 2.0 now covers Hoosier adults age 19-64 with a household income at or less than 138% of the federal poverty level who are otherwise ineligible for Medicaid. The program provides full health benefits including free preventive services, hospital HIP Income Limits services, mental health care, physician services, Family Size Monthly Income Limit 1 $1,370 prescriptions and diagnostic exams. Other new 2 $1,854 features of the HIP expansion include coverage for 3 $2,338 maternity, dental, and vision services. There are 4 $2,822 several different categories of HIP coverage 5 $3,306 outlined in this guide. 63 HIP Plus The initial plan selection for all members is HIP Plus which offers the best value for members. For Hoosiers with incomes up to 138% FPL Required POWER Account contributions (2% member income) No other cost-sharing (except non-ER use of ER) Offers dental, vision, and more comphrensive prescription drug benefit POWER Account jointly funded by member and the state of Indiana Covers Maternity services with no costsharing Other Benefits: 100 visit limit for home health Coverage for Temporomandibular Joint Disorders (TMJ) Bariatric surgery 75 visits annually of physical, speech and occupational therapies 100 day limit for skilled nursing facility Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds Dental—limited to 2 cleanings and 4 restorative procedures per year Pregnant women receive transportation and chiropractic services FPL <22% 23%-50% 51%-75% 76%100% 101%138% Maximum POWER Account Contributions Monthly Income, Maximum Maximum Monthly Single Individual Monthly PAC*, Income, Household Single of 2 Individual Less than $214 $4.28 Less than $289 $214.01 to $487 $9.74 $289.01 to $656 $487.01 to $730 $14.60 $656.01 to $984 $730.01 to $973 $19.46 $984.01 to $1,311 $973.01 to $1,358.70 $27.17 Maximum Monthly PAC, Spouses** $1,311.01 to $1,831.20 $2.89 each $6.56 each $9.84 each $13.11 each $18.31 each *Amounts can be reduced by other Medicaid or CHIP premium costs **To receive the split contribution for spouses, both spouses must be enrolled in HIP HIP Basic HIP Basic is the fallback option for members with household income less than or equal to 100 percent of the federal poverty level (FPL) who don't make their POWER account contributions. HIP Basic can be much more expensive than HIP Plus. 64 For Hoosiers with incomes ≤100% FPL Reduced benefit package (no dental or vision) No required POWER Account contributions Requires copayments for all services POWER Account funded by the state of Indiana Covers Maternity services with no cost-sharing Other Benefits: 100 visit limit for home health 60 visits annually of physical, speech and occupational therapies 100 day limit for skilled nursing facility Early periodic screening diagnosis and testing (EPSDT) services for 19- and 20-year olds Pregnant women receive transportation, vision, dental and chiropractic services Service HIP Basic Copay Amounts $4 $75 $4 $8 Outpatient Services Inpatient Services Preferred Drugs Non-preferred Drugs Non-emergency ED visit Up to $25 HIP State Plus Available to individuals who qualify as low-income parents and caretakers, low-income 19- and 20-year-olds, and individuals with serious and complex medical conditions deemed "medically frail.” Medically frail individuals have been determined to have one or more of the following: disabling mental disorder, chronic substance abuse disorder, serious and complex medical condition, physical, intellectual, or developmental disability, or a disability determination from the Social Services Administration. HIP State Basic If a State Plus member does not make his or her monthly contribution and the member’s income is at or below 100% of the FPL, the member will be enrolled in HIP State Plan–Basic, which requires copayments. Members whose incomes are over 100% of the FPL who do not make their monthly contributions will be subject to a six-month lockout unless they are medically frail or are residing in a domestic violence shelter or in a state-declared disaster area. There are no benefit differences between the two HIP State Plan options; however, individuals are required to either make contributions to their POWER Accounts (HIP State Plan–Plus) or pay copayments (HIP State Plan–Basic). HIP State Plan Benefits: No visit limit for home health 65 Coverage for Temporomandibular Joint Disorders (TMJ) Chiropractic services Bariatric surgery Requires authorization for physical, speech and occupational therapies—but unlimited No limit for skilled nursing facility Early periodic screening diagnosis and testing (EPSDT) services for 19 and 20 year olds Pregnant women receive access to all pregnancy-only benefits on HIP Plus or HIP Basic plan and full State Plan benefits HIP Maternity HIP Maternity is the Medicaid pregnancy program for women eligible for HIP. Women becoming pregnant while enrolled in HIP should report their pregnancy within 10 days of knowing to their MCE and the Department of Family Resources (DFR). With HIP Maternity, all cost-sharing is eliminated until 60 days post-partum. If annual redetermination occurs during pregnancy, federal guidelines require the member to be moved to HIP Maternity. HIP Link HIP Link is an option for eligible members age 21-64 who work and have access to their employer's health plan. HIP Link members also have a POWER account and contribute to their coverage like other HIP members. With HIP Link, the POWER account (valued at $4,000) can be used to pay insurance premiums and out-of-pocket medical expenses associated with the member's employer-sponsored plan. Employers register (http://www.in.gov/fssa/hip/2489.htm) their health plans to participate, then their employees who are eligible and want to participate in HIP Link sign-up with the state. Once an employee is enrolled in the employer-sponsored health plan, the employer will deduct the cost of premiums charged from the employee’s pay, per normal procedures. In turn, the State will reimburse the employee directly for the amount of the deduction, minus a small contribution made by the employee. The employer must pay at least 50 percent of the enrollee’s premium. Most types of employer plans are eligible for HIP Link, so long as the plan meets the minimum benefits requirements of the Affordable Care Act and is verified as an affordable option for employees. Power Account The program provides a Personal Wellness and Responsibility (POWER) Account valued at $2,500 per adult to pay for medical costs. Enrollees contribute approximately 2% of gross income; employers and non-profits can also contribute up to 100% of the contribution amount. Individuals who fail to make their monthly POWER Account contribution after a 60-day grace period may be disenrolled for 6 months if their household income is above 100% of the federal poverty level (FPL); individuals below 100% FPL are kicked to HIP Basic. The POWER Account cannot be used to pay HIP Basic copays. Five-percent (5%) of Income Limit Members are protected from paying more than 5% of their quarterly income toward HIP cost sharing requirements, including the total of all: • POWER account contributions (PAC) • Emergency Room copayments • HIP Basic copayments Members meeting their 5% of income limit on a quarterly basis will have cost-sharing responsibilities eliminated for the remainder of the quarter. 66 Account Rollover HIP Plus: Unused member contributions rollover to offset next year’s required contribution. This amount if doubled if preventive services are completed—up to 100% of the contribution amount. Example: Member has $100 of member contributions remaining in POWER account. This is credited to next year’s required contribution amount. Credit is doubled to $200 if preventive services were completed. HIP Basic: If preventative services are completed, members can offset required contribution for HIP Plus by up to 50% the following year. Members may not double their rollover as in HIP Plus Example: Member receives preventive services and has 40% of original account balance remaining at year end. May choose to move to HIP Plus the following year and receive a 40% discount on the required contribution. Gateway to Work Program HIP members who are unemployed or working less than 20 hours a week will be referred to available employment, work search, and job training programs that will assist them in securing new or potentially better employment. Gateway to Work is a voluntary program, and HIP members will be notified if they have been referred to the program. Eligibility for HIP coverage is not affected if a member chooses to not participate. Those interested in participating in Gateway to Work should call 1-800-403-0864 and select Option 1 for the health coverage menu and then Option 6 for Gateway to Work. Once engaged in the Gateway to Work program, members may receive case management services, participate in a structured job readiness program and receive help with their job search. Additional training, volunteer work experiences and/or education may be provided, as appropriate. Gateway to Work participants will also be invited to attend hiring events with employers. Managed Care All benefits in the new HIP program, with the exception of Medicaid Rehabilitation Option (MRO) services, are provided through the MCEs. This includes dental and pharmacy services, which were previously carved out of HIP. The MCEs are responsible for providing coverage for these benefits and issuing payment to providers. MRO services available to qualifying HIP State Plan members are carved out and reimbursed as fee-for-service claims. Three Managed Care Entities (MCEs) Hoosier Care Connect, Hoosier Healthwise, and HIP enrollees select one of the three managed care entities (MCEs), or they are auto-assigned 14 days after enrollment. In 2015, 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? 67 Changing MCEs Hoosier Healthwise enrollees can change MCES… Anytime during the first 90 days with a health plan 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 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 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 Helpful Tool IPHCA’s HIP 2.0 Hub www.indianapca.org/?page=OEHIP2HUB Hoosier Care Connect Hoosier Care Connect (HCC) is the program that replaced Care Select and serves as the state’s program for the aged, blind, and/or disabled (ABD), population, wards of the court or foster children, 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, comorbidity of Diabetes and Hypertension or other combinations, or other approved serious or chronic conditions. HCC includes all covered services that are covered under Hoosier Healthwise Package A. Members of HCC also receive special services for their personal health needs such as medication therapy management and health care coordination. Traditional Medicaid (Fee-For-Service) The following individuals who meet income and resource requirements are eligible: Persons in nursing homes and other institutions, such as intermediate care facilities for the intellectually disabled (ICFs/ID, formerly ICFs/MR) 68 Immigrants whose alien status is unverified or undocumented Persons receiving hospice services Persons with both Medicare and Medicaid (called dually eligible) Persons with breast and cervical cancer Refugees who do not qualify for any other aid category Current and former foster children Wards of the State 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 Package E Family Planning Presumptive Eligibility (PE) DESCRIPTION Full Medicaid coverage QMB: Medicare Part A & B premiums, deductibles, & coinsurance SLMB/QI: Medicare Part B premiums QDWI: Medicare Part A premiums Emergency Services only– for certain immigrants who do not qualify for full Medicaid coverage Family planning services only Services to members determined presumptively eligible for temporary coverage via the PE process are reimbursed by FFS except for those in the Adult aid category (HIP Basic) and those found presumptively eligible under the Presumptive Eligibility for Pregnant Women (PEPW) process. 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. MED WORKS PREMIUMS Monthly Income $1,472 - $1,716 $1,717 – $1,962 Single Married Premium $48 $69 $1,963 - $2,452 $2,453 - $2,943 $107 $134 $2,944 - $3,433 $3,434 $1,992 - $2,323 $161 $187 $65 $2,324 - $2,655 $2,656 - $3,319 $93 $145 $3,320 - $3,983 $3,984 - $4,647 $4,648 $182 $218 $254 69 590 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 Aged and Disabled Traumatic Brain Injury Community Integration & Habilitation Family Supports ELIGIBILITY SPECIFICS Income: Up to 300% Supplemental Security Income (SSI) benefit (Parental income & resources disregarded for children under 18) Meets ANSA “Level of Care” Would otherwise be place in institution such as nursing home without waiver or other home-based services Complex medical condition which required direct assistance Diagnosis of Traumatic Brain Injury 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. Behavioral and Primary Healthcare Coordination Program (BPHC) BPHC assists individuals with serious mental illness (SMI) who otherwise will not qualify for Medicaid or other third party reimbursement Individuals meet the following eligibility criteria: Age 19+ Medicaid Rehabilitation Option (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: $2,942/month o Married: $3,982/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. 70 Program Qualified Medicare Beneficiary (QMB) Income Threshold 100% FPL Resource Limit Single: $7,280 Couple: $10,930 Benefits Medicare Part A & B Premiums Co-pays, deductibles, coinsurance Part B Premiums (Specified Low Income) SLMB 120% FPL Single: $7,280 Couple: $10,930 Qualified Individual (QI) 135% FPL Single: $7,280 Couple: $10,930 Part B Premiums Qualified Disabled Worker (QDW) 200% FPL Single: $7,280 Couple: $10,930 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 Breast and Cervical Cancer Program (BCCP) of the Indiana State Department of Health (ISDH). Enrollees are also eligible for Hoosier Healthwise Package A during the course of treatment and must meet the following criteria: Must be younger than 65 years old Must not be eligible for another Medicaid category Must not be covered by any other insurance that includes breast or cervical cancer treatment Alternatively, a woman can receive coverage for treatment under the BCCP program if she was diagnosed with breast or cervical cancer, but not screened through BCCP if: She is between the ages of 18 and 65 She has income at or below 200% of the FPL She is not eligible for Medicaid under any other category She has no health insurance that will cover treatment Uninsured or underinsured Indiana residents below 200% FPL (age 40+) may qualify for free breast and cervical cancer screenings and tests. 71 Age 40-49 50-64 65 and older Eligible Services Free office visit & Pap test Free office visit, Pap test, and mammogram 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. Program for All-Inclusive Care to the Elderly (PACE) The Program for All-inclusive Care to the Elderly (PACE) was designed and implemented by the state of Indiana to provide quality community-based care for Indiana Health Coverage Programs (IHCP) members who: Are 55 years old or older Are certified by their state to need nursing home care Are able to live safely in the community at the time of enrollment Live in a PACE service area Presumptive Eligibility (PE) Presumptive Eligibility (PE) is a process that allows Qualified Providers (QPs) to make temporary IHCP eligibility determinations for individuals. PE allows individuals to obtain medical services from any IHCP provider prior to their Indiana Application for Health Coverage (IAHC) is processed and a determination by Family and Social Services (FSSA) is complete Qualified Providers (QPs) The following entities may make PE determinations: QP Criteria QPs must meet the following criteria: Be enrolled as an Indiana Health Coverage Program (IHCP) provider 72 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 Qualifying Individuals Benefits and Limitations 73 Application Process Information is entered on Web interChange 24/7 and is based on self-attestation with real-time responses. QPs are not permitted to ask for supporting documentation to verify eligibility. An individual can apply for all members in his or her family. An application cannot be completed for incapacitated individuals until coherent. 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) Eligible women are pregnant, Indiana residents, and U.S. citizens or qualified immigrants with a household income of less than 213% FPL. PEPW does not pay for hospital stays, hospice, long term care, abortion, postpartum services, labor and delivery, or services unrelated to pregnancy. 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. 74 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. • 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, but if there is not sufficient information, a pre-populated renewal form will be sent to the enrollee. 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) within ten (10) days. Examples of changes include: • Change in address • Income • Family composition (gaining or losing a dependent; marriage) • Citizenship • Residency • Employment • Disability status • Medicaid eligibility • Incarceration • Tax filing status • Babies born to Medicaid enrollees receive coverage for the first year of life without the need for a separate application—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) Community Integration & Habilitation or Family Supports Waiver Family Planning Eligibility Program Healthy Indiana Plan (HIP) Apply for Medicaid coverage, option 3; Family Helpline: 1-855-435-7178 Hoosier Care Connect (HCC) Hoosier Healthwise (HHW) Traditional Medicaid Apply at Bureau of Developmental Disabilities Services (BDDS) office or call 1-800-545-7763 Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in person at DFR office Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in person at DFR office HIP Helpline: 1-877-GET-HIP9 Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in person at DFR office HCC Helpline: 1-866-963-7383 Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in person at DFR office Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in person at DFR office 75 Steps for Resolving Casework 1. Start with verifying information on your Web interChange portal 2. Check Department of Family Resources (DFR) Benefits Portal https://www.ifcem.com/CitizenPortal/application.do 3. Troubleshoot with your Outreach & Enrollment team 4. Use DFR mailbox to submit question or issue http://www.in.gov/fssa/dfr/2999.htm 5. Contact local DFR and speak with a representative Region 1 (Lake): [email protected] Region 2 (St. Joseph): [email protected] Region 3 (Allen): [email protected] Region 4 (Grant): [email protected] Region 5 (Marion): [email protected] Region 6 (Vigo): [email protected] Region 7 (Vanderburgh): [email protected] Region 8 (Clark): [email protected] Region9 (Tippecanoe): [email protected] Region 10 (Wayne): [email protected] 6. Ask to speak with DFR Regional Manager (information current as of June 2015) State Region E-mail Contact Regional Manager Region 1 (Lake) [email protected] Carlean Gadling Region 2 (St. Joseph) [email protected] Kim Teska Region 3 (Allen) [email protected] Kim Yann Region 4 (Grant) [email protected] Stacey Young Region 5 (Marion [email protected] Tim Bolton Region 6 (Vigo) [email protected] Felecia Vaccaro Region 7 (Vanderburgh) [email protected] Donna Martin Region 8 (Clark) [email protected] Nancy Lowry Region9 (Tippecanoe) [email protected] Vickie Woody Region 10 (Wayne) [email protected] Mary Medler (as of 6/25/15) 7. Submit question or issue to Jessica ([email protected]) or Emily ([email protected] (317) 630-0845 76 NOTES: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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____________________________________________________________________________ ____________________________________________________________________________ Download a hyperlinked copy of this guide online: https://indianapca.site-ym.com/?page=OEResources i Center for Health Care Strategies, Inc. KFF Other resources include: The Indiana Navigator Training Content Manual, Centers for Medicare and Medicaid, and Enroll America. ii 79