About These Materials

1. About These Materials Families USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for a training program for DC eligibility workers. These workers determine eligibility for Medicaid and other benefit programs (including SNAP and TANF). They will help consumers apply for coverage and financial assistance, report changes, renew coverage, and verify the information that is needed to determine eligibility. These workers will not be responsible for helping consumers select health plans. These training materials are posted here as an example that can be adapted for other training programs. They contain information that is specific to the District of Columbia, which would have to be changed if used in another state. Contact Families USA at stateinfo@familiesusa.org for assistance with adapting these materials.

2. ESA Policy Training Day 5

3. Reconciliation

4. Recap: How Premium Tax Credits Work • Size of credit based on annual household income as a percent of poverty • Determined by household size and annual income DC Health Link will calculate a household’s income as a percent of poverty and the size of a household’s tax credit.

5. Example:Poverty Level Shifts with Household Size • Household size of one:Bianca is single and makes $35,500 a year. • Bianca’s annual household income is at 308% of poverty for a household size of one. • Household size of two: Kat and Chris are married. Their combined income is $35,500 a year. • Kat and Chris’s annual household income is at 229% of poverty for a household size of two.

6. Three Ways to Take Premium Tax Credits • Take credit in advance: Credit goes to DC Health Link plan directly to lower monthly premium • Based on estimation of income and family size at time of enrollment • Take credit at tax time: Receive full annual credit as part of tax refund • Must pay full health insurance premiums up front • Take some credit in advance, some at tax time: • Take only a portion of credit up front to lower premium

7. Recap: Reconciliation People who opt to take some or all of their tax credit in advance must recalculate their credit at the end of the year. Reconciliation: • IRS recalculates credit based on total annual income and family size at end of year • If too much was taken in advance, people must pay back portion of credit at tax time • If too little was taken in advance, people get additional portion of credit through tax refund

8. Example: Reconciliation When Jody applies for coverage, she is found eligible for a $3,000 premium tax credit. She takes $2,500 in advance to lower her premiums ($208/month). At the end of the year, based on her total annual income, it turns out she was eligible for only a $2,800 premium tax credit. Since she took only $2,500 of the credit in advance, she gets the remaining amount ($300) back as part of her tax refund.

9. Example: Increase in Income Gloria and Sean are married. Their estimated annual household income is $46,500 (almost 300% of poverty) when they apply. They are found eligible for a premium tax credit of $2,146 ($178.83/month). Mid-way through the year, Sean’s salary increases so that their total annual income at the end of the year is $48,000 (309% of poverty). Sean forgets to report the change to DC Health Link. This decreases their tax credit to $2,001. This is $145 less than what they received in advance over the course of the year. They must pay back the $145 when they file their taxes.

10. Example: Increase in Household Size The next year, Gloria and Sean apply for tax credits again. This year, they estimate their annual income to be $48,000 (309% of poverty). They are eligible for a premium tax credit of $2,001 ($166.75/month). In July, Gloria and Sean have a baby. Their annual income for that year stays as expected at $48,000, but their household size increases that year. Again, they forget to tell DC Health Link about the change. With a household size of three, they are actually at 245% of poverty at the end of the year. They are eligible for a larger tax credit of $4,685 a year. They get $2,684 back in their tax refund.

11. Common Changes • Increase in income: lowers premium tax credit • Decrease in income: increases premium tax credit • Changes in family size (marriage/divorce, baby): could increase or decrease credit, depending on family

12. Key Points to Remember • Consumers can choose to take credit in advance, at the end of the year, or a mix • Mid-year changes in household size and income will affect the size of a household’s tax credit • Consumers must report changes promptly to avoid having to pay back a portion of the credit at the end of the year • Consumers can opt to take only a portion of their premium tax credit in advance to help compensate for mid-year changes

13. Plan Enrollment

14. Overview • What is the enrollment process? • When can people enroll? • When will coverage begin? • Why is it important to maintain coverage?

15. The Enrollment Process:Three Groups of People • Group #1:Found eligible for Medicaid • Group #2:Found eligible for a DC Health Link plan with premium tax credits • Group #3:Found eligible for a DC Health Link plan without premium tax credits

16. Group #1:People Who Are Eligible for Medicaid • MAGI groups (parents/caretaker relatives, children, pregnant women, adults 21-64 without dependent children) enroll in Medicaid managed care • Will receive information from Medicaid enrollment broker • Enrollee automatically assigned to a plan if he or she does not choose one in 30 days

17. Group #2: People Who Are Eligible for a DC Health Link Plan with Premium Tax Credits DC Health Link: • Notifies applicant of premium tax credit amount • Asks how much person wants to take in advance • Provides plan choice information, including share of premiums person will pay in various bronze, silver, gold, and platinum plans • People with incomes at or below 250% of poverty qualify for plans with lower cost-sharing Important: Applicants must choose a plan for coverage to go into effect.

18. Group #3: People Who Are Eligible for a DC Health Link Plan without Premium Tax Credits • This group either does not qualify or chooses not to apply for premium tax credits • Must select a DC Health Link plan in order for coverage to take effect

19. Getting Help with Enrolling in a DC Health Link Plan • ESA staff will not help applicants choose plans • Applicants can go online and choose a plan • Applicants can get help from: • In-person assisters • Insurance brokers • You will have a list of those who can help applicants choose plans

20. When can people enroll in Medicaid? • Apply for Medicaid anytime throughout the year • Pick a Medicaid managed care plan within 30 days of being found eligible or be auto-assigned • Change plans anytime for “good cause” and once a year for other reasons

21. When is open enrollment for DC Health Link?

22. Review: Question #1 James wants to enroll in Medicaid. When can he do this?

23. Answer: Question #1 He can apply and enroll at any time. After he is found eligible, he has 30 days to select a plan before he is automatically assigned to one.

24. Review: Question #2 Dan knows that he is not eligible for Medicaid. He is uninsured and wants to be in a DC Health Link plan in 2014. When can he apply and enroll?

25. Answer: Question #2 Dan can apply at any time, but in order to start coverage in 2014, he must apply and enroll between October 1, 2013, and March 31, 2014, unless he qualifies for a special enrollment period.

26. When will Medicaid coverage begin? • No changes to when Medicaid coverage starts • Coverage starts on the first day of the month the beneficiary applied • Beneficiaries can get three months covered retroactively if they have medical expenses and meet all of the eligibility requirements during the three-month period

27. When will DC Health Link coverage begin? • Select plan and premium payment received on or before the 15th of the month: coverage will start the following month • Enroll after the 15th of the month: wait another month for coverage • Enroll October 1, 2013 – December 20, 2013 for coverage effective January 1, 2014

28. Example: Dan • Dan enrolls in a DC Health Link plan November 1, 2013. His coverage is effective January 1, 2014, when DC Health Link plans begin. • Dan enrolls January 21, 2014. Since it is later than the 15th of the month, his coverage is effective March 1, 2014. • Dan picks a plan on January 15 and pays his first premium on January 15, but DC Health Link does not receive the payment until January 20. His coverage is effective March 1, 2014.

29. Example: Dan (cont’d) • Dan enrolls and pays his premium is received on January 15, 2014. His coverage is effective February 1, 2014. • Dan tries to enroll April 1, 2014. Open enrollment is closed, so he has to either wait until 2015 to get coverage or apply for a special enrollment period.

30. Example: Candace and Peyton Candace receives premium tax credits that help her pay for a DC Health Link plan. She adopts a baby named Peyton on July 3. She is too busy to tell DC Health Link about the adoption until July 20. Peyton is found eligible for Medicaid. When does Peyton’s coverage start?

31. When does Peyton’s coverage start? • Peyton’s coverage starts on the first day of the month he was adopted (July 1) • Medicaid will pay any covered benefits from Medicaid providers received in the month of July

32. What if applicants experience major life changes? There are certain special periods when you can enroll in a DC Health Link plan outside of open enrollment season.

33. Special Additional Periods for Enrolling in DC Health Link Plans • People can enroll outside of open enrollment if one of the following occurs: • Birth, adoption, placement for adoption • Marriage • Loss of other coverage, but not due to failure to pay premiums • Change in immigration status (e.g., becoming a lawfully present resident) • DC Health Link or broker/assister error/non-enrollment • Move • Applicant is newly eligible or ineligible for premium tax credit • American Indians can change/enroll anytime

34. What is the timing of special enrollment? • Generally, the person has 60 days after the special event to enroll • In the cases of birth, adoption, or placement for adoption: • Coverage retroactive to the date of event • Premium tax credits and cost-sharing reductions begin the first of the next month • You’ll receive more training on this later in the year

35. Examples • Dan had a job that offered health insurance. He lost that job and the insurance in April. He has a special 60-day period to enroll in a DC Health Link plan. • Sabrina pays a lot for her job-based coverage, but her income is pretty high. Her income goes down when her hours are cut in June. She is now eligible for premium tax credits. She has 60 days to enroll, starting on the day she is determined newly eligible for premium tax credits.

36. What happens after people enroll in a DC Health Link plan? • Enrollees pay a share of premiums monthly • Government will directly pay its share of premiums (tax credit amount) to the plan • Coverage can be terminated if people do not pay • If eligible for tax credits, three-month grace period to catch up and maintain coverage • If not eligible for tax credits, one-month grace period • If coverage is terminated, it will end on the last day of the last month for which the premium was paid • People can cancel their coverage at any time • Must give 14 days notice before coverage ends, unless health plan agrees otherwise

37. The Importance of Maintaining Coverage Remind people that they: • Will need coverage if they get sick • May be subject to individual responsibility penalties if they go three months without coverage • Cannot get back into a plan if they lose coverage unless it is an open or special enrollment opportunity

38. Movement between Medicaid and DC Health Link

39. Transitioning from Medicaid to DC Health Link • If enrollee becomes ineligible for Medicaid, notice received at least 15 days before coverage ends: • Terminates end of month, if 15 days remaining • Terminates end of next month, if less than 15 days remaining • Must choose a health plan for DC Health Link coverage to start • Must choose within 60 days of re-determination • Enroll on or before 15th of month before Medicaid coverage ends to avoid coverage gap • Choosing early will ensure DC Health Link coverage starts when Medicaid coverage ends

40. Transitioning from DC Health Link to Medicaid Medicaid coverage is retroactive to the first day of the month in which the re-determination is made. Example: James had a DC Health Link plan and premium tax credits. He loses his job and reported the change in mid-March. He is found eligible for Medicaid. His Medicaid coverage begins March 1.    

41. Example: Jodi Jodi has been getting coverage through Medicaid. In July, she gets a new job with higher pay. She reports the change. On July 18, DC Health Link sends her notice that she is no longer eligible for Medicaid, but she is eligible for premium tax credits to buy a DC Health Link plan. When does Jodi’s Medicaid coverage end? What does she need to do to avoid a gap in coverage?

42. Example: Answer Jodi will maintain Medicaid coverage through the end of August. In order to not have a gap in coverage. Jodi must enroll in a DC Health Link Plan by August 15.

43. Referrals

44. When to Make a Referral Refer consumers who need help with: • Plan selection: Picking a Medicaid managed care plan or a DC Health Link plan • Appeals: Gathering documentation, getting representation, or checking on status of a decision • Getting health services: Finding a provider, appealing a coverage denial, or understanding benefits

45. Help Selecting a Medicaid Plan For help enrolling in a Medicaid managed care plan, refer consumers to the Medicaid enrollment broker (Maximus). If consumers do not select a Medicaid managed care plan, they will be automatically assigned to one.

46. Help Selecting a DC Health Link Plan Those who are eligible for DC Health Link plans can get help choosing a plan from: • In-person assisters, who are trained to provide free help with choosing DC Health Link Plans • An insurance agent or broker, who can make a recommendation about which plan to choose There will be a directory of in-person assisters, agents, and brokers on DC Health Link. Remind consumers that their coverage will not start until they choose and pay for a health plan.

47. In-Person Assisters • Located in community-based organizations throughout the District • Receiving special training to help consumers choose DC Health Link plans

48. Choosing an In-Person Assister • Location • Hours of operation • Availability of bilingual staff • Expertise in specific health care needs • Ability to do home visits

49. Help with Appeals After an appeal of an eligibility determination is started, if a consumer needs help with the appeals process, refer to: • Office of the Health Care Ombudsman • Legal services programs

50. Help Getting Health Services After consumers enroll in a health plan, if consumers need help connecting with health care services or understanding their coverage: • Medicaid enrollees should contact their MCO directly • Refer DC Health Link enrollees to the Office of the Health Care Ombudsman and/or their health plan