1. What is the ACA?
The Affordable Care Act (ACA) was signed in to law on March 23, 2010 by President Obama. This new health reform bill requires the majority of all Americans to obtain health insurance beginning in January 2014. Under the ACA, health reform will make health care more affordable, guarantee choices when purchasing health insurance through a new Health Benefit Exchange, expand health coverage to more Americans and enhance the quality of care.
2. How will the Health Benefit Exchange impact Medicaid?
In 2014 the Health Benefit Exchange will provide a new option to apply for health coverage through an online application portal. The Exchange will also help families enroll in a Qualified Health Plan (QHP). More information on additional aspects of the Exchange can be found on the Health Benefit Exchange page.
3. What is the definition of MAGI?
Modified Adjusted Gross Income – MAGI is the new methodology for calculation of income for certain Medicaid programs (see below) which closely mirrors how the IRS determines adjusted gross income for tax purposes. MAGI will replace multiple income disregards with one 5% income disregard for all programs and will remove asset/resource limits. Household composition will now mirror federal tax filing rules in most situations. This simplified income calculation will be used to determine Medicaid eligibility and also by the Exchange to determine Premium Tax Subsidy Credits for those who do not qualify for Medicaid.
4. Will all MAGI-related determinations, including Advanced Premium Tax Credit (APTC) subsidies, be made using the ACES Rules Engine (eligibility determination system)?
Yes, these determinations will be made using a new rules engine currently under development by the IT staff at DSHS/ESA in partnership with HCA and the Exchange.
5. Is there a tool available that will provide estimates for the Advanced Premium Tax Credit (APTC) subsidy program?
Yes, the Kaiser Family Foundation has a link on their website that provides “general estimates” for the APTC program at Health Reform Subsidy Calculator
6. Under the ACA which medical groups must use MAGI methodology for eligibility determinations?
- Families (parents/ caretaker relatives)
- Pregnant women
- Newly eligible
7. What if an individual has filed federal taxes including someone living outside of the country? (such as a seasonal farm worker) Can they claim this person in their household size?
If the question is, do they get to increase their household size when determining which standard to use for their own Medicaid application, the answer would be, yes, if they intend to claim the person as a dependent on their current year’s tax return, they can include that person in their application for purpose of establishing the income standard to use. REMINDER: Anyone residing outside of WA State would not be eligible to receive Medicaid, but could be included in the household size.
8. What is the definition of the “newly eligible” group?
This new group is made up of individuals who:
- Are age 19 up to 65 who are not eligible for a current Medicaid program
- Have income under 138% FPL
- Meet citizenship requirements
- Are not incarcerated
- Are not entitled to Medicare
9. Which current medical groups will not follow MAGI methodology in 2014?
The following groups will not follow MAGI methodology and will continue to receive “classic Medicaid” under the existing eligibility rules:
- SSI Cash Recipients
- Aged, Blind or Disabled Individuals
- Foster Care Children
10. Will the Medicare Savings Program fall under the “classic” Medicaid eligibility?
Yes. The Medicare Savings Program will fall under “classic” Medicaid and the rules will remain unchanged.
11. When will the new MAGI methodology rules be implemented?
The use of MAGI methodology will begin on October 1, 2013 for children, pregnant women and families. Coverage for the newly eligible group will begin on January 1, 2014.
12. Under the ACA, what is required for the development of a new simplified application for medical?
The new application must be one of the following:
The application developed by Health & Human Services (HHS) Secretary in accordance with the ACA; or An alternative single streamlined application developed by Washington state that has been approved by the HHS Secretary
13. When will the draft application be available for review?
Plan to hold stakeholder webinars for review and input of the new application in late August. Please see the ME 2014 Stakeholdering web page for more information.
14. Who will use the new application?
A new simplified application will be developed for use by everyone applying for Medicaid, CHIP and the Premium Tax Credit Subsidy program. Applications for “classic Medicaid” may require the completion of additional forms.
15. How can an application be submitted for medical?
An application for medical can be submitted via the following methods:
- Online – preferred method via the new Exchange web portal
- By telephone
- Via mail or facsimile
16. What will be the alternative for non-English speakers or those without digital access or literacy?
The Exchange web portal will be available in Spanish. Applicants who need assistance may contact the Exchange call center using an interpreter service. Letters will be available in the supported languages.
17. How will people who are accessing Medicaid through a web portal access food stamps and cash assistance?
At the end of the application for health care coverage, families will be offered the option to be referred to a Connection web portal to apply or inquire about other public assistance programs.
18. Will outreach workers have the ability to use the Exchange web portal to assist clients with applying for medical coverage?
Yes. An outreach worker may assist a client with completing a health care coverage application online as long as the client is present.
19. What are the limits of liability for assistors?
While opportunities to assist clients looking for health care coverage will increase in 2014, we view that responsibilities will remain the same as they are today which would include: 1) only entering information provided by the client 2) information entered will be an accurate representation of the client’s circumstances as confirmed by the client’s electronic signature.
20. Will the DSHS Application for Assistance continue to include an option to request medical benefits?
No. The State must have a simplified and streamlined application specifically for insurance affordability programs, which means Medicaid, CHIP and the Exchange. The agency’s goal is to have a user-friendly streamlined and simplified application that comports with Health & Human Services (HHS) and meets our customer needs for an eligibility determination as envisioned by both CMS and the state. If an applicant appears potentially eligible for a public assistance benefit program, then once the medical determination has been made through the Exchange web portal, the applicant will be advised of their potential eligibility for other programs and will be referred electronically to the web portal for follow-up.
21. Will the system for applying for medical through the CSOs look the same as it does today?
No. All applications for healthcare coverage will be processed through the Exchange web portal. “Classic” Medicaid will be referred to WA Connection web portal for processing by DSHS under the current rules.
22. If someone applies through the new program, when will their coverage begin?
For example: People who come in to the hospital that do not have a disability determination but obviously need medical coverage for the stay and their medications, etc. If they applied at the time of the stay or shortly thereafter would it go back to the first of the month, the beginning of the stay, the date of application or the next month?
Medicaid has always allowed and will continue to allow eligibility back to the first of the month of application for Medicaid eligible individuals. This will not change under the new rules for Medicaid. For example: A patient is hospitalized and does not have any medical insurance. The individual or someone on their behalf can apply for medical coverage through the Exchange post 2014. If that individual is found eligible for Medicaid, coverage will go back to the first of the month of application. Retroactive medical coverage of three months prior to the month of application will continue for Medicaid clients.
If an individual has income under 138% FPL they would not have to have a disability decision to be approved for Medicaid. The “newly eligible” Medicaid group expands coverage up to 138% for adults and does not require that the adult be disabled. Currently, an individual cannot be Medicaid eligible unless they are related to one of the coverage groups (a child, pregnant, a parent of dependent children or an aged, blind or disabled individual). The newly eligible group allows individuals to be eligible based on income alone.
23. How will income be verified using the MAGI methodology for Medicaid?
Income will be verified under the MAGI methodology for Medicaid by using:
- Automated data match
- If no data match is available then self-attestation will be accepted
24. Will there be an asset test for Medicaid adults in 2014?
No. There will be no asset/resource limits for Medicaid adults under MAGI methodology.
25. How would a client proceed if they are not sure of their income (such as self-employment), but believe the data match is inaccurate or out of date?
Answering the series of MAGI questions through the Exchange web portal should guide the applicant smoothly through the income portion of the application. They will have the option to contact an eligibility worker with questions about income calculation.
26. Which data sources will be used during the automated data match to determine application and renewal eligibility?
The agency continues to finalize details regarding data matching, but at this time plans to use the IRS – Federal Data Hub as well as current state systems such as Employment Security, SSA and TALX (The Work Number).
27. Will providers be able use the Federal Hub to obtain IRS MAGI information for their own business purposes?
No. IRS information is protected and can only be used by HCA and the Exchange to determine MAGI. This information can only be used for this purpose and cannot be shared.
28. What is the length of the “reasonable opportunity period” during which individuals can present documentation to resolve data match discrepancies?
Self-attestation will be accepted; therefore it is likely that the reasonable opportunity period will only apply to citizenship/alien status. Based upon our experience with verifying citizenship/alien status, the numbers are anticipated to be relatively small. HCA will continue to use the centralized citizenship team to work with families to obtain documents they need, so it will be business as usual for this population. A decision has yet to be made regarding a set “period.”
29. What is self-attestation? Would this include a written statement from the client?
This is an income declaration by a client when no data match is found or the information is outdated or incorrect. A series of questions will be asked through the Exchange web portal application process to assist the family in declaring their self-attested income at the time of application.
30. If a “self-attestation” is used, how will the agency ensure correct eligibility?
The agency will use data matching and a strong “post-eligibility” review process to ensure eligibility for Medicaid and CHIP is correct and the household is enrolled in the correct program.
31. Will HCA accept self-attestation and/or data matching for eligibility renewals?
The agency plans to complete a data match for all renewals. If the data match shows that the household’s income remains below the Medicaid standard – the case will be re-certified without any further action by the family. A notification will be sent sharing the income and household composition used to determine a continuation of benefits and will also ask the family to report any changes if the information stated on the letter is incorrect. For households where a data match cannot be completed or the data match shows income above the Medicaid standard – the family will be sent a pre-populated renewal form and asked to update and return the paper form or update their renewal online through the Exchange web portal. Other options for completing a renewal will be provided for those households who do not have access to the internet.
32. Will applicants be continuously eligible for Medicaid until renewal time, regardless of changes in income and household composition? How will changes in income and household composition be handled throughout the year?
Pregnant women and children will have continuous eligibility as they do today. There is no continuous eligibility for adults. Changes can be reported via:
33. Under the new MAGI methodology, will there be any changes to the medical benefits renewal process?
In an attempt to reduce the number of families who lose Medicaid for failure to complete the renewal process the following steps will be in place:
- Automated renewal using an electronic data match to verify income
- 12 month certification periods
- Pre-populated review form to be sent only if eligibility cannot be verified through electronic data match
34. Will the length of re-certification periods remain the same?
All those under MAGI will have a one year certification period. This will eliminate the six month mid-certification review currently required for family medical.
35. Many individuals do not qualify for Medicaid when they also have Medicare and income in excess of $698 per month. They must meet a spend down first before being eligible for Medicaid. Will the MAGI tool reduce the number of individuals on spend down?
Medicaid expansion includes the requirement to provide coverage to single adults and parents/caretaker relatives who have countable income below 138% of the federal poverty level as long as those individuals are not otherwise entitled to Medicare and are under the age of 65. To the extent that the state has many single adults with disabilities who are not yet eligible for Medicare, those clients would move into full Medicaid coverage under the new eligibility criteria and would no longer have to meet a spend down if their net income was over $698 per month. MAGI does not change how we determine eligibility for clients who are age 65 or older or who are entitled to Medicare. If the spend down program is still available to clients in January 2014 you are correct that we would anticipate seeing a drop in enrollment in this program due to other coverage options that will be available.
36. Will the federal poverty level income apply in determining eligibility for Medicaid instead of the current threshold of $698?
The 138% FPL will apply only to the newly eligible single adult/parent group. Higher FPLs will continue to apply for pregnant women and children in our state. Any person who remains subject to a spend down in 2014 will continue to have their eligibility based on the medically needy income level in effect on that date (currently $698).
37. Will the new Medicaid population include people with less than 5 years legal residency?
For Medicaid, the 5 year residency rule will continue to be in effect.
38. An auto-enrollment for American Indian/Alaska Native (self-identified) – will this be to the nearest Indian Health program based on zip code?
Yes, if a contracted clinic is available within a reasonable distance.
39. Will there be procurement for Medicaid before 2014 to allow Qualified Health Plans (QHP) not currently offering coverage to begin offering it?
At this time it is not our intention to release procurement prior to Medicaid Expansion in 2014. There will likely be discussion about allowing additional plans to participate in Medicaid managed care for 2014.
40. Is your plan to add a large number of staff to be able to accommodate this influx of new Medicaid clients?
No. HCA does not anticipate the need to hire a large number of staff for the upcoming changes in Medicaid Expansion. With the new streamlined application and automated data match through the new Exchange web portal we should see a significant decrease in processing time versus the way we do business today. Therefore a need to hire a large number of staff is not anticipated.
41. Where can I find more information about Medicaid Expansion under the ACA?
You may obtain additional information about Medicaid Expansion by visiting the recently updated website here: Health Care Reform Medicaid Expansion.
This includes the following additional information regarding Medicaid Expansion:
- Existing medical eligibility rules and how it will look in 2014
- Policy options being developed
- Stakeholdering plan coming soon
- Current workgroups underway
- Other helpful resources
42. Can I submit public comments on the policy options being developed by Health Care Authority?
Yes. You may review current Medicaid Expansion Policy Options and may submit Public Comments on these options.