the affordable care act part 2: eligibility and enrollment

THE AFFORDABLE CARE ACT:

ELIGIBILITY & ENROLLMENT

OVERVIEW

• Eligibility Requirements

• Exchange Enrollment

• Eligibility & Enrollment Verification

• Penalties

• Appeal Process

• Key Dates

EXCHANGE ELIGIBILITY

ELIGIBILITY: REQUIREMENTS

• For an individual to qualify for the Exchange they need to:

o Be a U.S. citizen, national, or legal resident

o Must reside in the same state that they are applying for coverage

o For programs that require an income eligibility, income will be based off Modified Adjusted Gross Income

• An individual is not eligible for coverage through the Exchange if incarcerated, unless charges are pending

• For CHIP, Medicaid, and Medicare, individual must meet that program’s specific eligibility requirements

ELIGIBILITY: EXEMPTIONS

• Individuals must have the minimum level of healthcare coverage provided or face a penalty

• The following categories provide exemptions for individuals from this coverage requirement:

o Religious Exemptions

o Undocumented Immigrants

o American Indians

o Financial Hardships

o Incarceration

ELIGIBILITY: PROHIBITED FACTORS

• Issuers can no longer deny coverage to individuals with pre-existing conditions

• Issuers are no longer able to drop individuals due to the diagnosis of serious illnesses

• Issuers are no longer allowed to set annual and/or lifetime limits

ELIGIBILITY: GOVERNMENT BASED

HEALTHCARE

Medicaid• A state-based healthcare program that provides coverage to low-

income households and individuals with disabilities

CHIP• CHIP is the Children’s Health Insurance Program

Medicare• A government health insurance program administered by the

Centers for Medicare and Medicaid Services

ELIGIBILITY: MEDICAID

Medicaid Eligibility Before ACA Medicaid Eligibility After ACA- Pregnant women and children (<6 years)

whose family income is ≤ 133% of the Federal Poverty Level

- Children under 19 whose families are at or below the FPL

- Families with children that meet the Aid to Families with Dependent Children

- Most Supplemental Security Income recipients

- Recipients of adoption or foster care individuals

- Special protected groups- Certain Medicare beneficiaries - Certain optional groups

Source: CMS.gov - Brief Summaries of Medicare and Medicaid and Kaiser Family - Medicaid A Primer

- Eligibility groups streamlined to - children - pregnant women - parents and caretaker relatives- adults (ages 19-64)

- Income eligibility will be based off modified adjusted gross income and household income

- Eligibility based off monthly income at time of application

- Minimum income eligibility for adults is 133% of FPL

Source: Federal Register - Medicaid Program Eligibility Changes under the ACA and Kaiser Family - Medicaid and the uninsured

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/Downloads/MedicareMedicaidSummaries2011.pdf

http://www.kff.org/medicaid/upload/7334-04.pdf

https://www.federalregister.gov/articles/2012/03/23/2012-6560/medicaid-program-eligiblity-changes-under-the-affordable-care-act-of-2010

https://www.federalregister.gov/articles/2012/03/23/2012-6560/medicaid-program-eligiblity-changes-under-the-affordable-care-act-of-2010

http://www.kff.org/medicaid/upload/8254.pdf

ELIGIBILITY: CHIP

• CHIP covers children whose family income is too high for Medicaid

• The ACA will keep the same eligibility standards in place through 2019

• The ACA has expanded eligibility beyond the original requirements of children under 19 and household incomes of 200%

ELIGIBILITY: MEDICARE

• Overall eligibility for Medicare does not change with the enactment of the ACA

• Medicare eligibility requirements include:o Being a U.S. citizen or legal immigranto Being age 65 or older

Source: SocialSecurity.gov Medicare and Proof of Citizenship

http://www.socialsecurity.gov/pubs/10043.html

http://www.socialsecurity.gov/hlp/isba/10/hlp-isba005-ctzn.htm

ELIGIBILITY: MEDICARE

Medicare Part Eligibility Requirements

Part A

Individual is eligible if under age 65 and:- Receives Social Security Disability Insurance for minimum of 24 months,- Receives disability from Railroad Retirement Board,- Receives disability due to Lou Gehrig’s disease,- Has worked 10 years in a governmental job where Medicare taxes were paid and

meet requirements for Social Security Disability; or be the child/widower of someone who has met those requirements, or

- Has permanent kidney failure or has received a kidney transplant

Individual is eligible if age 65 or older and:- Receives benefits from Social Security or Railroad Retirement,- Has an eligible spouse, - Has worked (either individual or spouse) in a government job where Medicare

taxes were paid, or- A dependent parent of a fully insured deceased child

Part B - Anyone eligible for Part A can enroll in Part B- Monthly premium is based off income

Part C - Anyone who is eligible for Parts A and B can enroll in Part C

Part D - Anyone who is enrolled in Parts A, B, or C is eligible for the prescription drug coverage

- Monthly premium is based off income

Source: SocialSecurity.gov Medicare

http://www.socialsecurity.gov/pubs/10043.pdf

ENROLLMENT PROCESS

ENROLLMENT PROCESS: APPLICANT

• Applicants can enroll in an Exchange through the Exchange website, in person at a designated assistance center, via toll-free telephone number, or by mail

• The following information will be needed when completing an Exchange application:o Nameo Addresso Date of birtho SSNo Proof of U.S. citizenship/immigration status


• Notifications of eligibility are sent out once the determination is complete

• Notifications letters should explaino the applicant’s eligibility determinationo the steps taken and any remaining steps needed to complete

enrollment processo the appeal process available to the applicant


• Through enrollment process, if applicant is found eligible for government-based healthcare (e.g., Medicare, CHIP, or Medicaid) the Exchange will automatically enroll applicant into program

• Applicants can shop through Exchange to find the best coverage option for their situation

• The Exchange will provide notification to the chosen insurance issuer

ENROLLMENT PROCESS: EMPLOYER

• Employers can submit an application to the Small Business Health Options Program (SHOP) Exchanges to determine eligibility*

• Once employer’s application is approved, the SHOP will help the employer both enroll and select health plan options for their employees

*UPDATES TO SHOP PROGRAM

• The requirement that a SHOP must allow employers the option to offer employees a choice among all qualified health plans (QHPs) at the metal level (i.e., bronze, silver, gold, or platinum) chosen by the employer has been delayed for one year.

• For plan years beginning before January 1, 2015 federally facilitated-SHOPs will not offer an employee-choice option but will instead allow employers to offer their employees a single QHP from the SHOP's available choices. State-operated SHOPs may, but are not required to, offer an employee-choice option.

• SHOP special enrollment period has been changed from 60 days to 30 days after a qualifying event.

• HHS has posted an application for SHOP eligibility for employers that are not able to apply online or are not working with a broker and an application for employees to submit to check their eligibility for SHOP coverage from their employer.

As of

6/2013,

HHS has

issued final

regulations

around the

SHOP

program

ENROLLMENT PROCESS: EMPLOYER/SHOP

• The SHOP will provide notification to:

o employers regarding eligibility to participate in the Exchange

o employees regarding the plan options and how to enroll

o the insurer containing the employees’ enrollment information

• The SHOP is also required to notify HHS that the employer is providing insurance and the eligible employees have enrolled in a QHP

ENROLLMENT VERIFICATION

ENROLLMENT VERIFICATION:

APPLICANT

• U.S. citizenship and incarceration status will be verified by:

o Comparing records at the Social Security Administration

o If the information cannot be confirmed, HHS will go to the Department of Homeland Security for confirmation

• Other application criteria will be verified against the respective federal agencies


APPLICANT

• HHS will conduct annual redeterminations to determine eligibility for upcoming plan yearo If applicants are approved, they will receive notification showing

data used to make the decision and their eligibility status o If applicants are not approved, they will receive coverage for one

month after notification and can no longer claim tax benefits

• Applicants will need to supply any information that has changed

• Applicants will need to sign and return the notification

• After the signed notification is received, applicants can re-enroll/terminate/change health plans


EMPLOYER

• To verify employer submitted information, the SHOP will cross reference the employer’s information with government agencies

• The SHOP will redetermine employer eligibility through review of the annual report submitted to it by the employer

PENALTIES

PENALTIES: INDIVIDUALS AND

EMPLOYERS

Individuals• Penalties will be imposed for failure to maintain the

minimum level of individual coverageo Penalties will either be a flat rate or a percentage of income,

whichever is highero Penalty rates will be adjusted annuallyo IRS will administer and collect the penalty

Employers (50+ employees)• If coverage is inadequate or not provided, a penalty will be

assessed based on the annual applicable dollar amount and number of full-time employees

APPEAL PROCESS

APPEAL PROCESS: APPLICANT

• Each state will be responsible for creating their own appeal process

• The Exchange will notify applicants if they are ineligible for government-based healthcare and provide alternative options for affordable healthcare

• Applicants can appeal adverse eligibility decisions and cost reimbursement denials from insurance companies through an internal or external appeal process

APPEAL PROCESS: EMPLOYER

• An employer will be able to appeal an adverse eligibility determination made by a SHOP

• The SHOP must give the employer 30 days notice to respond to an eligibility denial and submit the necessary documentation to the SHOP

• If the SHOP still denies eligibility after receiving documentation from the employer, the employer may request an external appeal review by a third party arbitrator

KEY DATES

KEY DATES: EXCHANGE ENROLLMENT

DATE EVENTJanuary 1, 2013 For 2012 tax year, employers need to include on the employee’s W-2

the cost of employer-sponsored health coverage. o They must include both employer and employee portions of the cost

of health benefits. The tax deduction will be eliminated for employers who receive

Medicare Part D retiree drug subsidy payments. o These payments are a federal subsidy paid to employers who offer

retirement benefits for prescription drugs. o Employers who receive this payment will have to include the amount

as taxable income.

March 1, 2013 • Employers must provide all employees with a written notice detailing:- the availability of the healthcare Exchange, - a description of the services provided, - contact information for assistance, - possible tax credit eligibility, and- information regarding loss of employer sponsored coverage if they

purchase individual coverage in a QHP through the Exchange.

KEY DATES: EXCHANGE ENROLLMENT

DATE EVENT

October 1, 2013 • Open enrollment period begins for the Exchanges

January 1, 2014 ACA Exchanges are in effect Any U.S. citizen/legal resident who does not have health insurance and

is not exempt will be liable for a tax penalty Employers that do not provide health insurance coverage will be fined

REED & ASSOCIATES, CPAS

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