Santa Clara County Social Services Agency page 1

Date: 10/23/13

References: N/A

Cross-References: N/A

Clerical: No

Handbook Revision: No

Update 2013-12: Medi-Cal Affordable Care Act (ACA) Questions and Answers

Background In September 2013, ACA (also referred to as Health Care Reform (HCR)) training was provided by Staff Development to all HCR Eligibility Workers (EWs) and designated eligibility staff.

Question and Answers

This Update addresses questions raised during the training sessions.

Applications Q 1. What is the Single Streamlined Application (SSApp)?

A 1. The SSApp is used to apply for health insurance coverage only, by collecting the information necessary to determine eligibility for Covered California Health Plans such as Advanced Premium Tax Credit (APTC), Cost-Sharing Reduction (CSR), or Unsubsidized Health Plans and Medi-Cal (MC). The SSApp cannot be used to apply for CalFresh (CF) or CalWORKs (CW); however, it can be used as a referral for those programs. Applicants will have to complete the CF Series or SAWS 2 plus for CF or CW, respectively.

Q 2. How many languages is the SSApp available in?

A 2. Currently the SSApp is only available in English. Eventually it will be translated into the 13 threshold languages.

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Q 3. Does Covered CA receive mail-in applications to process for Modified Adjusted Gross Income (MAGI) MC?

A 3. Covered CA agents will input all SSApp mail-in applications they receive into California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) and let CalHEERS make the determination as to whether the consumer(s) is eligible for MAGI MC or APTC/CSR. If the consumer is determined to be MAGI MC eligible, then the MAGI MC application(s) will be forwarded to the county of residence for appropriate follow-up and case maintenance.

Q 4. What are the time frames to process mailed/faxed applications from Covered CA?

A 4. The time frame to process mailed/faxed applications with no inconsistencies (i.e. no missing verification) for APTC or other subsidized health plans from Covered CA is 10 calendar days. The time frame for processing MC applications remains the same (within 45 days).

Q 5. If an application is processed after 45 days, will coverage be effective from the date of application?

A 5. The 45-day processing requirement only applies to MC and it does not apply to Covered CA applications.

Medi-Cal Application

If a MC application is processed after 45 days and the client is determined eligible for MC, then his/her coverage will be effective from the date of application.

Covered CA Application

If an application for Covered CA health coverage is processed after 45 days and the consumer is determined eligible for a Covered CA health plan, then he/she has 30 days to choose a health plan. A consumer who enrolls in a health plan between the 1st and 15th of the month will have health coverage beginning the first day of the next month, if his/her premium is paid 4 business days prior to the next month. A consumer who enrolls in a health plan between the 16th and last day of the month will have health coverage beginning the first day of the following month, if his/her premium is paid 4 business days prior to the following month.

Health Coverage & Enrollment

Q 6. If a consumer applies on 1/15/2014 for Covered CA health coverage, when does the coverage start?

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A 6. A consumer who applies, is determined eligible, and selects a Covered CA health plan on 1/15/2014 will have health coverage starting on 2/1/2014 if he/she has paid the premium prior to 1/28/2014.

Q 7. Is specialized care and diagnostics included in the preventive services?

A 7. Specialized care and diagnostics vary in the preventive services depending on the health coverage plan and provider. A list of preventive services that must be included in all health plans can be found at: http://www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforAdults.

Q 8. Do consumers need to wait until the next open enrollment period if they do not report a life qualifying event within 60 days?

A 8. Yes. While consumers may apply for APTC/CSR coverage at any time, if the consumer does not report a life qualifying event within 60 days, the consumer would need to wait until the next open enrollment period to enroll for APTC/CSR coverage. Individuals may apply for Medi-Cal or purchase unsubsidized coverage at any time.

Q 9. Can different members, within the same family, enroll in different metal tier plans?

A 9. No. When all members of a family in the same APTC household are enrolling in a Covered CA health plan, they all must enroll in the same one.

Q 10. Are the applications pending plan enrollment selection being monitored for completion within 30 days?

A 10. Covered CA will send a reminder notice to the consumer 15 days after eligibility determination if they have not yet selected a health plan. If by the 30th day the consumer has still not selected a health plan, then Covered CA will send another notice to inform the client that his/her application has expired, and if he/she still desires coverage he/she will have to re-apply.

Q 11. Can consumers change their health plan option during the enrollment period and before 1/1/2014?

A 11. No, once a check-out has been made with a specific plan, the plan selection can no longer be changed. However, a consumer can choose to Terminate Participation (in CalHEERS), with a minimum waiting time of 14 days. After the 14 days the consumer will be able to submit a new application, and then select a different health plan.

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Q 12. When a consumer meets the Out of Pocket (OOP) limit, will he/she have to pay a co-insurance? What about co-pay?

A 12. No. Once the OOP limit is met, as long as the services the consumer seeks are in-network, he/she will not have to pay anything (i.e. co-insurance, co-pays), for the rest of the calendar year.

Q 13. Will consumers be able to purchase a dental plan and a vision plan through Covered CA?

A 13. Dental and vision benefits will be available for children. Covered CA is considering adding vision and dental plans as “supplemental plans” for adults through Covered CA in 2014. The timing of adding these benefits has not been determined. As a supplemental benefit, the federal premium assistance would not apply to these benefits.

Premiums Q 14. Is regional cost of living taken into consideration for premiums?

A 14. Yes, premiums are based on the following factors:

• Plan design (the services covered and how much the plan pays for them),• Geographic pricing regions (19 pricing regions in California), • Age, and • Income.

A 15. Are premiums based on health and age?

Q 15. The unsubsidized annual insurance premium is not based on health or pre-existing conditions, but it is based on age.

Q 16. Will applicants be reimbursed for premiums paid while pending for DDSD?

A 16. Applicants will not be reimbursed for premiums paid while pending for DDSD. While an applicant is pending for DDSD, he/she can enroll temporarily in a Covered CA health plan and use any premium assistance and cost-sharing reductions, if applicable. Once a DDSD decision has been made for the applicant, he/she would dis-enroll from the Covered CA health plan.

Q 17. Can Health Savings Account (HSA) be used to pay towards premiums?

A 17. Yes, HSA can be used to pay towards premiums.

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Q 18. Are premiums paid in October 2013 or January 2014?

A 18. Consumers can pay their premiums directly to the provider once they have selected a health coverage plan. Consumers must pay their premium payment 4 business days prior to the effective date of coverage. For coverage starting January 1, 2014, consumers must pay their premium prior to December 26, 2013. Coverage for MAGI MC and Covered CA health plans begin January 1, 2014.

Q 19. Would a 50 year-old with income of $24,000/year pay higher premium amounts than a 40 year-old with the same income? Is there a maximum that the premium can increase?

A 19. The unsubsidized annual insurance premium will increase based on age; however, the amount of premium the individuals actually pay is the same.

Example:For a 50 year-old with $24,000 in annual income, the unsubsidized premium cost would cost $5,390; however, the amount he/she pays for the premium is only $1,587 (6.61% of his/her income); therefore, the tax credit for the 50 year-old is $3,803 ($5,390 - $1,587). For a 40 year-old with $24,000 in annual income, the unsubsidized premium cost would be $3,857; however the amount he/she pays for the premium is only $1,587 (6.61% of his/her income); therefore, the tax credit for the 40 year-old is $2,270 ($3,857 - $1,587).

Q 20. Are premium payments to the health coverage providers paid in cash only?

A 20. Premiums are billed to the client by the health coverage provider they signed up for and must be paid to them directly. Consumers may pay for their premiums via personal check, cashier's check, Electronic Fund Transfer (EFT), money order, and debit card. In the future, consumers will be able to make electronic payments via their account in CalHEERS.

Q 21. Can consumers buy minimum coverage plan (5th level) using APTC?

A 21. No. A “minimum coverage plan,” helps protect a person from financial disaster in the event of a serious and expensive medical emergency. Minimum coverage plans are designed to cover excessive medical bills that occur above the limit that you would be able to manage financially. Covered CA will provide minimum coverage to those up to age 30, or those individuals who prove they are without affordable coverage options or are experiencing financial hardship.

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MEC Q 22. What health insurances qualify as Minimum Essential Coverage (MEC)?

A 22. The following types of health insurances qualify as MEC:

• Employer-sponsored coverage, including coverage offered to former employees (such as COBRA) and retiree medical coverage.

• Qualified health plans purchased in the individual market• Medi-Cal (federally known as Medicaid)• Children’s Health Insurance Program (Healthy Kids in Santa Clara

County)• TRICARE (Department of Defense Health Care Program)• Certain types of veteran’s coverage• Medicare plans• Foreign health coverage• Self-funded student health insurance plans• Refugee Medical Assistance (RMA)• AmeriCorps coverage offered to AmeriCorps volunteers, which is a

domestic counterpart to the Peace Corps.

Q 23. What is the process for claiming adequate health coverage (<60%) or 9.5% exception pre-Federal HUB or post Federal HUB?

A 23. This is determined first, prior to enrollment in CalHEERS. The applicant can obtain verification of MEC by providing the Summary of Benefits and Coverage from his/her employer.

Q 24. Is it a requirement for consumers to be without other health coverage (OHC) to be able to buy in Covered CA?

A 24. Only individuals who do not have MEC may obtain subsidized coverage through Covered CA. Unsubsidized coverage may be purchased by anyone (excluding undocumented individuals) at any time.

Income Q 25. Are Veteran's benefits received as a pension for disability and/or retirement, counted or not counted in MAGI MC as income?

A 25. Veteran's disability, pension, and education benefits are not countable income for MAGI MC or APTC/CSR. For military retirement pay, if your retirement pay is based on age or length of service, it is taxable and must be included in your income as a pension.

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Q 26. What are the income tax deductions?

A 26. For the determination of Adjusted Gross Income (line 37 on Form 1040) the following are deducted from the total income, per Form 1040:

• Educator expenses• Certain business expenses of reservists, performing artists, and

fee-basis government officials • Health savings account deduction. • Moving expenses. • Deductible part of self-employment tax • Self-employed SEP, SIMPLE, and qualified plans• Self-employed health insurance deduction• Penalty on early withdrawal of savings • Alimony paid • Recipient's SSN • IRA deduction • Student loan interest deduction • Tuition and fees • Domestic production activities deduction

Q 27. Do DIB/SDI and Worker's Compensation count as earned income?

A 27. No, DIB/SDI and Worker's Compensation do not count as earned income.

Q 28. Is there a deduction for child care?

A 28. There is no deduction for child care when determining the Adjusted Gross Income.

Q 29. Is the 9.5% affordability rule regarding employer-sponsored coverage based on MAGI or “gross” income?

A 29. The 9.5% is based on the household MAGI of the employee and any members of the employee's family (which includes spouse and dependents) who are required to file an income tax return. One of the conditions to be eligible for APTC (individual or family) is meeting the 9.5% affordability rule.

Example:Kim has MAGI of $50,000. Kim's employer offers health coverage to its employees. Kim’s required contribution for this health coverage for herself only is $2,500 (5% of her HH’s MAGI). Kim’s required contribution for this health coverage for herself and her family is $5,000 (10% of her HH’s MAGI). Because the required contribution for self-only coverage does not exceed 9.5% of MAGI, her employer-sponsored health coverage is considered

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affordable for Kim and her family (despite that the actual cost of covering the entire family is over 9.5%). Kim and her family are considered eligible for MEC from the employer-sponsored health coverage; therefore, cannot obtain APTC through Covered CA. This rule also applies even if Kim declines coverage for her family, because they were offered employer-sponsored health coverage that is considered MEC.

Q. 30. Is the 8% affordability rule regarding the Individual Mandate Penalty based on MAGI or “gross” income?

A. 30. The 8% is based on the household MAGI of the employee and any members of the employee's family (which includes spouse and dependents) who are required to file an income tax return. The 8% is used to determine whether or not an individual is subject to the Individual Mandate Penalty. [Refer to Q. 44 under Penalties for penalty amounts.]

Example:Kim has MAGI of $50,000. Kim's employer offers health coverage to its employees. Kim’s required contribution for this health coverage for herself only is $2,500 (5% of her HH’s MAGI). Kim’s required contribution for this health coverage for herself and her family is $5,000 (10% of her HH’s MAGI). Because the required contribution for self-only coverage does not exceed 8% of MAGI, Kim must accept her employer-sponsored health coverage in order to avoid the Individual Mandate Penalty. However, the required contribution for herself and her family exceeds 8% of MAGI, her family (spouse and dependents) are not subject to the Individual Mandate Penalty. Reminder: The family would still not be eligible for APTC. [Refer to Q & A 29]

Verifications Q 31. Is verification needed for self-reported required changes?

A 31. Verification is only required when the results from the Federal Hub returned as “not compatible” with the consumer's reported change(s).

Q 32. How do we indicate consent for Federal HUB for an adult dependent?

A 32. Consent for the Federal HUB is only required to be provided by the Head of the Household of the tax filing unit. Adult dependents are not required or needed to provide consent for the Federal data match.

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Q 33. Do verifications that are “sight verified” in CalHEERS need to be sent to Covered CA?

A 33. Verifications must be sent to Covered CA for all APTC cases. All verifications for Medi-Cal and Medi-Cal/APTC mixed cases must be scanned into Integrated Document Management (IDM).

Q 34. What is the address for Covered CA to send verifications for APTC/ CSR only cases?

A 34. The address is:

Covered California--Verifications P.O. Box 989725 West Sacramento, CA 95798-9725

Verifications may also be faxed to Covered CA at: 1-888-329-3700.

Household Composition

Q 35. How do undocumented individuals with income fit into the tax filing unit and how is income counted?

A 35. If an undocumented individual(s) has an Individual Tax Payer Identification Number (ITIN) and files taxes, his/her information would be entered into CalHEERS and he/she would be considered as part of the filing unit; however, he/she is not eligible to purchase any Covered CA health plan, including unsubsidized health coverage for him/herself. Undocumented parents of U.S. citizen or lawfully present children may apply for APTC and CSR on behalf of their children, but not for themselves.

For MC, his/her income would also be counted and if otherwise eligible, then the undocumented individual(s) would receive restricted MC.

Q 36. How do we enter mixed households (MC & APTC) when married & filing separately in CalWIN or CalHEERS?

A 36. All individuals who are married must file as “Married- Filing Jointly” in order to receive APTC. Medi-Cal household composition for a married couple filing separately will be exactly the same as if they are filing jointly, as long as they live in the same home, and children will be included in the household of the parent who is actually claiming the child. If spouses and children are not living in the same house, the household situation needs to be analyzed household member by household member.

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Q 37. How do we enter three-generational household information into CalWIN after 1/2014?

A 37. It would depend on who the Head of the Household is in the three-generation household.

Example:If the household consists of adult mom, child, and grandmother, with the head of the household being the Adult mom, then two separate cases would be created. One for the grandmother on her own and another one with the adult mom and her child as “requesting aid” and the grandmother as “not requesting aid.”

Example:If the household consists of teen mom, child, and grandmother, with the head of the household being the grandmother, then one case would be created consisting of all three household members requesting aid.

Residency Q 38. If a consumer travels between California and another state (i.e Texas), can he/she apply for MC or Covered California, and if approved, receive health coverage? Would he/she be able to use his/her health coverage in Texas? Would the consumer get penalized if he/she does not have health coverage because he/she travels between the two States?

A 38. The consumer is eligible to apply and receive health coverage in his/her state of residence. Therefore, it has to be determined which state (California or Texas) is the consumer's state of residence. If he/she is a resident of California, then he/she can apply for health coverage and potentially be eligible for either MC or Covered CA health plans. If the consumer is eligible for MC, then only specific medical services are covered for services received outside of CA (refer to Medi-Cal Handbook 64.15.1). If he/she is eligible for a Covered CA health plan, then coverage for out-of-state medical services will depend on the plan and/or provider selected by the consumer.

Q 39. A consumer (26 years old) files his/her taxes separate from his/her parents, and just moved to Boston from CA for college for 4 years with summer breaks spent in CA. The consumer's mother calls and asks, if her child should change his/her residency to Massachusetts and apply for health coverage there? Or, can her child apply for MAGI MC and still obtain medical services in Boston?

A 39. An EW should not advise a consumer on whether or not he/she should change his/her residency. Typically, residency is where one holds a valid driver's license, where mail is sent, where immediate family lives, where you are registered to vote, where one files taxes, etc. In this specific situation, since the child is currently a CA resident and files taxes as a CA resident,

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his/her school attendance is considered a temporary absence and he/she could apply for health coverage in CA. Given this scenario, if the child is determined eligible for MAGI MC, then only specific medical services are covered for services received outside of CA (refer to MC Handbook 64.15.1). Same scenario, if the child is determined eligible for a Covered CA health plan, then coverage for out-of-state medical services for individuals or students attending college will depend on the plan and/or provider selected by the consumer.

APTC Q 40. When a consumer decides to use his/her tax credit at the end of the year, is it used to reduce his/her annual income? For example, a consumer has $10,000 gross annual income but has $1,000 APTC that has not been used, does the credit reduce (deduction) his/her income to $9,000 annual income? Or does the tax credit reduce a tax bill or increase a refund?

A 40. The Advanced Premium Tax Credit is calculated in the “tax and credits” portion of the IRS Form 1040; therefore, this credit will either reduce the consumer's amount he/she owes to the IRS or increase the amount of refund he/she will receive.

Q 41. Will ATPC and APTC/CSR only cases be maintained by the county or Covered CA?

A 41. Currently the agreement is that Covered CA will maintain APTC and APTC/CSR only cases.

CalWIN Q 42. How do the CalWIN Call Disposition windows populate?

A 42. The CalWIN Call Disposition windows will populate with the call data as follows:

The Search for Call Disposition Window:

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The Call Disposition Detail Window:

Note:An EW must select a disposition reason in the New Disposition field.

CalHEERS Q 43. Where is the Authorized Representative (AR) information stored in CalHEERS?

A 43. The AR information in CalHEERS is located under the Household section of the application.

Penalties Q 44. What are the penalties for not having MEC?

A 44. The penalties for individuals (excluding exempted individuals) who choose not to obtain MEC are as follows:

• In 2014, an individual who does not maintain MEC will face a penalty of $95 or 1 percent of income, whichever is greater. In 2014, a family will be charged a penalty of $95 per uncovered adult and $47.50 per uncovered child (up to $285 for a family) or 1 percent of the family’s income, whichever is greater.

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• In 2015, the penalty increases to $325 per adult and $162.50 per child (up to $975 for a family) or 2 percent of family income, whichever is greater.

• In 2016, the penalty is $695 per adult and $374.50 per child (up to $2,085 for a family) or 2.5 percent of family income, whichever is greater.

Q 45. Who applies penalties and what are the consequences for not paying them?

A 45. Consumers who do not have MEC in 2014 will be required to pay a penalty when filing their 2014 federal income tax return in 2015. These penalties are part of the federal law and will be collected by the Internal Revenue Service (IRS) as part of individual tax filing. The IRS routinely works with taxpayers who owe amounts they cannot afford to pay. The law prohibits the IRS from using liens or levies to collect any payment taxpayers owe related to the taxpayer, his/her spouse or a dependent included on his/her tax return that does not have minimum essential coverage. However, if a taxpayer owes a payment, the IRS may offset that liability against any tax refund he/she may be due.

Miscellaneous Q 46. Does the Social Services Agency get money/funding for online applications?

A 46. The County of Santa Clara will get minimal funding from the State/Covered CA for APTC applications. EWs, as individuals, will not get paid a separate amount per application.

Q 47. Will Medi-Cal Status Report (MSR) rules still apply?

A 47. Starting January 2014, the MSR will no longer be a requirement for Medi-Cal. MSRs will not be mailed to clients effective November 1, 2013.

Q 48. When would an EW refer an applicant/client to call Covered CA?

A 48. The Affordable Care Act “No Wrong Door Policy” dictates that consumers can apply in any way that best suits their needs which includes contacting their local county office. However, the two instances in which a county EW would refer consumers to Covered CA are:

(1) An employer requesting information on Small Business Health Options Program (SHOP).

(2) Case management on ongoing APTC/CSR cases only.

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Q 49. How will the AIM program (for pregnant women) be affected by the ACA?

A 49. The AIM program will continue to be available for families with income between 251% - 400% FPL. The Department of Health Care Services (DHCS) will make eligibility determinations for these cases and these cases will not be maintained at the county level.

Q 50. The Quick Sort Phone Script (Home Application) states that EWs help clients select MC Managed Care Plans and give clients the phone number.

A 50. EWs will provide the MC client with the Health Care Options telephone number (1-800-430-4263). MC Managed Care Plans are not selected through CalHEERS and EWs cannot enroll or assist clients with the selection and/or enrollment of MC Managed Care Plans.

Q 51. Does CalHEERS have information on consumers who have been dis-enrolled and are trying to re-apply before open enrollment?

A 51. If an account was previously created, then the information remains in CalHEERS.

Q 52. How far thru the workflow process do EWs process the horizontal integration?

A 52. If an applicant is requesting CW, then the applicant is referred to Intake. If the applicant is requesting CF, then mail the SAWS 2 Plus to the applicant.

Q 53. Where can we find the other counties’ phone numbers to complete courtesy applications?

A 53. The contact information for the other California counties is available on the intranet in the DEBS Forms Library as form number SCD 2352.

Q 54. What phone number should be given out to the general public?

A 54. The phone number to be given out to the general public for SSA - Santa Clara County is our Intake phone number (408-758-3800).

Q 55. Do consumers report changes to Covered CA or county?

A 55. Consumers can report changes to either the county or Covered CA; however, they are advised to report all Medi-Cal-related changes to their county of residence. EWs should advise consumers that the reporting

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requirement for Medi-Cal is still 10 calendar days and consumers should report any changes as soon as possible whether or not they have Medi-Cal or a Covered CA health plan.

Q 56. How will EWs access other counties’ online applications/accounts?

A 56. EWs have access to all consumer's applications and information located in CalHEERS regardless of county of residence. However, EWs do not have certain access to consumer's CalHEERS accounts, such as a consumer's account password, user name, or secure mailbox.

Q 57. What is the phone number for Covered CA?

A 57. Main phone: 1-800-300-1506 TTY: 1-888-889-4500

Q 58. What is the difference between CalHEERS and Coveredca.com?

A 58. Both refer to the California web application which is used to apply for, determine, and maintain health coverage information. Coveredca.com is the public name that is used by consumers and media. CalHEERS is another name that government staff, assistors, and enrollment counselors also use for this web application.

DENISE BOLAND, DIRECTOR, Department of Employment and Benefit Services

Contact Person(s): Idelle Villarreal, Application & Decision Support Specialist, (408) 755-7540 Flavio Barbosa, Application & Decision Support Specialist, (408) 755-7540.