PEAL Center
PRESENTER ANN BACHARACHPA HEALTH LAW PROJECT
FEBRUARY 9 , 2015
"Children’s Health Coverage through Medicaid, CHIP and the Marketplace"
Webinar will begin at NOONIf you have not received an email with the PowerPoint download
a copy at: http://pealcenter.org/trainings-upcoming.php
1
PEAL Center
PRESENTER ANN BACHARACHPA HEALTH LAW PROJECT
FEBRUARY 9 , 2015
Children’s Health Insurance in the Brave, New World of the
Affordable Care Act2
Good News!!!
Children in Pennsylvania have access to health insurance It may be free – Medical Assistance and
CHIP
It may be low-cost – CHIP and Marketplace
It may be at-cost - Marketplace
3
Overview
Coverage Medical Assistance, CHIP and Marketplace
Special SituationsNew rules for eligibilityChild to Young AdultHow to ApplyWhere to go for help
4
Coverage – Medical Assistance
Free for children No premiums, no co-payments
Staircase of eligibility Babies up to 1st birthday – 220% Children age 1 to 6th birthday – 162% Children age 6 to 19th birthday – 138%
Administered by Department of Human Services (formerly Department of Public Welfare)
Delivered through managed care plans – HealthChoices
Can have other private insurance – MA as secondary coverage
5
Coverage – Medical Assistance
Benefits – children under 21 are entitled to all medically necessary services Physical health care services
Well and sick visits, hospital and ER care, prescription drugs, lab tests and radiology
Durable medical equipment, home health care, shift nursing, OT, PT and Speech, assistive devices
Behavioral health care services In patient, partial hospitalization, and outpatient
services, family-based mental health services, mobile therapy, prescription drugs
6
Coverage - Medical AssistanceSpecial Situations - CYSCHN
Children and Youth with special health care needs Meet the Supplemental Security Income (SSI)
disability criteria for children Eligibility based only on the child’s income
Up to age 18Sometimes called “family of one”, “children
with special health care needs” “PH-95”Disability category – rules remain the same
as before expansion of Medicaid
7
Coverage – Medical AssistanceSpecial Situations – Former Foster Youth
Special eligibility for foster care youth who have aged out On January 1, 2014, all youth who turned 18 in
foster care between 2007 and 2013 became eligible for Medicaid without counting income.
Youth who were in foster care and enrolled in Medicaid on their 18th birthday are eligible for Medicaid until age 26
Youth who were in foster care and Medicaid in any state at age 18 or older
8
Coverage - Former Foster Youth
Youth are presumptively eligible for this category of Medicaid and should be automatically enrolled as they age out of foster care Under 21, EPSDT Over 21, adult benefits
Group of youth who have aged out but are still under 26 will have to apply. Application will ask if in foster care
Online - only if someone is between 18 and 26 On paper for each applicant Should result in automatic enrollment
9
Coverage – Medicaid Expansion
Expands eligibility for non-elderly, non-disabled adults 19 – 64
As many as 600,000 PennsylvaniansIncome less than 138% of povertyHealthy PA waiver
Three benefits packages Healthy, Healthy Plus, Healthy PA Private Coverage
Option (PCO) Likely to be modified by Wolf Administration
10
Coverage – CHIP
Eligibility above Medical Assistance levels Free
Income up to 213% No premiums, no co-payments
Low-cost Income between 213% and 319% Premiums $51 and $81 per month Co-payments $5 for PCP, $10 specialist, $6 generic drug, $25 ER visit
Full-cost Income above 319% Premium $226 per month Co-payments $15 for PCP, $25 specialists, $10 generic drug, $50 ER visit
Administered by Insurance Department
Delivered through managed care plans Cannot have other insurance
11
Coverage – CHIP
Benefits Equivalent to very good employer coverage Benefits include, with some limits:
Primary and specialty care Hospital and emergency room visits Lab work and radiology Prescription drugs, eyeglasses, hearing aids, DME
supplies OT, PT, Speech therapies, Home health care – with limits
Not an entitlement – no requirement to cover all medically necessary services
12
Coverage – Marketplace Plans
Eligibility to buy a plan Reside in Pennsylvania Be lawfully present Not be incarcerated
Eligibility for Premium Tax Credits Income between 100% and 400% of poverty* Additional cost-sharing reductions between 100% and 250% Not have an offer of employer-based coverage File income taxes for the year in which the credit is used Not eligible for Medical Assistance, CHIP or Medicare
* Can be below 100% if not eligible for Medical Assistance due to five year immigration requirements
13
Coverage – Marketplace Plans
All plans cover Essential Health Benefits10 areas of coverage: Outpatient care Emergency room care Inpatient care Prenatal and postpartum care Mental health and substance use disorder services Prescription drugs Services and devices to help you recover if you are injured, or
have a disability or chronic condition. (PT, OT, Speech, psychiatric Your lab tests
Preventive services including counseling, screenings and vaccines and care for managing a chronic disease.
Pediatric services: Including dental care and vision care
14
Coverage – Marketplace Plans
Highest Premiums & Lowest Cost Sharing*
Lowest Premiums & Highest Cost-Sharing
15
NEW RULES FOR ELIGIBILITY
MAGI16
MAGI
MAGI stands for Modified Adjusted Gross Income Adjusted gross income + foreign income + tax-exempt interest + Social
Security benefits*New rules for eligibility for Medical Assistance, CHIP and
MarketplaceBased on IRS tax rules for household and incomeNot surprisingly – complexApplies to non-disabled, non-elderly households
Does not apply to children with special health care needsSystems for applying will know who to count and how to
count
* Children’s Social Security benefits most often do not count unless child has earned income above certain thresholds.
17
MAGI
What are the differences between old rules and MAGI?
Household composition Household is tax household – tax filer + tax
dependents If not filing taxes – non-filer rules
Income Child support received, veterans’ disability benefits,
workers compensation - no longer count as income Generally, income counts unless it’s tax exempt
18
MAGI
Non-filer household rules For adult – adult + spouse and children living with
adult For children – child + parents and siblings living with
child
Some special exceptions for children in Medicaid Children living with both parents who are not married
to each other Children not living with a parent Children who are living with one parent but claimed
by non-custodial parent Apply non-filer rules
19
How to Apply20
Applying for Marketplace plans
Online: Healthcare.gov
By phone: 1-800-318-2596 (available 24/7) FFM
By mail: Paper application (available through Healthcare.gov) – not recommended
In person: Navigators & Certified Application Counselors (“CACs”)
When: Special Enrollment Period only(next open 2014: Nov 15, 2014 – Feb. 15, 2015enrollment)
21
Applying for Medicaid and CHIP
COMPASS – Pennsylvania’s online application www.compass.state.pa.us COMPASS includes the new rules
New paper application – PA 600 HC http://
www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/document/p_036125.pdf
Over the phone 1-866-550-4355 – (business hours) DPW
Apply directly to CHIP plans www.chipcoverspakids.com for plans
22
Where to go for help
PA Health Law ProjectAnn Bacharach – 215-625-3596
[email protected] – 1-800-274-3258
For advice on applying, enrolling, renewal, obtaining services
For clients who need a lawyer to represent them at hearings and appeals
23