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

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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

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Overview

Coverage Medical Assistance, CHIP and Marketplace

Special SituationsNew rules for eligibilityChild to Young AdultHow to ApplyWhere to go for help

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Coverage – Marketplace Plans

Highest Premiums & Lowest Cost Sharing*

Lowest Premiums & Highest Cost-Sharing

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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.

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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

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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

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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)

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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

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Where to go for help

PA Health Law ProjectAnn Bacharach – 215-625-3596

abacharach@phlp.orgHelpline – 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

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