Medicaid Eligibility: Children, Parents, and Pregnant Women

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1 Medicaid Eligibility: Children, Parents, and Pregnant Women Kyle Fisher Staff Attorney October 2013 Who We Are Pennsylvania Health Law Project is a statewide legal services organization that helps low-income consumers, seniors, and persons with disabilities access health insurance and health care services Contact HELPLINE: (800) Medicaid Basics Topics Category & Income Limits Modified Adjusted Gross Income (MAGI) What income counts Whose income counts How the pieces fit together Insurance Marketplace Coverage & Subsidies How to apply 3 1

2 Medicaid Basics 4 Medicaid (a.k.a. Medical Assistance) Federal/state health insurance program for low-income children, families, persons with disabilities, and elderly Dozens of ways to qualify (categories of eligibility) Each category has different income and asset guidelines Medicaid Eligibility 5 Residency Category Income Limits Immigration Status Do analysis for each person Child may be Medicaid-eligible and parent not Pregnant parent may be Medicaid-eligible, and child not Practice tip: For children: Medicaid Eligibility First check Medicaid eligibility Then CHIP Then Marketplace subsidies For adults: Medicaid -> Marketplace subsidies Why? 6 If eligible Medicaid/CHIP, not eligible for premium tax credits 2

3 Medicaid & CHIP 7 CATEGORY, INCOME LIMITS, IMMIGRATION STATUS Category 8 Categorical Eligibility Children Pregnant Women Parents & Caretakers Persons with Disabilities Temporary Permanent or 12 months+ Workers with Disabilities Has 5% premium Seniors Definitions: Child Age 0-18 Category Age (Medically Needy Only) Up to age 26 (if aged out of foster care) Parent Biological or adoptive parent of a deprived child age 0-17 (or age 18 if a full-time student) Caretaker 9 Specified relative = relative through 1 st cousin once removed (MAEH ) with care and control of a deprived child 3

4 Medicaid 10 Income Eligibility Infants (age 0-1) Children (age 1-5) Children (age 6-18) Children w/ special needs FPL 215% 157% 133% ** Pregnant Women Parents & Caretakers *See DPW attachment 3 FPL 215% 33% Income Limits Infants (0-1) & Pregnant Women (215% FPL) 11 Household Size Monthly Annual HH of 1 $2,059 $24,704 HH of 2 $2,779 $33,347 HH of 3 $3,500 $41,990 HH of 4 $4,220 $50,633 HH of 5 $4,940 $59,276 *Plus 5% Disregard *Pregnant Woman is at least a household of two Income Limits Children age 1 through 5 (157% FPL) 12 Household Size Monthly Annual HH of 1 $1,504 $18,040 HH of 2 $2,030 $24,351 HH of 3 $2,556 $30,663 HH of 4 $3,082 $36,974 HH of 5 $3,608 $43,285 *Plus 5% Disregard 4

5 Income Limits Children age 6 through 18 (133% FPL) 13 Household Size Monthly Annual HH of 1 $1,274 $15,282 HH of 2 $1,720 $20,629 HH of 3 $2,165 $25,975 HH of 4 $2,611 $31,322 HH of 5 $3,056 $36,669 *Plus 5% Disregard Income Limits Parents/Caretakers (33% FPL) 14 Household Size Monthly Annual HH of 1 $316 $3,792 HH of 2 $427 $5,119 HH of 3 $538 $6,445 HH of 4 $648 $7,772 HH of 5 $759 $9,099 *Plus 5% Disregard CHIP Eligibility Basics 15 Child is under age 19 Resides in PA Citizen or lawfully present Uninsured & ineligible for Medicaid 5

6 CHIP Income Limits Children age 0 through 18 (208% + 314% FPL) 16 Household Size Free CHIP Monthly Free CHIP Annual Low-cost Monthly Low-cost Annual HH of 1 $1,993 $23,899 $3,008 $36,096 HH of 2 $2,689 $32,261 $4,060 $48,720 HH of 3 $3,386 $40,622 $5,112 $61,344 HH of 4 $4,083 $48,984 $6,164 $73,968 HH of 5 $4,780 $57,346 $7,216 $86,589 *Plus 5% Disregard Example: mixed households 17 Vanessa lives with her sons Huey (age 5) and Riley (age 6), whom she claims as tax dependents. All are uninsured. She works as a pharmacy tech, and earns $2500 per month. Who is eligible for Medicaid/CHIP? Huey Riley Vanessa Medicaid Free CHIP Marketplace Why? Age 5; HH 3 income under 157% FPL Age 6; over 133% FPL, under 208% Parent; over 33% FPL Example: pregnant mother Tomas and Ana have one child, Sofia (age 3), and are expecting a second in December. Their income is Tomas salary of $37,000 per year. Who is eligible? 18 Ana Sofia Medicaid Market place Why? Pregnant; HH 4 income under 215% FPL Age 3; under 157% FPL with 5% disregard Tomas Parent; over 33% FPL 6

7 Lawfully Present Legal term of art Standard for: Children Pregnant women Immigration Status Marketplace coverage (for anyone) Examples (there are many more!): Legal Permanent Resident (green card) Nonimmigrant Visa holders (students, tourists, visitors) Temporary Protected Status (TPS) https://www.healthcare.gov/immigration-status-and-the-marketplace/ 19 Immigration Status 20 Qualified Alien More narrow than lawfully present Standard for: Parents (Medicaid) Disability and age-based categories (Medicaid) Five Year Bar Depending on the status, may be subject to a 5 year bar Have to be in qualified status for 5 years before eligible See MAEH 322, Appendix A Immigration Status 21 Emergency Medical Assistance no immigration status required must be otherwise eligible (meet category & income req.) Temporary Full benefit, but limited to time period of emergency condition An emergency medical condition is a medical condition with acute symptoms of such severity including severe pain, that without immediate attention, the result may be: The patient s health is in serious jeopardy. Serious impairment to bodily functions. Serious dysfunction of any body organ or part. (see MAEH 322) 7

8 Example: pregnant mother Ana is undocumented. She is pregnant and has one child, Sofia (age 3), who was born in PA. Ana works informally and earns $800/month. 22 Sofia Ana Medicaid EMA only Why? Citizen, age 3; HH 3 income under 157% FPL Not lawfully present ; limited to EMA. Under 215% FPL. Labor and delivery covered. Modified Adjusted Gross Income 23 INCOME-COUNTING & HOUSEHOLD SIZE RULES What Income Counts Modified Adjusted Gross Income (MAGI) New, tax-based measure AGI + tax exempt interest + foreign income + Social Security benefits Rule: income counts unless exempted by tax rules MAGI does not count: child support, workers compensation, veterans benefits 24 8

9 MAGI Categories What Income Counts 25 MAGI Children Medicaid & CHIP Pregnant Women Parents & Caretakers Non-MAGI Persons with Disabilities Temporary Permanent or 12 months+ Workers with Disabilities Seniors *no resource test What Income Counts Types of Income Counted in MAGI 26 Counted Wages & tips Unemployment Compensation Social Security benefits Pensions Dividends and interest Alimony received Rents & royalties Child s income (if req. file tax) Not Counted TANF SSI Child support Workers compensation Veterans benefits Scholarship income IRA contributions Student loan interest Gifts and inheritances What Income Counts Budget periods Medicaid counts current monthly income lump sums count in month received 27 Marketplace counts estimated annual income for calendar year 9

10 Example: income types Vanessa lives with her sons Huey (age 5) and Riley (age 6). Vanessa was hurt on the job and receives $1250/month in workers compensation. She also receives $600/month in child support. 28 Medicaid CHIP Why? Huey MAGI = $0. Age 5; under 157% FPL Riley Age 6; under 133% FPL Vanessa Parent; under 33% FPL Example: income types Vanessa lives with her sons Huey (age 5) and Riley (age 6). Vanessa was laid off and receives $1250/month in unemployment compensation. She also receives $600/month in alimony. 29 Medicaid CHIP Why? Huey MAGI = $1850/mnth Age 5; under 157% FPL Riley Age 6; under 133% FPL Vanessa Parent; over 33% FPL Household Size 30 Determining household size Important in converting income to FPL Household size affects eligibility $20,000 = 175% FPL for HH of one vs. 129% FPL for HH of two Household size based on tax unit Tax filer plus individuals claimed as dependents Marketplace vs Medicaid Rules for determining household size are not the same 10

11 Whose Income Counts? 31 For Marketplace subsidies, household size equals the tax unit Household = Tax Unit Filer Spouse Qualifying Children & Relatives Whose Income Counts? For MAGI categories of Medicaid: Individual-based determination based on expected tax filing status Three categories: (1) tax filers (2) tax dependents (3) non-filers and not claimed as tax dependent 32 Whose Income Counts? 33 Medicaid rule for Tax Filers: Household = tax filer and all expected dependents 11

12 Whose Income Counts? 34 Medicaid rule for Tax Dependents: Household = household of tax filer claiming the dependent 3 exceptions: in these cases, apply the rule for non-filers Tax dependent who is not a child or spouse of the taxpayer Children living with both parents who are unmarried Children claimed as tax dependent by a non-custodial parent Whose Income Counts? 35 Medicaid rule for non-filers and non-dependents: For adults: Household = individual plus, if living with individual, spouse and children For children: Household=child plus siblings and parents (including stepparents) living with the child Household Size Flow Chart 36 Meredith s chart 12

13 Example: grandparent caretaker 37 Thelma cares for her granddaughter Maggie (age 12), whom she claims as a tax dependent. What is each person s household size for Medicaid? Counted in HH Thelma Maggie Medicaid HH size Thelma 2 Maggie 4 Why? Tax Filer + dependent Dependent, but meets exception Example: multiple generations Tina, age 17, is in school and has a newborn, Max. She lives with and is supported by her parents, who intend to claim her and Max as tax dependents. 38 Counted in HH GM GD Tina Max Medicaid HH size Grandmom 4 Granddad 4 Tina 4 Max 2 How the Pieces Fit Together 39 MARKETPLACE SUBSIDIES 13

14 40 Marketplace Basics - Subsidies Who qualifies for marketplace subsidies? Premium Tax Credits 41 Income between % FPL Cannot be eligible for other minimum essential coverage Medicaid, Medicare, CHIP, VA care = minimum essential coverage Cannot be offered affordable (<9.5%) employer-based coverage Cost-Sharing Reductions Income between % FPL Eligible for premium tax credits Enroll in Silver-level plan 14

15 Example: coverage gap Vanessa lives with her sons Huey (age 5) and Riley (age 6). All are uninsured. She works as a preschool teacher and earns $1500/month. ($18,000/year) 43 Huey Riley Medicaid Market place Premium tax credits Vanessa No Why? Age 5; under 157% FPL Age 6; under 133% FPL Under 100% FPL (HH 3), no PTC! How to Apply 44 MEDICAID & CHIP How to Apply Medicaid & CHIP 45 COMPASS or Healthcare.gov Children Pregnant Women Parents & Caretakers COMPASS Persons with Disabilities Temporary Permanent or 12 months+ Workers with Disabilities Seniors 15

16 How to Apply 46 Online: COMPASS or Healthcare.gov By phone: (DPW; MAGI categories) (CHIP) By mail: In person: paper County Assistance Office When: anytime Marketplace & DPW Interface 47 No wrong door Marketplace screens Medicaid/CHIP eligibility DPW forwards ineligible applicants to the FFM Via account transfers, no new application needed Real time eligibility & electronic data verification Resources 48 Medical Assistance Eligibility Handbook DPW Ops Memo on MAGI - OPS See link for MAEH -> Operations Memoranda CHIP s Eligibility and Benefits Center on Budget and Policy Priorities Beyond the Basics PHLP Helpline: For wrongful Medicaid or CHIP denials, or coverage gap cases 16

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