Basic Eligibility for Public Programs

Basic Eligibility for Public Programs

Trainer Your trainer today is Ralonda Mason Head shot of the trainer Supervising Attorney Mid-Minnesota Legal Aid (320)257-4866 rmason@mylegalaid.org

Topics for this session Financial Help Overview Medical Assistance Basic Eligibility Criteria MinnesotaCare Basic Eligibility Criteria

Financial Help Overview 4

Financial assistance for low and moderate income households Advance Premium Tax Credits (APTC) tax credit which reduces the monthly premium payment for a private plan sold on MNsure Cost Sharing Reductions (CSR) subsidies that reduce the out-of-pocket costs of private insurance sold on MNsure such as co-pays and deductibles MinnesotaCare (MCRE) public plan with low monthly premiums, limited co-pays and no deductibles Medical Assistance (MA) public plan with no premiums, limited co-pays and no deductibles 5

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Modified Adjusted Gross Income What counts: Adjusted Gross Income (1040, line 37) + Foreign Income + Tax Exempt Interest + Non-taxable Social Security Benefits Modified Adjusted Gross Income (MAGI) What doesn t: Child Support SSI Benefits Veteran s Benefits Worker s Comp Income tax deductions Self-employment expenses Interest on student loans Tuition and fees Alimony paid

No asset limit Photo: Ken Teegardin (hhtp://bit.ly/14cbfov) 8

Medical Assistance Basic Eligibility Criteria 9

Basic eligibility considerations Income State residency Citizenship/immigration status Category of eligibility Incarceration status 10

Categories of eligibility Non-disabled, non-pregnant adults age 19-64 Pregnant women Children under the age of 19 Blind or disabled adults Adults age 65 and over 11

Citizenship/immigration status US citizens are eligible for MA Qualified aliens are eligible for MA Lawful Permanent Residents (LPRs or Green Card Holders) who have had that status for 5 years Asylees and refugees Cuban/Hatian Entrants and other Special Immigrant Entrants Battered Non-Citizens who have had that status for 5 years Victims of Human Trafficking and T visa holders Withholding of Deportation status holders Veterans and military families Center for Victims of Torture service recipients 12

Citizenship/immigration status Other lawfully present non-citizens are ineligible for MA Lawful Permanent Residents who have had that status for less than 5 years Applicants for Asylum and Withholding of Removal Lawful Temporary Residents (LTRs) Deferred Action U and V visa holders Temporary Protected Status Citizens of Micronesia, the Marshall Islands and Palau Pending Immigration Status 13 Exception: Pregnant women and children under age 21 are eligible

Citizenship/immigration status Other non-citizens ineligible for MA Student Visa holders Tourist Visa holders Non-citizens without valid authorization to be present in the US Exception: Children under age 21 who are lawfully present on a temporary basis Exception: Pregnant women and those with an emergency medical condition 14

State residency Residency is conferred by presence in the state with the intent to reside Does not require a fixed address Can retain state residency if temporarily absent Children under age 21 are generally residents of the state where their parent or caretaker lives Cannot be a resident of another state 15

Income and asset limits Category of Eligibility Income Calculation Methodology Income Limit Asset Limit Parents, adults and children > 19 MAGI 133% FPG No Asset Limit Pregnant women MAGI 278% FPG No Asset Limit Children < 19 MAGI Age 0-2 283% FPG Age 2-18 275% FPG No Asset Limit Elderly Non-MAGI 100% FPG Blind or disabled Non-MAGI 100% FPG $3,000 for HH 1 $6,000 for HH 2 $3,000 for HH 1 $6,000 for HH 2 16

Spenddowns Some people who are over the income limit can qualify for MA by meeting a spenddown A spenddown is like a deductible: The applicant is responsible for the spenddown amount before MA eligibility begins Spenddowns can be calculated either on a monthly or 6 month basis 17

Eligibility start date Eligibility start dates for MA are not subject to the open enrollment period Eligibility begins the 1 st day of the month of application Example: Sergio submits an application on October 17 and is determined eligible for MA. His eligibility begins October 1. Retroactive eligibility possible for the 3 months prior to the month of application Applicant can request retroactive coverage on the application 18

Verifications required Income information must be verified prior to approval of application MNsure will attempt to verify information electronically If electronic verification is unavailable, applicant will be required to submit paper verifications Application will be pended until income verifications received Notice will be sent requesting verification Limited time to provide verification Other information such as SSN and citizenship/immigration status can be verified after approval 19

Private insurance is NOT a barrier to Medical Assistance eligibility An applicant can be eligible for MA regardless of whether they have access to private insurance. They can even be enrolled in a private insurance plan and be eligible for MA. MA will become the secondary payer and will cover healthcare costs not paid by the primary plan (deductible, co-pay, non-covered care) provided the service is a MA covered service MA will reimburse the applicant for the cost of the premium if the private plan is determined to be cost effective 20

Special rules for special populations Auto Newborns: Children born to mothers who are enrolled in MA when the child is born are automatically eligible for MA and remain eligible for 12 months regardless of any change in their income. Foster Children: IV-E foster children are automatically eligible for MA. In addition, children who are in foster care and on MA when they turn 18 remain eligible for MA until age 26. SMRT: Disabled individuals who do not yet have a determination of disability from SSA can request a determination from the State Medical Review Team (SMRT) in order to qualify for services available only to enrollees under the blind or disabled category. 21

Specialized MA eligibility TEFRA: An option for certain disabled children whose eligibility is based on their income rather than their household (HH) income. MA-EPD: Allows disabled people who work to maintain MA eligibility by paying a monthly premium based on their income. Medicare Savings Programs: A series of programs that pay for Medicare premiums and some costs not covered by Medicare. Emergency Medical Assistance (EMA) 22

Emergency Medical Assistance (EMA) Provides coverage for certain medical conditions for people who would be eligible for MA except for their immigration status. Covers emergency room and in-patient hospitalization resulting from a condition that places the applicant s health in serious jeopardy Covers on-going care necessary to prevent subsequent hospitalization within 48 hours subject to a Certified Care Plan submitted by applicant s physician Covers certain care for patients with chronic conditions such as dialysis and chemotherapy 23

MA for pregnant women All pregnant women with incomes at or below 278% FPG are eligible for MA regardless of citizenship or immigration status Women not otherwise eligible for MA, are eligible from the month of conception through 60 days post partum Exception: Women whose immigration status is undocumented and who are enrolled in other insurance coverage are eligible only for EMA coverage of the inpatient stay related to labor and delivery No verification of pregnancy is required beyond self attestation 24

How to apply for Medical Assistance Program Application Type Where to Submit MA Paper: DHS-6696; on-line Fax to MNsure; on-line MA Elderly Paper: DHS-3876 Fax to county of residence EMA Paper: DHS-6696 Fax to county of residence SMRT MA-EPD TEFRA Medicare Supplement Paper: DHS-6696, unless all HH members need MA-EPD: DHS- 3876, SMRT application Paper: DHS-6696, unless all HH members need MA-EPD: DHS- 3876 Paper: DHS-6696, on-line TEFRA worksheet Paper: DHS-6696, unless all HH members need Medicare Supplement: DHS-3876 Fax to MNsure, unless all applicants in HH need SMRT determination and in that event fax to county of residence Fax to MNsure, unless all applicants in HH need MA-EPD and in that event fax to county of residence Fax to MNsure; on-line Fax to MNsure, unless all applicants in HH need Medicare Supplement and in that event fax to county of residence 25

Reporting changes MA recipients are required to report the following changes within 10 days of the change: Change in income Change in address Change in HH size, including pregnancy Change in access to health insurance or Medicare 26

MinnesotaCare Basic Eligibility Criteria 27

Basic eligibility considerations Income State residency Citizenship/Immigration status Tax filing unit Access to private insurance Payment of premium Incarceration status 28

Income and asset limits Must have income above the MA limit and at or below 200% FPG Exception: Individuals ineligible for MA for reasons other than income who are otherwise eligible for MinnesotaCare No asset limit 29

Citizenship/immigration status US citizens are eligible for MinnesotaCare Qualified aliens are eligible for MinnesotaCare Other lawfully present non-citizens are eligible for MinnesotaCare Student Visa holders are eligible for MinnesotaCare Note: Some Student Visa holders may have difficulty meeting the state residency requirement Visitors and aliens without valid authorization to be present in the US are ineligible for MinnesotaCare 30

Tax filing requirement MinnesotaCare rules do not currently require applicants to intend to file taxes for 2014 or 2015. However, applicants who answer the question on intent to file taxes No on the application will have their application denied. This is a system error 31

Access to private insurance Applicant is not eligible for MinnesotaCare if s/he is currently enrolled in a private health insurance plan Applicant is not eligible for MinnesotaCare if s/he is enrolled in or eligible for Medicare Part A and B Applicant is not eligible for MinnesotaCare if s/he has access to affordable insurance from an employer that provides minimum value Insurance may be from the applicant s employer or another household member s employer 32

Minimum Essential Coverage (MEC) In order for other insurance to bar eligibility for MinnesotaCare, it must provide Minimum Essential Coverage What plans provide Minimum Essential Coverage? Government-Sponsored Coverage such as Medicare; Medical Assistance; and Veterans and Military coverage such as TRICARE or CHAMPUS Private Insurance: Most plans sold in the private market both inside and outside MNsure; nearly all employersponsored insurance, regardless of affordability or minimum value 33

Employer Sponsored Insurance (ESI) In order for access to Employer Sponsored Insurance to be a bar to MinnesotaCare eligibility it must provide Minimum Value and it must be affordable Affordable coverage is coverage for which the employee pays less than 9.5% of the household s income for the cost of the premium This only applies to the cost of the employee s coverage for the lowest cost plan offered If the employer also offers coverage for the employee s dependents, that coverage will be deemed affordable for everyone if it is affordable for the employee Minimum Value means that the plan's actuarial value is bronze level or higher 34

MinnesotaCare premiums MinnesotaCare enrollees pay a monthly premium for coverage Exception: American Indians enrolled in a federally recognized tribe and families with Active Duty Military within last 24 months pay no premiums for 12 months Premiums range from $4 - $50 per person per month and are based on the enrollee s income. Income Percent FPG Individual Premium Amount Income Percent FPG Individual Premium Amount 0% - 55% $4 130% - 140% $21 55% - 80% $6 140% - 150% $25 80% - 90% $8 150% - 160% $29 90% - 100% $10 160% - 170% $33 100% - 110% $12 170% - 180% $38 110% - 120% $15 180% - 190% $43 35 120% - 130% $18 190% - 200% $50

Eligibility start date MinnesotaCare coverage begins the first day of the month following the month in which the enrollee pays his/her first premium DHS has temporarily suspended the requirement that enrollees pay their first month s premium before coverage begins due to system errors in sending out correct premium statements Currently MinnesotaCare coverage begins the first of the month following the month of application Example: Amina submits an application on Oct. 17 and is found eligible for MinnesotaCare, her coverage begins Nov. 1 36

Verifications Provisional eligibility will be approved prior to the receipt of verification of eligibility information MNsure will attempt to verify information electronically If electronic verification is unavailable, application will be processed based on information provided in the application Enrollee must provide verification within a reasonable amount of time or eligibility will be terminated 37

How to apply for MinnesotaCare Applicants for MinnesotaCare can apply on-line or with a paper application. DHS-6696 Fax paper application to MNsure 38

Reporting changes MinnesotaCare enrollees are required to report the following changes within 10 days of the change: Change in income Change in address Change in household size, including pregnancy Change in access to health insurance including Medicare 39

Continuity between programs Medical Assistance and MinnesotaCare are intended to provide a seamless transition as individuals experience life changes that move them from one program to the other Both programs require most (MA), if not all (MinnesotaCare), recipients to enroll in a managed care plan Plan availability is based on the county of residence. Most counties have the same plans available for both MA and MinnesotaCare recipients. 40

41 Questions?