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The Affordable Care Act for Family Law Practitioners
July 10, 2014
LAF & The Sargent Shriver National Center on Poverty Law
About Us: The Shriver CenterThe Sargent Shriver National Center on Poverty Law provides national leadership in advancing laws and policies that secure justice to improve the lives and opportunities of people living in poverty. We specialize in practical solutions. Through our advocacy, communication, and training programs, we advocate for and serve clients directly, while also building the capacity of the nation’s legal aid providers to advance justice and opportunity for their clients.
Like us on Facebook: www.facebook.com/shrivercenterFollow us on Twitter: @shrivercenterwww.povertylaw.org
AGENDA• 1:00 – 1:45 pm: ACA Overview• 1:45 – 2:00 pm: Questions• 2:00 – 2:45 pm: ACA/Family Law
Scenarios and Considerations• 2:45-3 pm: Questions
ObjectivesThis session will help you understand:• The basics of Medicaid and the Health
Insurance Marketplace in Illinois.• Who might be eligible for premium tax
credits and cost sharing reductions in the Marketplace.
• Minimum essential coverage (MEC).• Individual and employer shared
responsibility requirements.
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The Affordable Care Act (ACA) at a Glance
ACA was signed into law on March 23, 2010 and the major provisions started on January 1, 2014.
“Health Insurance Marketplaces” opened on October 1, 2013 across the nation: Get Covered Illinois is a single entry point for the Illinois Marketplace and Medicaid enrollment.
Individuals are responsible to obtain health coverage through an employer, directly from an insurance company or through the Marketplace, Medicaid or Medicare. Employers over 50 FTE are responsible for providing coverage - but employer penalty delayed until 2015/2016 depending on employer size.
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Four New Ways to Get Covered
#1 New Medicaid Adult Group available to adults age 19-64.#2 New Insurance Marketplace to buy insurance and receive financial help to pay for it.#3 Medicaid available to former foster children up to age 26 at any income level.#4 Young adults 19-25 years old can stay on their parents’ policy.
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New Consumer Protections for All Insurance
1. No pre-existing condition exclusions.2. Essential Health Benefits must be covered. 3. Holds insurance companies accountable for rate
increases.4. Coverage information in plain language.5. Preventive services available without cost sharing.6. No rescissions.
7. No lifetime or annual limits on care.8. Extended dependent coverage available up to age 26.9. Marriage equality.
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*There are still some grandfathered health plans that do not need to provide these ACA protections:
http://insurance.illinois.gov/cb/2014/CB2014-04.pdf Also, there are some noncompliant, non-grandfathered plans in the
individual and small group markets that do not have to cover ACA changes until 2016 or 2017:
http://insurance.illinois.gov/cb/2014/CB2014-04.pdf
Prevention Services
New private plans offered after Sept. 23, 2010 are required to provide these new preventive services (and others) without cost sharing
Type of Preventive Service
Alcohol Misuse HIV
Aspirin Diet/Obesity
Blood Pressure Sexually Transmitted Infection (STI)
Cholesterol Tobacco Use
Colorectal cancer Breast Cancer/Mammograms
Depression Immunizations
Type 2 Diabetes Developmental screening for children
Full list of no cost preventive screenings available:https://www.healthcare.gov/what-are-my-preventive-care-benefits/
1. Tax Filing Status 2. Household Composition/Size 3. MAGI (Modified Adjusted Gross
Income)
New Household and Income Considerations for Families under the ACA
Tax Filing Status: Common TermsThere are five (5) filing statuses. (The status is based on whether you are considered married or unmarried by the Internal Revenue Service (IRS)):• Single • Married filing jointly• Married filing separately• Head of Household• Qualifying Widow/Widower with a dependent child
A person’s filing status is based on their marriage status as of the last day of the calendar year for which taxes are being filed.• If more than one status applies, the person can choose the one that
gives them the lowest tax rate.
Why is Filing Status Important?
The tax filing status determines:
• The tax rate; and • Standard deduction; and • Eligibility for some tax credits.• Premium Tax Credits can be claimed by
persons who file as Single, Married Filing Jointly, Head of Household and Qualifying Widow(er) with a dependent child.
• Premium Tax Credits CANNOT be claimed if Married but Filing Separately.
Tax Filing Status: Head of Household
A person may file as Head of Household if:
Unmarried or “considered unmarried” on the last day of the year; AND
Files a separate return; AND
A spouse did not live in the home in the last 6 months of the year; AND
Paid more than half the cost of keeping up a home for the year; AND
Able to claim an exemption for a child (however, this test is also met if unable to claim the exemption only because the noncustodial parent can claim the child); AND
Must pay more than half the cost of keeping up the home for a “qualifying person”
Tax Status and Medicaid
The state considers three factors when defining a Medicaid household:• If the person expects to file a tax return; AND• If the person is a tax dependent on a return; AND • Relationship of the people who live in the home.
** If a married couple who live together is applying for children in common, it’s important to know if they are filing jointly or separately to determine whether the children use tax filer rules or non-filer rules to determine their family size.
Medicaid Household Grid
These rules apply to all living situations including people who are homeless.
Tax FilerTax Dependent
(regardless of age) of a parent or step-parent
Not a Tax Filer and Not a Tax Dependent
Include in the household …
Applicant Applicant Applicant and the following, if living in the home:• spouse• children (biological, adopted, and step)• parent of their child if applying for the child
All claimed dependents
The person filing the taxes If applicant is under 19, include the following people living in the home: • parents (biological, adopted, and step); and • siblings (biological, adopted, and step) Spouse if living in
the home, whether or not
filing jointly
The spouse of the tax filer if living in the home
Names you don’t have to include
Anyone not on the tax return
Anyone not on the tax return
• unmarried partner not requesting coverage• unmarried partner’s children• if over 19, parents in the home who do NOT
claim you as dependent• other adult relatives and unrelated persons
who file their own tax returns
Optional Names to include
• unmarried partner if there is a child in common; or• any other child under age 19 that the applicant takes care of
Determining MAGIInclude in MAGI Not included in MAGI
• Wages and tips, cash income• Unemployment compensation• Taxable amount of pensions, annuities, IRA
distributions and Social Security benefits from retirement, disability and survivors benefits (do not include Supplemental Security Income)
• Business income, farm income, capital gain, other gains (or loss)
• Dividends and taxable interest• Tax exempt interest• Alimony received• Rental real estate, royalties, partnerships,
trusts, etc. • Foreign income• Other income not specifically excluded
• TANF, SNAP, SSI or other public benefits (LIHEAP, WIC, etc.)
• Child support received• Gifts/Inheritances• Qualified scholarships (for tuition only)• Certain salary deferrals (e.g., flexible
spending plans, contributions to 401(k) plans)
• Contributions to a health savings account• Job-related moving expenses• Student loan interest• IRA contributions• Alimony paid• Self-employment expenses• Educator expenses
Adjustments
MAGI vs non-MAGI Groups in IL
MAGI rules apply to:
• ACA Adults• All Kids (children up to age 19)• Moms and Babies • FamilyCare –Parents / Caretaker relatives• ACA Adult Medical
When using MAGI rules, resources/assets are not counted when determining eligibility.
MAGI rules do NOT apply to:
• Seniors (people 65 and over) who are not parents or caretaker relatives• Cash/SNAP applicants• Most people with disabilities
Who is Eligible for the Medicaid Expansion?
• Age 19-64 and not eligible for other Medicaid category.
• Citizen or Qualified Non Citizen• Under 138% FPL or about $1340 per
month for a household of one ($16,105/year).
• No asset or disability test.
25
26
Federal Poverty Level: Income Limits for CoverageMedicaid adjusts its’ income standards in April each year using the FPL amounts issued at the end of January. The Marketplace uses the FPL that is in place at the start of Open Enrollment and does not adjust the amount until the next Open Enrollment so for all of 2015 the Marketplace will use the 2014 FPL.
2014 Federal Poverty Level
Medicaid Programs Marketplace
AABDACA
Adult FamilyCare
All Kids Level 1
Moms and Babies
All Kids Level 2 CSR APTC
Household Size 100%* Adult Child
Pregnant or child under 1
Child 250% 400%
1 $11,670 $16,105 $24,396 ----- $37,116 $29,175 $46,680
2 $15,730 $21,707 $32,880 $33,504 $50,016 $39,325 $62,920
3 $19,790 $27,310 $41,364 $42,156 $62,928 $49,475 $79,160
4 $23,850 $32,913 $49,848 $50,796 $75,840 $59,625 $95,400
The income increases as the number of persons in the household increases.
Medicaid in Illinois At A Glance
Pre-ACA
• FamilyCare for parents and other caretaker relatives of children under 19
• All Kids• Moms and Babies• Aid to the Aged Blind and
Disabled (AABD)• Health Benefits for Workers
with Disabilities (HBWD)• Health Benefits for Persons
with Breast and Cervical Cancer (apply with Illinois Dept. of Public Health)
Post-ACA
• ACA Adult• Former Illinois Foster Child• FamilyCare for parents and
other caretakers of children under 18
• All Kids• Moms and Babies• Aid to the Aged Blind and
Disabled (AABD)• Health Benefits for Workers
with Disabilities (HBWD)• Health Benefits for Persons
with Breast and Cervical Cancer (apply with Illinois Dept. of Public Health)
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Medicaid Benefits for ACA AdultsACA Adults are receiving a Medicaid benefit/service package called the Alternative Benefit Plan (ABP).
• The ABP for adults is required to include:– Essential Health Benefits– Early and Periodic Screening, Diagnosis, and
Treatment services (EPSDT) for 19 and 20 year olds– Federally Qualified Health Center (FQHC) and Rural
Health Clinic (RHC) services– Non-emergency transportation– Family planning services and supplies
Cost Sharing under Medicaid• No Premiums• ACA Adults will have the same co-payments as other Medicaid
adults, such as:– Hospital inpatient services: $3.90– Prescription drugs: brand $3.90, generic $2.00– Primary care provider visit: $3.90
• No co-payment for Immunizations, Preventive Services, Diagnostic Services or Family Planning. Family planning related medical services require a co-pay for office visits.
• For more information: http://www2.illinois.gov/hfs/SiteCollectionDocuments/100app12.pdf
New Medicaid Managed Care in Illinois• 2011 Medicaid reform law (P.A. 96-1501) mandates 50% of clients to
be enrolled in “care coordination” by January 1, 2015• Different health plans for different Medicaid populations
– Seniors and Persons with Disabilities (SPD) – Medicaid only & Medicare/Medicaid (duals)
– Children, Parents/Caretaker Relatives, Pregnant Women – called “Family Health Plans (FHP)”
– Children with Special Needs (CSN)– Newly Eligible Adults under the Affordable Care Act – called
“ACA Adults”• 4 different models of Managed Care Entities
– Managed Care Organizations (MCO)– Managed Care Community Networks (MCCN)– Care Coordination Entities (CCE)– Accountable Care Entities (ACE)
Care Coordination in Mandatory Regions• Clients are in process of enrolling or being
enrolled in Health Plans in 5 mandatory regions– Chicago region – 6 counties– Rockford region – 3 counties– Central Illinois region – 3 counties– Quad Cities region – 3 counties– Metro East region- 3 counties
• Clients in rural counties will continue to be in fee for service (IL Health Connect) for awhile
• About 2 million Medicaid clients will be in Health Plans by mid-2015
http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx
2014 & 2015 Open Enrollment 2014 Open Enrollment Oct. 1, 2013 – March 31, 2014
(April 15 for those “in line” )2015 Open Enrollment Nov. 15, 2014 – Feb. 15, 2015
Enrollment Date/Period Effective Coverage Begins 1st – 15th of month 1st of following month
16th – last day of month 1st of second following monthQualifying Life Events (such as moving to a new state, marriage, or having a baby) open a Special Enrollment Period (SEP)Complex Cases during 2014 Open Enrollment also can open a SEP.
Medicaid is always open!
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Special Enrollment Periods are called “SEP”
• Means that you can enroll in Marketplace any time during the year even outside of open enrollment.
• Must be “triggered” by specific life event that causes loss of MEC or other designated limited circumstances.
• Usually gives person 60 days after event to enroll.• Healthcare.gov has a screening tool to determine
is someone is eligible to enroll in a SEP.
https://www.healthcare.gov/how-can-i-get-coverage-outside-of-open-enrollment/
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* 165 plans and 6 carriers• Aetna• Blue Cross Blue Shield• Coventry• Health Alliance• Humana• Land of Lincoln
* 13 Rating Areas
In 2015? DOI Announces 10 IssuersApply to Offer 504 QHPs
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2014 Qualified Health Plans in Illinois
Catastrophic Health PlansWhat is catastrophic coverage?• Plans with high deductibles and lower premiums• Pay all medical costs up to a certain amount• Includes 3 primary care visits per year and preventive
services with no out-of-pocket costs• Protects you from high out-of-pocket costs
Who is eligible?• Young adults under 30• Those who qualify for a hardship exemption• Those whose plan was cancelled and believe
Marketplace plans are unaffordable**Financial assistance (premium tax credits and cost sharing reductions) is not available
Cost: Two Types of New Financial Assistance
Premium Tax
Credits
•Helps people pay the monthly cost to have a plan
Cost-Sharing
Reductions
•Decrease the charges (e.g., copays, deductibles) enrollees must pay when receiving health care services covered by the plan
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Who Is Eligible for Tax Credits/Cost Sharing Subsidies?
A U.S. Citizen and
• Ineligible for “minimum essential coverage,” such as coverage provided through an employer, Medicaid or Medicare• Eligible to enroll in a QHP through the Marketplace• Part of a tax filing unit• Has household income between 100% and 400% FPL
A non-citizen who is lawfully present and
• Unable to obtain affordable minimum essential coverage, such as coverage provided through an employer, Medicaid or the Marketplace• Eligible to enroll in a QHP through the Marketplace• Part of a tax filing unit• Has household income between 0-400% FPL although tax credit will be based on an income of 100% FPL even if income is below 100% FPL.
Cost sharing subsidies are provided if eligible for a tax credit with an income between 100%-250% FPL and enrolled in a silver plan through the Marketplace
42
43
Federal Poverty Level: Income Limits for CoverageMedicaid adjusts its’ income standards in April each year using the FPL amounts issued at the end of January. The Marketplace uses the FPL that is in place at the start of Open Enrollment and does not adjust the amount until the next Open Enrollment so for all of 2015 the Marketplace will use the 2014 FPL.
2014 Federal Poverty Level
Medicaid Programs Marketplace
AABDACA
Adult FamilyCare
All Kids Level 1
Moms and Babies
All Kids Level 2 CSR APTC
Household Size 100%* Adult Child
Pregnant or child under 1
Child 250% 400%
1 $11,670 $16,105 $24,396 ----- $37,116 $29,175 $46,680
2 $15,730 $21,707 $32,880 $33,504 $50,016 $39,325 $62,920
3 $19,790 $27,310 $41,364 $42,156 $62,928 $49,475 $79,160
4 $23,850 $32,913 $49,848 $50,796 $75,840 $59,625 $95,400
The income increases as the number of persons in the household increases.
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Expected Premium Contributions
Premium Tax Credit Calculator: http://kff.org/interactive/subsidy-calculator/
Impact of Marketplace Financial Help on People with Employer Insurance• Not intended for those with employer
coverage.• Provisions in place to discourage those
with employer offer buying into exchange with financial help.
• Employer offer of self-only coverage to employee is not more than 9.5 % of the household income.
• Dependent coverage “glitch”
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Culture of Coverage: Individuals
• The Individual Mandate requires most Americans to have “minimum essential health coverage (MEC)” for each month starting January 1, 2014.
• Also, called “Shared Responsibility Provision,” “Required Coverage,” or “Health Insurance Requirement.”
• This applies to adults and children. The adult or married couple who can claim a child or another individual as a dependent on their federal income taxes is responsible for making the payment if the dependent does not have coverage (or an exemption).
• Payments will begin in 2015
Culture of Coverage: Employers• Employer Mandate/ Employer Shared
Responsibility– Only for Firms with 50+ FTEs (3.6% of firms in
the US)– Small Businesses (below 50 FTEs) are exempt!– Must provide affordable and minimum value
coverage to employees and dependents– Pay a penalty IF an employee takes a premium
tax credit in the Marketplace.– Most larger firms already provide insurance – Penalty waived until 2016 for firms w/ 50-99
FTEs; for larger firms, it will be 2015 (must cover 70% of employees)
** More information: http://www.irs.gov/uac/Newsroom/Questions-and-Answers-on-Employer-Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act
Requirement to Have Health Coverage• Everyone is required to have minimum essential coverage (MEC)
• Those without MEC will pay a shared responsibility payment unless exempt– Taxpayer is responsible for dependents
• Coverage requirement, penalties and most exemptions apply on a monthly basis
• One day rule: – A person has coverage for the month if they
have coverage for at least one day in the month
– A person is eligible for an exemption for the month if they are exempt for at least one day in the month
What Counts As MEC?• Employer-sponsored coverage, COBRA coverage and retiree
coverage• Coverage purchased in the individual market (inside or outside
the Marketplace)• Government Sponsored Coverage, such as:
– Medicare Part A coverage and Medicare Advantage plans– Most Medicaid coverage– Children's Health Insurance Program (CHIP) coverage– Certain types of veterans health coverage – Most types of TRICARE coverage – Refugee Medical Assistance
• Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014
• State high risk pool plans that begin on or before Dec. 31, 2014• Other coverage recognized by the Secretary of HHS as minimum
essential coverage
Full List here: http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision
What Doesn’t Count As Minimum Essential Coverage?
• Coverage consisting solely of excepted benefits, such as:• Stand-alone vision care or dental care• Workers' compensation• Accident or disability policies
• Medicaid providing only family planning services• Medicaid providing only tuberculosis-related services• Medicaid providing only coverage limited to treatment of
emergency medical conditions• Pregnancy-related Medicaid coverage• Medicaid coverage for the medically needy• Section 1115 Medicaid demonstration projects• Specific TRICARE coverage
Not MEC, but Transition Relief Available
Individual Mandate or the “Penalty”The penalty in 2014 is calculated in one of 2 ways. If the consumer does
not maintain MEC, they will pay whichever of these amounts is higher:
• 1% of yearly household income. (Only the amount of income above the tax filing threshold, $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan.
• $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.
In 2015, the fee will go up to 2% of annual household income or $325 per adult ($162.50 per child).
It is prorated for number of months without insurance in a year. This calculator can be used to estimate the penalty for a consumer:http://taxpolicycenter.org/taxfacts/acacalculator.cfm
Helpful Resources• LAF – Specific Enrollment Resources
• HelpHub is an online community where ACA enrollment specialists in Illinois can share their experiences helping consumers enroll & ask questions to each other and policy experts. To request an invite, email [email protected] with your name, the name of your organization & details of your ACA involvement.
• Get Covered Illinois – FAQs & Resourceshttp://getcoveredillinois.gov/how-to-get-covered/faq-resources/
• Illinois Health Resources – a directory of useful websites, fact sheets, and other resources on a variety of different topics for navigators and other assisters: http://www.illinoishealthresources.org/