Affordable Care Act (ACA) Transition Plan
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Affordable Care Act (ACA) Transition Plan


Revised October 21, 2013


Changes in Eligibility Requirements for Washington Apple Health (WAH)


Purpose: To explain the changes in Medicaid eligibility requirements that will occur during the transition to MAGI-based Washington Apple Health (WAH) in connection with the implementation of the Affordable Care Act (ACA).

Affordable Care Act Transition Plan

  Summary

In addition to the many consumer protections that it has already implemented, the Affordable Care Act (ACA) does the following on October 1, 2013:

  • Converts the Medicaid income calculation methodology for the Family, Children, Pregnant Women, and Take-Charge medical assistance programs, from the "classic" Medicaid net income methodology with its various income disregards to the modified adjusted gross income (MAGI)-based methodology with one 5% income disregard.
  • Eliminates all resource and asset limits for the Family, Children, Pregnant Women, and new Adult programs.
  • Increases the federal poverty level (FPL) thresholds for the Family, Children, Pregnant Women, and Take-Charge medical assistance programs to new percentages based on the MAGI methodology.
  • Expands Medicaid (the State of Washington agreed with this expansion) to cover a new MAGI-based group: all otherwise eligible adults with MAGI less than or equal to 133% FPL after taking into account the 5% income disregard (this is known as the new Adult group); while people will be able to apply beginning on October 1, 2013, coverage for the new Adult group will start on January 1, 2014.
  • Authorizes the Washington Health Benefit Exchange to offer qualified health plans (QHPs) in an online marketplace, the Washington Healthplanfinder (HPF).
  • Creates a health insurance premium tax credit system where those with MAGI below 400% FPL receive tax credits to offset their monthly QHP premiums.
  • Encourages the Medicaid agency to coordinate with HPF to create a single application and shopping experience in HPF for everyone who seeks health insurance coverage in HPF.

In addition, the 2013-2015 Biennial State Budget that was passed in June 2013 eliminated both the ADATSA program and the medical coverage that was provided under the Aged, Blind, and Disabled (ABD) program associated with cash (formerly referred to as the General Assistance (GAX) or Disability Lifeline (DL-X) programs). Clients with medical coverage under these programs, along with Medical Care Services (MCS) clients, will be converted to other programs for which they are eligible, including the new Adult Medical (N05) program. These changes will be implemented for an effective date of January 1, 2014.

Both the ACA and the 2013-2015 Budget leave in place, unchanged, all other Medicaid programs, such as the SSI, SSI-related, foster care children, long-term care, and Medicare savings programs (all S, G, L, D, R codes) – what we are calling "Classic Medicaid".

For more information on how to apply for the MAGI-based Family, Child, Pregnant Women, and Adult Medical programs, clients and prospective clients should call the Washington Healthplanfinder (HPF) Customer Support Center at 1-855-923-4633. In addition to providing trained customer support specialists, HPF maintains a list of in-person assister organizations in every county, who will be able to provide in-person help to clients or prospective clients who want it.

For questions regarding Medicaid eligibility requirements, clients and prospective clients should contact the Health Care Authority’s Medical Eligibility Determination Services (MEDS) by phone at 1-855-623-9357 or by email at AskMAGI@hca.wa.gov.

Department of Social and Human Services (DSHS) workers will no longer be able to provide personal assistance to prospective clients who want to apply for MAGI-based medical assistance. However, DSHS workers will continue to be able to provide personal assistance to clients and prospective clients for Classic Medicaid.

Table of Changes to Existing Medicaid Programs

The following table summarizes the major changes to the various Medicaid programs, by ACES program code:

 Medicaid Program

FPL Threshold pre-10/1

Changes

FPL Thresholds on 10/1*

F01 - TANF Family Medical (TANF-cash recipients)

Approx. 35%

MAGI Parent/Caretaker (N01)**

 54%

F04 – TANF Related Family Medical (TANF-cash eligible non-recipients)

 Approx. 35%

MAGI Parent/Caretaker (N01)**

 54%

F03 – Post-TANF Child/Spousal Support (4 months)

 N/A

Ends on October 1, 2013

N/A 

F02 – Transitional Medical

 N/A

Transitional Medical for MAGI Parent/Caretaker (N02)**

 N/A

F06 – Child Medicaid/Washington Apple Health for Kids (no premiums)

 200%

For documented children, MAGI WAH for Kids (no premiums) (N11)**

For undocumented children, MAGI WAH for kids (no premiums) (State-Funded) (N31)**

 210%

F07 – CHIP/Washington Apple Health for Kids with Premiums

Tier 1:

200-250%

Tier 2:

250-300%

For documented children, MAGI WAH for Kids with Premiums (N13)**

For undocumented children, MAGI WAH for Kids with Premiums (State-Funded) (N33)**

Tier 1:

210-260%

Tier 2:

260-312%

F05 – Newborn Medical (first year)

N/A 

MAGI Newborn Medical (first year) (N10)**

N/A

F09 – Alien Emergency Medical

N/A 

MAGI Alien Emergency Medical (N21)**

N/A

F99 – Medically Needy

N/A

MAGI Medically Needy (same code, F99)***

N/A

P02 – Pregnant Women with 60 day post-partum care

185%

MAGI Pregnancy Medical (N03)

193%

P04 – Undocumented Pregnant Women with 60 day post-partum care

185%

MAGI Pregnancy Medical, Not Lawfully Present (N23)

193%

P05 – Family Planning Only (10 months post-partum)

 N/A

No change (same code, P05)

 N/A

P06 – Take-Charge Family Planning

 250%

MAGI Take-Charge Family Planning (same code, P06)*****

 260%

P99 – Medically Needy Pregnant Woman with 60 day post-partum care

 N/A

MAGI Medically Needy Pregnant Woman with 60 day post-partum care (same code, P99)***

 N/A

G02 – ABD Cash with CN Medicaid (ABD Cash and either Presumptive SSI or ABD Aged or ABD NGMA Determination)

 N/A

Converts to MAGI Adult Medical (N05) if client is eligible****

Converts to ABD Categorically Needy (S02) if client is not eligible for MAGI Adult Medical (N05)****

 N/A

G01 – Medical Care Services (MCS)

 N/A

Converts to MAGI Adult Medical (N05) if client is eligible****

Remains on Medical Care Services (G01) if client is not eligible****

 N/A

W-1/W-2/W-3 – ADATSA

 N/A

Converts to MAGI Adult Medical (N05) if client is eligible****

Ends December 31, 2013 if client is not eligible****

N/A

 N/A

 N/A

New Adult Medical (N05) with coverage effective January 1, 2014 and applications accepted starting October 1, 2013

133% 

N/A

N/A 

New Alien Emergency Medical for Adults (N25) with coverage effective January 1, 2014

 133%

All other programs

N/A

No change

N/A

*All MAGI-based programs except for the MAGI Parent/Caretaker (N01) program apply a 5% income disregard before comparing AU income to the appropriate FPL threshold.

**Applicants for these programs will need to apply for coverage in www.wahealthplanfinder.org.

***Applicants for these programs will need to apply for coverage with Medical Eligibility Determination Services (MEDS) by phone at 1-855-623-9357 or by email at AskMAGI@hca.wa.gov.

****Conversion of clients from the MCS and ADATSA programs and from the medical coverage that was provided under the ABD program associated with cash (formerly referred to as the General Assistance (GAX) or Disability Lifeline (DL-X) programs) to the new MAGI Adult program or other programs will be automated. These clients will not need to apply for continuation of coverage, and they will receive notification of any change in coverage in December 2013 (for most clients, who will be in the early conversion group) or in January 2014 (for clients receiving coverage under the ABD program associated with cash, MCS, or ADATSA for the first time in December, who will be in the later conversion group). Any clients who lose coverage under these programs because they are not eligible for the new MAGI Adult program will receive notification and be considered for eligibility for any other Medicaid program.

*****A Medicaid State Plan waiver has been submitted to the Centers for Medicare and Medicaid Services (CMS) for the Take-Charge program. The new MAGI-based FPL threshold is expected to become effective, with related WAC amendments, on or before January 1, 2014. MAGI-based Take-Charge applications will continue to be submitted by providers directly to the Health Care Authority and not in HPF.

 

New Medicaid Program – MAGI-Based Adult Medical (N05)

Beginning on January 1, 2014, Medicaid will cover the new MAGI-based Adult Medical group. People who are ages 19-64 with modified adjusted gross income below 133% FPL may be eligible for Categorically Needy (CN) Medicaid coverage. For WACs related to this program, see http://www.hca.wa.gov/medicaid/manual/Lists/WAC/wac_index.aspx.

 

New Alien Emergency Medical (N25) relatable to MAGI-Based Adult Medical

Beginning on January 1, 2014, the Alien Emergency Medical program will offer coverage to adults who are relatable to the MAGI-Based Adult Medical (N05) program. Undocumented immigrants or those who are not federally qualified due to immigration status who meet all of the eligibility requirements for the N05 program other than immigration status will now be eligible for emergency medical coverage if their emergent condition qualifies. Applicants in need of coverage under this new AEM program will need to apply for coverage in www.wahealthplanfinder.org. For WACs related to this program, see http://www.hca.wa.gov/medicaid/manual/Lists/WAC/wac_index.aspx.

 

Washington Healthplanfinder (www.wahealthplanfinder.org)

Beginning on October 1, 2013, all applicants for Family, Pregnant Women, Child Medicaid programs, as well as the new Adult Medicaid program, will apply for coverage through Washington Healthplanfinder (HPF). Eligibility for these programs will be based on the new MAGI methodology.

Clients or prospective clients who need assistance to apply for these programs should call the Washington Healthplanfinder Customer Support Center at 1-855-923-4633.

If a client or prospective client has questions about MAGI-based Medicaid eligibility requirements or wants to appeal a MAGI-based eligibility determination, he or she should contact the Health Care Authority’s Medical Eligibility Determination Services (MEDS) unit by phone at 1-855-623-9357 or by email at AskMAGI@hca.wa.gov.

Department of Social and Human Services (DSHS) workers will no longer be able to provide personal assistance to prospective clients who want to apply for MAGI-based medical assistance. However, DSHS workers will continue to be able to provide personal assistance to clients and prospective clients for Classic Medicaid.

 

Modified Adjusted Gross Income (MAGI) Methodology

As mentioned above, the new MAGI methodology will replace the legacy Medicaid net income methodology for determining eligibility for the MAGI Family, Pregnant Women, Child, Adult, and Take-Charge Medical programs. MAGI methodology follows Internal Revenue Service (IRS) rules for counting income – in other words, if it’s included in adjusted gross income (AGI), it is countable income – with the following 3 exceptions:

  • Educational assistance (WAC 182-509-0335) – Under IRS rules, educational assistance is generally included in adjusted gross income. The ACA excludes a portion of educational assistance from MAGI for purposes of determining eligibility for MAGI-based programs. To determine the amount of educational assistance that is included in MAGI (in other words, that is countable income):
    • Add all educational grants, scholarships, awards, and other money that does not need to be repaid, and

    • Subtract all tuition, fees, and expenses for books and course materials.
     

  • American Indian/Alaska Native income (WAC 182-509-0340) – The ACA excludes certain income received by American Indians and Alaska Natives from MAGI for purposes of determining eligibility for MAGI-based programs, such as income from the exercise of treaty rights and from legal settlements between tribes and the federal government.  

  • Lump Sums (WAC 182-509-0375) – Under IRS rules, lump sum payments (such as one-time bonus payments or insurance settlement proceeds) are generally included in adjusted gross income. The ACA, however, excludes lump sum payments from MAGI for purposes determining eligibility for MAGI-based programs.

HPF is programmed to ask for only countable income (in other words, income that is included in MAGI). If IRS rules exclude income from AGI, that income is not countable for purposes of determining eligibility for MAGI-based medical assistance programs. Examples of non-countable income include needs-based assistance from state agencies, foster care payments, federal income tax refunds, and earned income tax credits.

 

MAGI-Based Assistance Units (Household Composition)

Similar to Classic Medicaid, the MAGI-based Medicaid programs will involve the determination of assistance units (AUs) for each Medicaid applicant. The rules on determining AUs for each applicant are different from those in "classic" Medicaid, however, as these rules are driven by tax-filing status. HPF has been programmed to ask for the tax-filing status of each applicant and the relationship between every applicant in the household to determine the AUs for each applicant. As a result, it will be very important for clients and applicants to accurately answer the questions on tax-filing status and relationships in HPF.

 

Eligibility Requirements that Will Not Change

Not all eligibility requirements will be changing for MAGI-based programs. The following non-financial eligibility requirements will not change:

  • Citizenship and Immigration Status Requirements

  • Residency Requirements

  • Social Security Number Requirements

  • Incarceration Requirements

  • Retroactive Coverage Requirements

 

Renewals: Special Rules for the ACA Transition Period (10/1/2013 – 9/30/2014)

For current recipients with renewals ending November 30, 2013 through September 30, 2014, ACES will send clients covered by the Family, Child, and Pregnant Women programs a series of 3 letters, beginning 60 days before their certification period ends, encouraging them to submit a renewal application in HPF. Clients will need to submit their renewal applications in HPF on or before their certification period end date to continue coverage. If a client does not submit his or her renewal application before his or her certification period ends, the client’s coverage will end on that date.

In addition, during the period from October 1, 2013 through March 31, 2014 (also known as the "Hold Harmless Period"), the process for how clients renew their coverage will be different – these are the special rules for the ACA Transition or Hold Harmless Period. For instance, if certain requirements are met, a client’s coverage will not be reduced even if the client’s income would normally cause the client’s coverage to be reduced or ended. These AUs may be referred to as "frozen". These changes and requirements are described below. If a Medicaid program is not discussed below, that means that the eligibility requirements for that Medicaid program will not change during the ACA transition period.

 

 Family Medical (F04 only)

How will covered Family Medical clients renew their coverage?

   If the client’s certification period ends on or after November 30, 2013:

  • The client will be required to complete a renewal application in HPF on or before the client’s renewal due date.
  • ACES will send a monthly conversion file to HPF to pre-fill the client’s information in the online renewal application.

For Family Medical renewals, what eligibility rules are changing for this transition period?

The Affordable Care Act protects Family Medical clients (F04) from losing coverage or having their coverage reduced as a result of the new MAGI rules until the later of (a) March 31, 2014 or (b) the end of their certification period. This protection does not apply to anyone who is not covered by the program at the time of renewal – these people will be treated as new applicants and their application will be assessed using the new MAGI rules.

 Changing:

  • ACES will freeze all Family Medical assistance units (AUs) on F04.
  • Financial eligibility rules will be modified during the transition period to preserve coverage for Family Medical clients in certain situations.

Staying the Same:

  • All other (non-financial) eligibility rules are staying the same.
  • That means, if a client’s situation changes such that he or she no longer meets non-financial eligibility requirements (such as residency, immigration status, incarceration status, etc.), the client will lose coverage or move from greater to lesser coverage (e.g., moving from CN coverage to MN coverage) as applicable.

How will the Family Medical financial eligibility rules work during this transition period for renewals?

For renewals processed October 1, 2013 through March 31, 2014:

  • If the client meets all MAGI-based financial and non-financial eligibility requirements for the same program:
    • The client’s coverage will be renewed under the MAGI N01 AU, and

    • The client’s case will not be flagged in ACES as "continued at conversion".

  • If the client continues to meet non-financial eligibility requirements but the client AU’s income is too high for the MAGI-based Family Medical program:
    • The client’s coverage will be renewed for that same program under the MAGI N01 AU, and
    • The client’s case will be flagged in ACES as "continued at conversion".

Example:

Sally is on F04 with her two children and her F04 renewal is due January 2014. Sally completes her renewal application in HPF, reporting that she now receives income at 50% of FPL for her household size.

  • Because the renewal is during this transition period (aka the "hold harmless period"), Sally's coverage is recertified under the same Parent/Caretaker program but with the new MAGI AU (N01) even though her income exceeds the FPL standard for the Parent/Caretaker group and would otherwise make her eligible under the new Adult program (N05).
  • In addition, a flag is set to indicate that Sally's Parent/Caretaker program eligibility was "continued at conversion."

Example (cont'd):

  • In her renewal application, Sally indicated that she recently married Stan, who now lives with Sally and her children. Sally asks for coverage for Stan as well.
  • Because Stan was not active on the F04 AU that is being renewed, Stan’s case is opened under the New Adult coverage group (N05) rather than the Parent/Caretaker coverage group.

 

Child Medical (F06, F07 only)

How will covered Child Medical clients renew their coverage?

If the client’s certification period ends on or after November 30, 2013:

  • The client will be required to complete a renewal application in Healthplanfinder (HPF) on or before the client’s renewal due date.
  • ACES will send a monthly conversion file to HPF to pre-fill the client’s information in the online renewal application.
 

Changing:

  • ACES will freeze all Child Medical assistance units (AUs) on F06 and F07.
  • Financial eligibility rules will be modified during the transition period to preserve coverage for Child Medical clients in certain situations.

Staying the Same:

  • All other (non-financial) eligibility rules are staying the same.
  • That means, if a client’s situation changes such that he or she no longer meets non-financial eligibility requirements (such as residency, immigration status, incarceration status, etc.), the client will lose coverage or move from greater to lesser coverage (e.g., moving from CN coverage to MN coverage) as applicable.

How will the Child Medical financial eligibility rules work during this transition period for renewals?

For renewals processed October 1, 2013 through March 31, 2014:

  • If the client continues to meet all MAGI-based financial and non-financial eligibility requirements for the same program, the client’s coverage will be renewed under the MAGI N11 or N13 AU.

  • If the client continues to meet non-financial eligibility requirements but the client AU’s income is too high for the MAGI-based Child Medical program (for example, the client AU’s income would push the child to the higher premium tier for WAH for kids with premiums):
    • The client’s coverage will be renewed for the same program under the MAGI N11 or N13 AU (i.e., the child is kept in the same coverage group and tier), and
    • The client’s case will be flagged in ACES as "continued at conversion".

Example:

Jackie has son, John, on Child Medical (F06), and his F06 renewal is due January 2014. Jackie completes her son’s renewal application in HPF, reporting that she now receives income at 220% of FPL for her household size.

  • Because the renewal is during this transition period (aka the "hold harmless period"), John’s coverage is recertified under the same Child Medical (CHIP) program but with the new MAGI AU (N11) even though Jackie’s income exceeds the FPL standard for the Child Medical F06 group and would otherwise make John eligible for the Child Medical with Premiums program (N13 - WAH for kids with premiums).
  • In addition, a flag is set to indicate that John’s N11 program eligibility was "continued at conversion."

Worker Responsibilities



1.  For changes of circumstance from a client on family (F04), child (F06/F07/F08), or pregnancy (P02) medical:

a. Look up the case in ACES:

i. If case still shows an ACES F or P program code:

A. The case has not yet been converted to MAGI.

B. CSD workers must update ACES with the change(s) of circumstance.

ii. If case shows the new ACES N program codes (N01 for family, N11/N13/N31/N33 for child, or N03 for pregnancy medical):

A. The case has been converted to MAGI.

B. CSD workers should forward the change of circumstance(s) documentation to HCA.

Modification Date: October 21, 2013