How To Get A Health Care Plan In Pennsylvania

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Medicaid Eligibility:

Children, Parents, and Pregnant Women

Kyle Fisher Staff Attorney October 2013

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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

[email protected]

HELPLINE: (800) 274-3258

Topics

Medicaid Basics

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

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Medicaid Basics

• 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

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

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Medicaid Eligibility Practice tip:

For children:

First check Medicaid eligibility Then CHIP

Then Marketplace subsidies For adults:

Medicaid -> Marketplace subsidies Why?

If eligible Medicaid/CHIP, not eligible for premium tax credits 6

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CATEGORY, INCOME LIMITS, IMMIGRATION STATUS

Medicaid & CHIP

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Categorical Eligibility

Children Pregnant Women Parents & Caretakers

Persons with Disabilities  Temporary

 Permanent or 12 months+ Workers with Disabilities

 Has 5% premium Seniors

Income Limits

Infants (0-1) & Pregnant Women (215% FPL)

*Plus 5% Disregard

*Pregnant Woman is at least a household of two

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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

Income Limits

Children age 1 through 5 (157% FPL)

*Plus 5% Disregard

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Income Limits

Children age 6 through 18 (133% FPL)

*Plus 5% Disregard

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Income Limits

Parents/Caretakers (33% FPL) *Plus 5% Disregard 14

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

CHIP Eligibility Basics

Child is under age 19 Resides in PA

Citizen or lawfully present

Uninsured & ineligible for Medicaid 15

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CHIP Income Limits

Children age 0 through 18 (208% + 314% FPL)

*Plus 5% Disregard 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

Example: mixed households

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?

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Medicaid _CHIPFree Market- _place Why?

Huey 

Age 5; HH 3 income under 157% FPL Riley  _{FPL, under 208%}Age 6; over 133% Vanessa  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?

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Medicaid Market_place Why?

Ana  Pregnant; HH 4 income _{under 215% FPL} Sofia  Age 3; under 157% FPL _{with 5% disregard} Tomas  Parent; over 33% FPL

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Immigration Status

“Lawfully Present”

Legal term of art Standard for:

Children Pregnant women

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/

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Immigration Status

“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 20

Immigration Status

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)

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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.

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Medicaid Why?

Sofia  Citizen, age 3; HH 3 income _{under 157% FPL} Ana EMA only

Not “lawfully present”; limited to EMA. Under 215% FPL . Labor and delivery covered.

INCOME-COUNTING & HOUSEHOLD SIZE RULES

Modified Adjusted Gross Income

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What Income Counts

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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:

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MAGI Categories

MAGI Children

Medicaid & CHIP Pregnant Women Parents & Caretakers *no resource test

Non-MAGI

Persons with Disabilities

 Temporary

 Permanent or 12 months+ Workers with Disabilities Seniors

What Income Counts 25

Types of Income Counted in MAGI

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 26

What Income Counts

27 Budget periods

Medicaid

counts current monthly income

lump sums count in month received

Marketplace

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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.

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Medicaid CHIP Why?

Huey  _{Age 5; under 157% FPL}MAGI = $0. 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.

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Medicaid CHIP Why?

Huey  _{Age 5; under 157% FPL}MAGI = $1850/mnth Riley  Age 6; under 133% FPL Vanessa Parent; over 33% FPL

Household Size

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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

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Whose Income Counts?

Household = Tax Unit

Filer Spouse Children & Qualifying Relatives 31

For Marketplace subsidies, household size equals the tax unit

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

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Whose Income Counts?

Medicaid rule for Tax Filers:

Household = tax filer and all expected dependents 33

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Whose Income Counts?

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

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Whose Income Counts?

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 step-parents) living with the child

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Household Size Flow Chart

Meredith’s chart

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Example: grandparent caretaker

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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 _Medicaid

HH size Why?

Thelma Maggie

Thelma   2 Tax Filer + _dependent

Maggie  4

Dependent, but meets exception

Example: multiple generations

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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.

Counted in HH _Medicaid HH size GM GD Tina Max Grandmom     4 Granddad     4 Tina     4 Max   2 MARKETPLACE SUBSIDIES

How the Pieces Fit Together

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Marketplace Basics - Subsidies

Who qualifies for marketplace subsidies?

Premium Tax Credits

Income between 100-400% 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 100-250% FPL Eligible for premium tax credits Enroll in Silver-level plan

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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)

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Medicaid Market_place Premium tax

credits

Why?

Huey  Age 5; under 157% _FPL Riley  Age 6; under 133% _FPL Vanessa  No Under 100% FPL _{(HH 3), no PTC!}

MEDICAID & CHIP

How to Apply

44 How to Apply COMPASS or Healthcare.gov Children Pregnant Women Parents & Caretakers

COMPASS www.compass.state.pa.us

Persons with Disabilities

 Temporary

 Permanent or 12 months+ Workers with Disabilities Seniors

Medicaid & CHIP 45

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How to Apply

Online: COMPASS or Healthcare.gov By phone: 866-550-4355 (DPW; MAGI categories)

800-986-5437 (CHIP) By mail: paper application

In person: @ County Assistance Office

When: anytime

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Marketplace & DPW Interface

“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 47

Resources

Medical Assistance Eligibility Handbook

 http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm

DPW Ops Memo on MAGI - OPS130904  See link for MAEH -> Operations Memoranda

CHIP’s Eligibility and Benefits

 http://www.chipcoverspakids.com

Center on Budget and Policy Priorities – ‘Beyond the Basics’

 http://www.healthreformbeyondthebasics.org/

PHLP Helpline: 1-800-274-3258

For wrongful Medicaid or CHIP denials, or ‘coverage gap’ cases 48