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The Affordable Care Act Part 2: Eligibility and Enrollment


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The Affordable Care Act Part 2: Eligibility and Enrollment

  2. 2. PAGE 2OVERVIEW• Eligibility Requirements• Exchange Enrollment• Eligibility & Enrollment Verification• Penalties• Appeal Process• Key Dates
  4. 4. PAGE 4ELIGIBILITY: REQUIREMENTS• For an individual to qualify for the Exchange they need to:o Be a U.S. citizen, national, or legal residento Must reside in the same state that they are applying for coverageo For programs that require an income eligibility, income will bebased off Modified Adjusted Gross Income• An individual is not eligible for coverage through the Exchange ifincarcerated, unless charges are pending• For CHIP, Medicaid, and Medicare, individual must meet thatprogram’s specific eligibility requirements
  5. 5. PAGE 5ELIGIBILITY: EXEMPTIONS• Individuals must have the minimum level of healthcare coverageprovided or face a penalty• The following categories provide exemptions for individualsfrom this coverage requirement:o Religious Exemptionso Undocumented Immigrantso American Indianso Financial Hardshipso Incarceration
  6. 6. PAGE 6ELIGIBILITY: PROHIBITED FACTORS• Issuers can no longer deny coverage to individuals withpre-existing conditions• Issuers are no longer able to drop individuals due to thediagnosis of serious illnesses• Issuers are no longer allowed to set annual and/or lifetimelimits
  7. 7. PAGE 7ELIGIBILITY: GOVERNMENT BASEDHEALTHCAREMedicaid• A state-based healthcare program that provides coverage to low-income households and individuals with disabilitiesCHIP• CHIP is the Children’s Health Insurance ProgramMedicare• A government health insurance program administered by theCenters for Medicare and Medicaid Services
  8. 8. PAGE 8ELIGIBILITY: MEDICAIDMedicaid Eligibility Before ACA Medicaid Eligibility After ACA- Pregnant women and children (<6 years)whose family income is ≤ 133% of theFederal Poverty Level- Children under 19 whose families are at orbelow the FPL- Families with children that meet the Aid toFamilies with Dependent Children- Most Supplemental Security Incomerecipients- Recipients of adoption or foster careindividuals- Special protected groups- Certain Medicare beneficiaries- Certain optional groupsSource: - Brief Summaries of Medicare andMedicaid and Kaiser Family - Medicaid A Primer- Eligibility groups streamlined to- children- pregnant women- parents and caretaker relatives- adults (ages 19-64)- Income eligibility will be based off modifiedadjusted gross income and householdincome- Eligibility based off monthly income at timeof application- Minimum income eligibility for adults is133% of FPLSource: Federal Register - Medicaid Program EligibilityChanges under the ACA and Kaiser Family - Medicaid andthe uninsured
  9. 9. PAGE 9ELIGIBILITY: CHIP• CHIP covers children whose family income is too high forMedicaid• The ACA will keep the same eligibility standards in placethrough 2019• The ACA has expanded eligibility beyond the originalrequirements of children under 19 and householdincomes of 200%
  10. 10. PAGE 10ELIGIBILITY: MEDICARE• Overall eligibility for Medicare does not change withthe enactment of the ACA• Medicare eligibility requirements include:o Being a U.S. citizen or legal immigranto Being age 65 or olderSource: Medicare and Proof of Citizenship
  11. 11. PAGE 11ELIGIBILITY: MEDICAREMedicare Part Eligibility RequirementsPart AIndividual is eligible if under age 65 and:- Receives Social Security Disability Insurance for minimum of 24 months,- Receives disability from Railroad Retirement Board,- Receives disability due to Lou Gehrig’s disease,- Has worked 10 years in a governmental job where Medicare taxes were paid andmeet requirements for Social Security Disability; or be the child/widower ofsomeone who has met those requirements, or- Has permanent kidney failure or has received a kidney transplantIndividual is eligible if age 65 or older and:- Receives benefits from Social Security or Railroad Retirement,- Has an eligible spouse,- Has worked (either individual or spouse) in a government job where Medicaretaxes were paid, or- A dependent parent of a fully insured deceased childPart B - Anyone eligible for Part A can enroll in Part B- Monthly premium is based off incomePart C - Anyone who is eligible for Parts A and B can enroll in Part CPart D - Anyone who is enrolled in Parts A, B, or C is eligible for the prescription drugcoverage- Monthly premium is based off incomeSource: Medicare
  13. 13. PAGE 13ENROLLMENT PROCESS: APPLICANT• Applicants can enroll in an Exchange through the Exchangewebsite, in person at a designated assistance center, via toll-freetelephone number, or by mail• The following information will be needed when completing anExchange application:o Nameo Addresso Date of birtho SSNo Proof of U.S. citizenship/immigration status
  14. 14. PAGE 14ENROLLMENT PROCESS: APPLICANT• Notifications of eligibility are sent out once the determination iscomplete• Notifications letters should explaino the applicant’s eligibility determinationo the steps taken and any remaining steps needed to completeenrollment processo the appeal process available to the applicant
  15. 15. PAGE 15ENROLLMENT PROCESS: APPLICANT• Through enrollment process, if applicant is found eligible forgovernment-based healthcare (e.g., Medicare, CHIP, orMedicaid) the Exchange will automatically enroll applicant intoprogram• Applicants can shop through Exchange to find the best coverageoption for their situation• The Exchange will provide notification to the chosen insuranceissuer
  16. 16. PAGE 16ENROLLMENT PROCESS: EMPLOYER• Employers can submit an application to the Small BusinessHealth Options Program (SHOP) Exchanges to determineeligibility*• Once employer’s application is approved, the SHOP will help theemployer both enroll and select health plan options for theiremployees
  17. 17. PAGE 17*UPDATES TO SHOP PROGRAM• The requirement that a SHOP must allow employers the option tooffer employees a choice among all qualified health plans (QHPs) atthe metal level (i.e., bronze, silver, gold, or platinum) chosen by theemployer has been delayed for one year.• For plan years beginning before January 1, 2015 federally facilitated-SHOPs will not offer an employee-choice option but will instead allowemployers to offer their employees a single QHP from the SHOPsavailable choices. State-operated SHOPs may, but are not required to,offer an employee-choice option.• SHOP special enrollment period has been changed from 60 days to 30days after a qualifying event.• HHS has posted an application for SHOP eligibility for employers thatare not able to apply online or are not working with a broker and anapplication for employees to submit to check their eligibility for SHOPcoverage from their employer.As of6/2013,HHS hasissued finalregulationsaround theSHOPprogram
  18. 18. PAGE 18ENROLLMENT PROCESS:EMPLOYER/SHOP• The SHOP will provide notification to:o employers regarding eligibility to participate in the Exchangeo employees regarding the plan options and how to enrollo the insurer containing the employees’ enrollment information• The SHOP is also required to notify HHS that the employer isproviding insurance and the eligible employees have enrolled ina QHP
  20. 20. PAGE 20ENROLLMENT VERIFICATION:APPLICANT• U.S. citizenship and incarceration status will be verified by:o Comparing records at the Social Security Administrationo If the information cannot be confirmed, HHS will go to theDepartment of Homeland Security for confirmation• Other application criteria will be verified against the respectivefederal agencies
  21. 21. PAGE 21ENROLLMENT VERIFICATION:APPLICANT• HHS will conduct annual redeterminations to determineeligibility for upcoming plan yearo If applicants are approved, they will receive notification showingdata used to make the decision and their eligibility statuso If applicants are not approved, they will receive coverage for onemonth after notification and can no longer claim tax benefits• Applicants will need to supply any information that has changed• Applicants will need to sign and return the notification• After the signed notification is received, applicants can re-enroll/terminate/change health plans
  22. 22. PAGE 22ENROLLMENT VERIFICATION:EMPLOYER• To verify employer submitted information, the SHOP will crossreference the employer’s information with government agencies• The SHOP will redetermine employer eligibility through reviewof the annual report submitted to it by the employer
  23. 23. PAGE 23PENALTIES
  24. 24. PAGE 24PENALTIES:INDIVIDUALS AND EMPLOYERSIndividuals• Penalties will be imposed for failure to maintain theminimum level of individual coverageo Penalties will either be a flat rate or a percentage of income,whichever is highero Penalty rates will be adjusted annuallyo IRS will administer and collect the penaltyEmployers (50+ employees)• If coverage is inadequate or not provided, a penalty will beassessed based on the annual applicable dollar amount andnumber of full-time employees
  26. 26. PAGE 26APPEAL PROCESS: APPLICANT• Each state will be responsible for creating their own appealprocess• The Exchange will notify applicants if they are ineligible forgovernment-based healthcare and provide alternative optionsfor affordable healthcare• Applicants can appeal adverse eligibility decisions and costreimbursement denials from insurance companies through aninternal or external appeal process
  27. 27. PAGE 27APPEAL PROCESS: EMPLOYER• An employer will be able to appeal an adverse eligibilitydetermination made by a SHOP• The SHOP must give the employer 30 days notice to respond toan eligibility denial and submit the necessary documentation tothe SHOP• If the SHOP still denies eligibility after receiving documentationfrom the employer, the employer may request an externalappeal review by a third party arbitrator
  28. 28. PAGE 28KEY DATES
  29. 29. PAGE 29KEY DATES: EXCHANGE ENROLLMENTDATE EVENTJanuary 1, 2013 For 2012 tax year, employers need to include on the employee’s W-2the cost of employer-sponsored health coverage.o They must include both employer and employee portions of the costof health benefits.The tax deduction will be eliminated for employers who receiveMedicare Part D retiree drug subsidy payments.o These payments are a federal subsidy paid to employers who offerretirement benefits for prescription drugs.o Employers who receive this payment will have to include the amountas taxable income.March 1, 2013 • Employers must provide all employees with a written notice detailing:- the availability of the healthcare Exchange,- a description of the services provided,- contact information for assistance,- possible tax credit eligibility, and- information regarding loss of employer sponsored coverage if theypurchase individual coverage in a QHP through the Exchange.
  30. 30. PAGE 30KEY DATES: EXCHANGE ENROLLMENTDATE EVENTOctober 1, 2013 • Open enrollment period begins for the ExchangesJanuary 1, 2014 ACA Exchanges are in effectAny U.S. citizen/legal resident who does not have health insurance andis not exempt will be liable for a tax penaltyEmployers that do not provide health insurance coverage will be fined
  31. 31. PAGE 31REED & ASSOCIATES, CPASFor more information on Reed & Associates, CPAs pleasecontact us at:inquire@reedassociatescpas.comPhone: 860-395-1996Or visit our website:reedassociatescpas.comQuality. Integrity. Experience.