State Innovation Waiver Policy Forum: Health Connector Non-Group - PowerPoint PPT Presentation

State Innovation Waiver Policy Forum: Health Connector Non-Group & Subsidized Coverage AMANDA CASSEL KRAFT - Chief of Staff, MassHealth, EOHHS ALISON KIRCHGASSER - Director of Federal Policy Implementation, MassHealth, EOHHS MARISSA WOLTMANN - Associate Director of Policy and ACA Implementation Specialist, Health Connector EMILY BRICE - Senior Advisor on State Innovation Waivers, Health Connector October 30, 2015

Overview: Section 1332 Flexibility ACA Topic & Citation Examples of Provisions That May Be Waived (see handout) Benefits and Exchange Subsidies  Essential Health Benefits  Cost-sharing limitations (Title 1, Subtitle D, Part 2)  Metallic tiers (Title 1, Subtitle E, Section 1401/  Individual and group market definitions 36B of the IRC and Section 1402)  Premium tax credits and cost-sharing reduction subsidies Exchanges and  Exchange structure and role Qualified Health Plans  Eligibility for Qualified Health Plans  Criteria for Qualified Health Plans ( Title 1, Subtitle D, Part 1) Individual and Employer Shared  Minimum essential coverage requirement Responsibility (Mandate)  Tax penalty for individuals who fail to maintain coverage  Tax penalty for employers who fail to maintain coverage for their full-time employees ( Title 1, Subtitle E, Section 1501/ 5000A of IRC) (Title 1, Subtitle E, Section 1513/4980H of IRC) 2

Overview: Policy Exploration Process Date Topic Open discussion # 1  Individual mandate Friday, Oct. 16, 9-11 AM  Employer mandate Open discussion # 2  Exchange and qualified health plan structure Friday, Oct. 23, 9-11 AM  Individual and group market structure  Essential health benefits Open discussion # 3  Exchange subsidies Friday, Oct. 30, 9-11 AM  Exchange eligibility  Other aspects of Exchange coverage State decision on whether to aim for Roll-up and next steps  Roll-up of discussion to date 1/1/17 start date Friday, Nov. 6, 9:30-11 AM  Revisit timeline for application, including topics for in-depth sessions or later start date In-depth discussion # 1  Topic TBD based on earlier sessions Friday, Nov. 13, 9-11 AM In-depth discussion # 2  Topic TBD based on earlier sessions Friday, Nov. 20, 9-11 AM In-depth discussion # 3  Topic TBD based on earlier sessions Wed., Nov. 25, 9-11 AM 3

Topics for Discussion  Eligibility considerations − Commonwealth Care approach − ACA approach, including differences in MAGI  Affordability considerations − Commonwealth Care approach − ACA approach, as supplemented by ConnectorCare  Continuity considerations − Commonwealth Care approach − ACA approach  Open public comment 4

Eligibility Preliminary Considerations

Historically: Comm Care Eligibility Under Chap. 58 and related laws:  Commonwealth Care subsidized coverage for uninsured up to 300% FPL  Eligibility: − Up to 300% FPL − Massachusetts resident − US citizen, US national, lawfully present immigrant (qualified and special status) or PRUCOL − Not eligible for MassHealth, Medicare, or other public programs, including SHIPs − Uninsured − Not incarcerated − Not eligible for employer-sponsored insurance (ESI), if employer subsidized 33% of the premium for individuals or 20% for families  Household composition, income counting, and income timing rules aligned with MassHealth 6

Status Quo: ACA Eligibility ACA introduced new eligibility standards for Health Connector:  Eligibility to purchase Qualified Health Plans (QHP) through Health Connector: − Massachusetts resident − US citizen, US national, or lawfully present immigrant (including qualified within 5-year bar, but not including PRUCOL) − Not incarcerated (except if pending disposition of charges) − Not enrolled in Medicare  Additional eligibility to receive federal subsidies: − Eligible tax-filing status − Income:  Between 100-400% FPL for premium tax credits (and under 100% for qualified immigrants in 5-year bar)  Under 250% FPL for cost-sharing reductions (greater for certain AI/AN) − Not eligible for/enrolled in other Minimum Essential Coverage (exception for employer-sponsored insurance that fails to meet minimum value and affordability standard) 7

Status Quo: ACA’s MAGI Standard Eligibility for federal subsidies measured by MAGI standard: ACA uses Modified Adjusted Gross Income standard to measure eligibility • for: premium tax credits, cost-sharing reductions, and certain MassHealth programs (e.g., CarePlus) MAGI is a federal tax law-based standard that turns on: • − The applicant’s tax -filing status − The applicant’s tax -filing household − T he applicant’s household income: Adjusted Gross Income Excluded Non-taxable Tax-exempt (gross foreign MAGI SS benefits interest income – income deductions) MAGI is used to convert household size/income to a FPL % standard • MAGI for MassHealth is not identical to MAGI for the Health Connector • 8

Status Quo: MAGI Comparison MAGI for MassHealth versus MAGI for the Health Connector: Health Connector/QHP MassHealth Household  Tax household – e.g., married couples  Tax household, but sometimes considers living Composition must file jointly (with few exceptions) arrangements and relationships (hybrid with former Medicaid standards) – e.g., married couples who live  Dependents may not receive a tax together always counted in same household, even if do credit on their own not file together Income Timing  Projected annual income for the tax  Point-in-time based on current monthly income (with year option to average over the calendar year or other period) Income Counting  Lump sums included in annual income • Lump sums only in month received • Special exclusions: certain educational income, certain AI/AN income • 5% income disregard FPL Standard  Switches to new FPL table at open • Switches to new FPL table on March 1 enrollment 9

Preliminary Policy Considerations Examples of Section 1332-related options could include:  Aligning MAGI rules for Health Connector and MassHealth, e.g., income timing standards  Modify Health Connector eligibility to include populations not otherwise eligible for coverage, e.g., certain immigrants  Modify premium tax credit eligibility to include populations not otherwise eligible, e.g., individuals whose total family costs of coverage are not considered in determining the affordability of an employer offer of coverage (a.k.a., “the family glitch) All options must meet Section 1332 guardrails: Scope of Coverage Comprehensiveness Affordability Federal Deficit Must provide “coverage and cost - Must provide Must provide sharing protections coverage to at least coverage at least as against excessive Must not increase “comprehensive” as out-of- pocket” as many people as the federal deficit the ACA Exchange spending at least as affordable as Exchange 10

Questions for Discussion Is there interest in modifying the status quo? • Are there populations that remain ineligible for full-scope coverage or subsidized coverage under MassHealth, Medicare, or the Health Connector? If these populations are eligible for other programs, such as the Health Safety Net, would they be better served through the Health Connector? • Are there opportunities to modify the MAGI methodology for subsidized coverage available through the Health Connector, in order to streamline the consumer experience or program administration? *Is a Section 1332 waiver needed to achieve these goals? Are there policy goals related to a Basic Health Program or other waiver option to consider? 11

Affordability Preliminary Considerations

Historically: Comm Care Subsidies Under Chap. 58 and related laws:  Commonwealth Care established a state-based subsidy program that bridged MassHealth and commercial coverage (<300% FPL)  Key features of approach: − Progressive, fixed dollar premium scale mirrored state individual mandate affordability schedule set by Health Connector Co-pays and deductibles limited through tiered plan design (Plan Types 1-3) − Annual income eligibility update tied to publication of federal FPL guidelines (same schedule as MassHealth) − Enrollees paid premiums to Health Connector, which bundled into capitated rate for MCOs − Health Connector had ability to permit exceptions (e.g., waiver of premium payments for hardships) 13

Status Quo: ACA Subsidies ACA offers two types of subsidies for plans in the Health Connector:  Premium tax credits (<400% FPL) can be taken in advance (APTC) or claimed at tax time − Based on projected income and reconciled at tax time − Amount of credit based on: Premium Tax Cost of Expected Credit benchmark plan premium (difference available to contribution between cost of each household (sliding scale benchmark and member based on FPL) expected contribution)  Cost-sharing reductions (<250% FPL) − Paid directly to the health plan to reduce out-of-pocket costs − Only available for silver level plans − 4 variants of CSRs, based on income (73%, 87%, 94% AV, zero-cost- sharing for certain AI/AN) 14