Powerpoint - Families USA

Report
About These Materials
Families USA developed these materials under contract with
DC Health Link, the District of Columbia's Health Benefits
Exchange, for a training program for DC eligibility workers.
These workers determine eligibility for Medicaid and other
benefit programs (including SNAP and TANF). They will help
consumers apply for coverage and financial assistance, report
changes, renew coverage, and verify the information that is
needed to determine eligibility. These workers will not be
responsible for helping consumers select health plans.
These training materials are posted here as an example that
can be adapted for other training programs. They contain
information that is specific to the District of Columbia, which
would have to be changed if used in another state. Contact
Families USA at [email protected] for assistance with
adapting these materials.
Prepared by Families USA for use in the District of Columbia
ESA Policy
Training Day 4
The Verification Process
Prepared by Families USA for use in the District of Columbia
Changes to Verification
• Current Medicaid rules:
• Documentation required for most
eligibility factors
• New rules:
• Use electronic data sources and selfattestation as much as possible
• Use paper documentation as a last resort
Prepared by Families USA for use in the District of Columbia
Electronic Data Sources
• DC Health Link will get data from two hubs,
which include several sources each:
• Federal data hub
• Local data hub
• DC Health Link will get this information
automatically. You will not need to know
which source to get information from.
Prepared by Families USA for use in the District of Columbia
The Federal Data Hub
• Connects DC Health Link to federal
government data sources
• Data sources include, among others:
• Social Security Administration
• Internal Revenue Service (IRS)
• The Work Number
• Department of Homeland Security
Prepared by Families USA for use in the District of Columbia
The Local Data Hub
• Connects DC Health Link to local data
sources
• Data sources include:
• DMV
• ACEDS
• Department of Employment Services
Prepared by Families USA for use in the District of Columbia
How DC Health Link Uses
Electronic Data Sources
1. Checks federal and local data hubs
2. Pre-populates information in application
3. Asks applicant to confirm or change prepopulated information and add
additional information
4. Asks for documentation if needed
Prepared by Families USA for use in the District of Columbia
Important Things to Remember
about Electronic Data Sources
• Some electronic data will be months old
• Always remember to check prepopulated data
• If a data source is temporarily unavailable,
DC Health Link will automatically check
other data sources if one hub is down
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When is paper documentation needed?
• When electronic data sources have no
information for applicant
• When electronic data sources are not
“reasonably compatible” with applicant’s
self-attestation
• When a non-applicant does not provide a
Social Security number
Prepared by Families USA for use in the District of Columbia
New Ways of Accepting Documentation
• Accept scanned or photocopied versions
of all documentation, including citizenship
and immigration status
• Documentation can be submitted:
• Online through “My Account”
• In person
• By mail
• By fax
• By email
Prepared by Families USA for use in the District of Columbia
Timeline for Providing Documentation:
Medicaid
• If verification needed for an eligibility factor
other than citizenship/immigration status:
• 45 days to provide documentation
• Applicant does not receive Medicaid during this
time
• If verification needed for
citizenship/immigration status:
• 90 days to provide documentation
• Applicant receives Medicaid during this time
Prepared by Families USA for use in the District of Columbia
Timeline for Providing Documentation:
DC Health Link
• Applicant has 90 days after receiving
notice
• If inconsistency is not resolved in this
time, financial assistance level may
change and/or coverage can be
terminated
Prepared by Families USA for use in the District of Columbia
What if applicants cannot
provide documentation?
• In some circumstances, applicants cannot
provide documentation
• For example, in cases of homelessness or
domestic violence
• ESA supervisory staff can waive paper
documentation requirements on a case-bycase basis
Prepared by Families USA for use in the District of Columbia
Review: Question #1
TRUE or FALSE:
Applicants providing documentation of
citizenship or immigration status must
bring the original version into an ESA
service center.
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Answer: Question #1
FALSE
Scanned and photocopied versions of all
documents, including citizenship and
immigration status, are accepted.
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Review: Question #2
TRUE or FALSE:
ESA workers will need to remember which
data sources are in which hub and choose
which hub to ask for information when
electronic data is needed.
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Answer: Question #2
FALSE
DC Health Link automatically checks the
right hubs and data sources for you.
Prepared by Families USA for use in the District of Columbia
Verifying Household Composition
Electronic data sources are not available for
household composition, so DC Health Link will
accept self-attestation unless:
• Two tax filers who do not file jointly say they
will claim the same dependent
• Two people who do not file taxes claim that
the same person lives with them
In these cases, documentation is required.
Prepared by Families USA for use in the District of Columbia
Tax Forms to Document
Household Composition
• Tax forms are the strongest type of
documentation
• Form 8332
• Custodial parent allows non-custodial parent
to claim child
• Form 2120
• Multiple taxpayers supported dependent
• Form indicates which person gets to claim
dependent
Prepared by Families USA for use in the District of Columbia
Other Documentation of
Household Composition
If neither person has tax forms, use:
• School or medical records
• Childcare records
• Statements from non-relatives
• Leases
• Mail to or regarding the person being claimed
• Records of religious or recreational activities
Prepared by Families USA for use in the District of Columbia
Five Steps for Verifying Income
1. DC Health Link checks IRS data
• If potentially eligible for premium tax credits,
application will ask for expected annual
income
• If potentially eligible for Medicaid, and IRS
data is not available or applicant disagrees
with IRS data, continue with steps 2-5
2. DC Health Link checks federal and local data
hubs and pre-populates application
Prepared by Families USA for use in the District of Columbia
Five Steps for Verifying Income (cont’d)
3. Applicant confirms or changes prepopulated information
4. DC Health Link asks about any additional
sources of income
5. DC Health Link calculates total income
and asks applicant to confirm
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility
Reasonable compatibility: any difference
between self-attestation and electronic data
sources is either small or does not make a
difference in eligibility
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility for Income:
Medicaid
As long as both self-attestation and electronic
data sources show household income is below
Medicaid eligibility level, the information is
reasonably compatible.
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility for Income: DC
Health Link
• If attestation of household income is above
electronic data source amount or is no more
than 10% below
• Reasonably compatible
• DC Health Link uses self-attestation to calculate
premium tax credits and cost-sharing reductions
• If attestation is more than 10% below electronic
data sources
• Not reasonably compatible
• Documentation is needed
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility between
Medicaid and DC Health Link
• When self-attestation is above Medicaid
eligibility limit and electronic sources are
below, use self-attested data
• When self-attestation is below Medicaid
eligibility limit and electronic data sources are
above:
• Not reasonably compatible, unless the
difference is less than 10%
• Documentation is needed
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility: Example #1
Sasha is 35 and has no one else in her
household.
• Electronic data sources say her income is
$23,000 (200% of poverty)
• She says her income is $9,000 (128% of
poverty)
Is this reasonably compatible?
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility: Example #1
Yes, this is reasonably compatible.
Even though there is a difference of 72% of
poverty between self-attestation and data
sources, this is reasonably compatible because
both are below the Medicaid eligibility level
for childless adults.
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility: Example #2
Christine is 48 and has no one else in her
household.
• Electronic data sources say her income is
$36,900 (320% of poverty)
• She says her income is $33,200 (289% of
poverty)
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility: Example #2
No, this is not reasonably compatible
This is not reasonably compatible
because she is eligible for premium tax
credits and her attestation is more
than 10% below what electronic data
sources report.
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility: Example #3
Bernie is 35 and intends to claim his 10-year-old son,
Marcus. He has no one else in his household.
• Electronic data sources say his income is $34,432
(about 222% of poverty for a family of two)
• He says his income is $33,036 (about 213% of
poverty)
Is this reasonably compatible?
Prepared by Families USA for use in the District of Columbia
Reasonable Compatibility: Example #3
Yes, this is reasonable compatible.
Because self-attestation is less than
10% below electronic data sources, the
information is reasonably compatible.
Prepared by Families USA for use in the District of Columbia
Documentation of Income
Documentation of income includes:
• Most recent paystubs
• Letter from employer
• Award letters (such as Social Security)
• Documentation of non-wage income,
such as interest, dividends, annuities
• Documentation of any planned
adjustments to income
Prepared by Families USA for use in the District of Columbia
Verifying Citizenship and
Immigration Status
• DC Health Link uses federal data hub to verify
citizenship and immigration status
• If verification is not possible:
• Applicant has a 90-day “reasonable
opportunity period” to provide
documentation
• Applicant gets coverage based on income
during this time
Prepared by Families USA for use in the District of Columbia
Documentation of Citizenship
Two types of documentation:
1. Primary
2. Secondary
Applicant can provide:
• Primary documentation by itself
• Secondary documentation plus another
form of ID
Prepared by Families USA for use in the District of Columbia
Documentation of Immigration Status
DC Health Link will need:
1. Nine-digit alien number
2. Copy of something that shows
immigration status
Prepared by Families USA for use in the District of Columbia
Verifying Residency
• Verification needed only for those over age 19
• DC Health Link checks:
• Department of Employment Services
• Department of Motor Vehicles
• The BENDEX file
• Residency verified even if sources show a
different DC address
Prepared by Families USA for use in the District of Columbia
Documentation of Residency
• Paper documentation of residency:
• Current driver’s license
• Current lease
• Current rent receipt
• Current utility bill
• Current letter from landlord
• Homeless applicants are not required to
provide paper documentation
Prepared by Families USA for use in the District of Columbia
Verifying Incarceration Status
DC Health Link will accept self-attestation of
incarceration status for the applicant and
applicant’s household members.
Prepared by Families USA for use in the District of Columbia
Verifying Age
• DC Health Link checks federal data sources
• Verification needed only if difference
between attested age and electronic data
sources affects eligibility
• Example: a person who has income of 250%
of poverty and could qualify for Medicaid as a
child, but not as an adult
Prepared by Families USA for use in the District of Columbia
Documentation of Age
• Birth certificate
• Driver’s license
• Other government-issued photo ID
• Other photo ID with name and date
of birth
Prepared by Families USA for use in the District of Columbia
Verifying Pregnancy
Application accepts attestation of:
• Pregnancy
• Number of children the pregnant
woman expects to deliver
Prepared by Families USA for use in the District of Columbia
Verifying Caretaker Relative Status
Application accepts attestation that an
applicant is a caretaker relative.
Prepared by Families USA for use in the District of Columbia
Review: Availability of Other Coverage
• Availability of other coverage affects:
• Eligibility for premium tax credits and cost-
sharing reductions
• Match rate that DC receives for certain
pregnant women and children
• Coverage can come from:
• Other government programs (for example,
Medicare or the VA)
• An employer (or a family member’s
employer)
Prepared by Families USA for use in the District of Columbia
Verifying Availability of Other Coverage
• Government coverage
• DC Health Link will check for eligibility
determination for other programs
• If found, applicant must provide documentation
that coverage has been cancelled
• Employer coverage
• Electronic data available for some federal
employees
• DC Health Link relies on information provided by
applicant and employer
Prepared by Families USA for use in the District of Columbia
Verifying an Applicant’s
Social Security Number
• DC Health link will check federal data hub
for match
• If no match is found, applicant must provide
documentation or resolve the inconsistency
with the Social Security Administration
Prepared by Families USA for use in the District of Columbia
Verifying American Indian Status
• Important for:
• Treatment of income in Medicaid
• Ability to enroll in DC Health Link at any time
• Higher levels of cost-sharing reductions
• DC Health Link does not currently have an
electronic data source for this information
• Applicant must provide documentation
Prepared by Families USA for use in the District of Columbia
Documentation of American Indian Status
Any formal documentation that verifies
American Indian status from:
• A tribe
• Indian Health Services (IHS)
• Bureau of Indian Affairs
Prepared by Families USA for use in the District of Columbia
Documentation of American Indian Status
(cont’d)
For those born outside of the U.S.:
• Form 1-94 with a notation of “S1-3”
• 1-551 Permanent Resident Card stamped “S1-3”
• Temporary 1-551 stamp coded “S1-3” in a
Canadian passport
• Tribal record or document certifying at least 50%
American Indian blood, and satisfactory evidence
of birth in Canada
Prepared by Families USA for use in the District of Columbia
Review: Question #1
Travis and Maggie have one daughter, Lindsay,
who is three. They say their income is $20,000
(102% of poverty for family of three).
Electronic data sources say their income is
$39,000 (200% of poverty for a family of 3).
Is this information reasonably compatible?
Prepared by Families USA for use in the District of Columbia
Answer: Question #1
YES, the information is reasonably
compatible.
Both sources of information say their income
is below the Medicaid eligibility threshold, so
their information is reasonably compatible.
Prepared by Families USA for use in the District of Columbia
Review: Question #2
Tomas gives you an address in SE. DC
Health Link finds an address for Tomas in
NW.
TRUE or FALSE:
Tomas must provide documentation to
prove his residency.
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
FALSE
Even though the addresses are different,
both Tomas and the data sources say he is
a DC resident, so he does not need to
provide documentation.
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Review: Question #3
DC Health Link cannot verify Ivan’s
immigration status, but his SSN and all
other Medicaid eligibility factors are
verified and he is otherwise eligible.
TRUE or FALSE:
Ivan cannot get covered by Medicaid
until his immigration status is verified.
Prepared by Families USA for use in the District of Columbia
Answer: Question #3
FALSE
Ivan has 90 days to provide documentation
of immigration status, and he can get
Medicaid during this time.
Prepared by Families USA for use in the District of Columbia
Recap: The Verification Process
• What you will do:
• Enter information into the application
• Help applicant check pre-populated
information
• Explain documentation requirements
• Verify documentation
• What DC Health Link will do:
• Check all electronic data sources automatically
• Pre-populate application
• Check for reasonable compatibility
• Let you know when documentation is needed
Prepared by Families USA for use in the District of Columbia
Case Processing
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The “Happy Path”
Eligibility determined when:
• Necessary eligibility factors are verified
electronically
• Information is reasonably compatible
with what the applicant says on the
application
Prepared by Families USA for use in the District of Columbia
Dealing with Inconsistencies
Before asking for documentation:
• Check for typographical or clerical
errors
• Contact the applicant about possible
application mistakes
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Reasonable Opportunity Periods:
Medicaid
• If verification needed for something other
than citizenship/immigration status:
• 45 days to provide verification
• Applicant does not get Medicaid during this
time
• If verification needed for
citizenship/immigration status:
• 90 days to provide verification
• Applicant gets Medicaid during this time
Prepared by Families USA for use in the District of Columbia
Reasonable Opportunity Periods:
DC Health Link
If documentation is needed:
• Applicant has 90 days to:
• Provide documentation that resolves the
inconsistency with the data source
• 90-day period can be extended by 30 days if
applicant makes a good faith effort to get
documentation
• Documentation requirement can be waived in
special circumstances (except for SSN and
citizenship/immigration status)
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Coverage while Dealing with Inconsistencies
• If otherwise eligible, applicant can receive
premium tax credits during reasonable
opportunity period
• Must pay back tax credits if found ineligible
• If otherwise eligible, applicant can receive
Medicaid if citizenship/immigration status is
the only inconsistency
Prepared by Families USA for use in the District of Columbia
MAGI-Eligible Applying for Non-MAGI Medicaid
• Can receive premium tax credits or
Medicaid based on income while waiting
for a determination – this helps
someone waiting for Medicaid based on
disability.
• Will not have to pay back premium tax
credits taken while waiting
Prepared by Families USA for use in the District of Columbia
Retroactive Medicaid Eligibility
Just like now, Medicaid starts three months
prior to the date of application if the person
was eligible during that time
• Ask the person to submit any back bills
for payment
Prepared by Families USA for use in the District of Columbia
Reporting Changes
Prepared by Families USA for use in the District of Columbia
The Importance of Reporting Changes
• Enrollees must tell DC Health Link when
information provided on their application
changes
• Even a small change can affect eligibility
• If changes are not reported, enrollees may:
• Not be getting as much help as they could
• Have to pay back money at the end of the year
• Be incorrectly receiving Medicaid benefits
Prepared by Families USA for use in the District of Columbia
Example: Alejandro
Alejandro is single and has no dependents.
When he applied, his income was at 265% of
poverty. A few months later, his hours are cut at
his job, and his income goes down.
Why is it important for Alejandro to tell DC
Health Link about this change?
Prepared by Families USA for use in the District of Columbia
Why Alejandro Should Report the Change
Alejandro should report the drop in his
income because:
• He could now be eligible for Medicaid
and would not need to pay monthly
premiums, OR
• He could be eligible for a bigger premium
tax credit and cost-sharing reductions
Prepared by Families USA for use in the District of Columbia
When to Report a Change
Enrollees must update DC Health Link if they
experience changes in:
• Income
• Household size
• Address or state of residence
• Employer coverage
• Eligibility for other coverage
• Student status
• Incarceration status
• Immigration status
• How they expect to file taxes
Prepared by Families USA for use in the District of Columbia
Income Thresholds for Reporting Changes
• Medicaid enrollees: Must report any change
(no threshold)
• DC Health Link plans with premium tax credits:
• Only required to report changes in income of
more than $150 per month ($1,800 annually)
• Should report smaller changes too because any
income change can affect premium tax credit
amount
Prepared by Families USA for use in the District of Columbia
Example: Teresa
Teresa is enrolled in a DC Health Link plan and
receives premium tax credits. Every year, Teresa’s
boss gives her a bonus. The exact amount varies
from year to year, but it is usually around $1,000.
Teresa asks if she needs to report the bonus
when she finds out the amount.
How would you respond?
Prepared by Families USA for use in the District of Columbia
Should Teresa report the change?
• Teresa has a DC Health Link plan with premium
tax credits, so she must report changes of more
than $1,800 per year
• Her bonus will be below this threshold, so
she is not required to report change
• It is a good idea to report anyway so she does
not end up owing back any of her premium tax
credit
Prepared by Families USA for use in the District of Columbia
Review: Question #1
TRUE or FALSE:
Consumers may not end up getting the full
amount of assistance they are eligible for if
they do not report changes in income.
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Answer: Question #1
TRUE
For example, someone may be paying
premiums for a DC Health Link plan but be
eligible for Medicaid.
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Review: Question #2
TRUE or FALSE:
Because people with DC Health Link plans
and premium tax credits are not required to
report changes of less than $150 per month,
a change of $100 that was not reported
would not affect the value of the premium
tax credit a person could get.
Prepared by Families USA for use in the District of Columbia
Answer: Question #2
FALSE
Premium tax credit amounts are based on
annual income. Any change in income can
change the amount of the premium tax
credit a person gets, even if the change is
below $150 per month.
Prepared by Families USA for use in the District of Columbia
How DC Health Link Handles Changes
There are two ways DC Health Link finds out
about a change:
1. When an enrollee reports a change to DC
Health Link
2. When DC Health Link gets information
about a change from electronic data
sources
Prepared by Families USA for use in the District of Columbia
How to Report a Change
Enrollees can report changes by:
• Using “My Account” online
• Calling the customer service call center
• Getting help from ESA, either in person
or over the phone
• Mailing information to ESA
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The Process for Reporting Changes
1. Enrollee reports the change within 30 days
2. DC Health Link sends a notice to the enrollee:
• Confirming that the change report was received
• Requesting documentation, if needed
• Explaining how the change affects eligibility
3. If a change affects eligibility, DC Health Link will
ask the consumer to enroll in new coverage or
explain how the amount of their premium credit
is changing
Prepared by Families USA for use in the District of Columbia
When DC Health Link Finds a Change
• DC Health Link will check electronic data
sources to find changes
• For example, DC records will show if a
household member who was eligible for
premium tax credits has enrolled in
Medicaid
• If DC Health Link finds a change the enrollee
has not reported, a notice will be sent to
the enrollee to get confirmation
Prepared by Families USA for use in the District of Columbia
Change Reporting Timeline:
Medicaid
• Enrollee has 15 days to respond to a
notice with documentation if the change is
incorrect
• If enrollee does not respond, eligibility is
re-determined
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Change Reporting Timeline:
DC Health Link
• Enrollees have 30 days to confirm or disagree
with change
• If enrollee disagrees, given 90 days to provide
documentation and coverage continues
• If enrollee does not respond, eligibility redetermined only if change is not related to:
• Household size
• Income
Prepared by Families USA for use in the District of Columbia
When Changes to Tax Credits
Will Go into Effect
• Changes to premium tax credits and cost-sharing
reductions will be made:
• At the end of the month, if redetermined by the 15th of
the month
• At the end of the next month, if redetermined after the
15th of the month
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When Coverage Will End: Medicaid
If a Medicaid enrollee is no longer eligible,
coverage will end:
• At the end of the month, if 15 or more days
left in the month from the date of redetermined
• At the end of the next month, if less than
15 or more days left in the month from the
date of re-determined
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When Coverage Will End: DC Health Link
If a DC Health Link enrollee is no longer eligible or
cancels their coverage, it will end:
• At the end of the month after the month in
which eligibility is re-determined
• When the enrollee requests coverage to end, if
the request is submitted at least 14 days in
advance
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Example 1: Pia
Pia is currently getting premium tax credits. Pia
loses her job and gets a notice from DC Health
Link telling her that data sources say that she is
receiving a certain amount in unemployment.
The amount Pia is receiving in unemployment is
actually higher.
What should Pia do?
Prepared by Families USA for use in the District of Columbia
Example 1: What should Pia do?
Let DC Health Link know that the information
from the electronic data sources is wrong
within 30 days to make sure the amount she
is receiving in premium tax credits is correct.
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Example 2: Santiago
Santiago has Medicaid and gets a notice from
DC Health Link saying that data shows his
income has increased.
TRUE or FALSE:
If Santiago does not respond to the notice,
his eligibility for Medicaid will not be redetermined.
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Example 2: Answer
FALSE
Since Santiago has Medicaid, DC Health
Link will re-determine his eligibility even if
he does not respond to the notice.
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Things to Remember
• When consumers apply for coverage, tell them they
must inform DC Health Link of any changes within
30 days
• Tell consumers they may receive notices about
changes that DC Health Link identifies through data
sources and must respond within 30 days
• DC Health Link will determine if a change affects
eligibility and tell the consumer what to do
• ESA is one of the ways consumers can get help
reporting changes
Prepared by Families USA for use in the District of Columbia

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