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MMW Topical Brief:

Illinois Affordable Care Act Update

December 2013

Implementation of the Affordable Care Act (“ACA”) is up and running in Illinois. Like is to Medicare Part D, is the go-to website to sign up for new ACA forms of health insurance coverage in Illinois. And, like Medicare Part D, there are local, community resources to assist individuals in signing up. This topical brief will cover how is set up, the main categories of healthcare coverage (old and new) now available through , the applicability of these coverage categories to Medicare beneficiaries, and community resources that will assist individuals in signing up for health insurance coverage.

A Brief Overview of Get Covered Illinois

is the website for accessing information on and signing up for ACA health insurance coverage in Illinois. Consumers can gain access to the new ACA Marketplace and Illinois Medicaid programs through .

States had three options in managing their ACA Marketplace implementation: they could establish their own state-run Marketplace, they could participate in a state-federal partnership with the federal government, or they could let the federal government operate a federal Marketplace. Illinois chose the state-federal partnership. In practical terms, this means that the federal government runs our private health insurance marketplace (“Marketplace”), including eligibility for tax credits and cost sharing subsidies for its Qualified Health Plans (“QHPs”), while Illinois conducts consumer assistance functions and coordinates with the Federal Government on oversight of the QHPs in the Marketplace.

In addition to the new ACA Marketplace, the ACA also created a new category of people who are now eligible for Medicaid. This new category is often referred to as “ACA Adult” Medicaid. ACA adult Medicaid will provide coverage to individuals who are low income but do not meet the categorical requirements of existing Medicaid programs (because they are not a child, parent, person with a disability, or over the age of 65). To qualify for ACA adult Medicaid, an individual must have income less than 133% of the federal poverty level, meet Medicaid’s citizenship/residency requirements (e.g., legal permanent residents must have lived in the U.S. for at least 5 years), and be between the ages of 19 and 64.

Both the new Marketplace and new Medicaid program are rolling out now, with coverage beginning January 1, 2014. Luckily, creates “no wrong door access” to these new health insurance programs. When someone starts the screening process on , initial questions determine if the person should complete an application for state-run Medicaid programs or the federally-run Marketplace. Those determined potentially eligible for the state Medicaid programs are directed to the ABE (Application for Benefits Eligibility) site at abe.. All others are directed to the federally-run Marketplace site at . When families include members eligible for state programs and others eligible for the Marketplace, the site will direct the individual family members to the appropriate site for their individual coverage application.

Applicability to Medicare Beneficiaries

Individuals eligible for premium free Medicare Part A are not eligible for the new ACA Adult Medicaid or any financial assistance in accessing QHPs on the Marketplace. Individuals who are eligible for Medicare but have not yet enrolled in their premium-free Part A coverage do have a choice between free Part A and a full-price QHPs on the Marketplace; however, choosing the Marketplace over premium-free Part A does not make much sense. It is illegal for private insurance companies with QHPs on the Marketplace to sell those QHPs to individuals already enrolled in Medicare, and there should not be any reason for people who are already on Medicare to sign up for a Qualified Health Plan on the Marketplace..

Individuals who must pay a premium to access Medicare Part A may choose to access coverage on the Marketplace instead, as long as they are not currently enrolled in Medicare Part A. If they choose the Marketplace, they may qualify for financial assistance in paying for a private plan. This is the only instance where a Medicare eligible individual might consider accessing the Marketplace. However, some of these individuals may still want to consider accessing Medicare Part A by paying a premium. If an individual has a low income, s/he may be able to obtain assistance paying for Medicare premiums through the QMB Medicare Savings Program.

Individuals enrolled in Medicare do qualify for some public healthcare programs available through the ABE site at abe., including AABD Medicaid, Health Benefits for Workers with Disabilities, and Medicare Savings Programs. In addition, ABE will assess eligibility and complete application for Supplemental Nutrition Assistance Program (SNAP or food stamps), Temporary Assistance to Needy Families (TANF) and AABD Cash. For the first time in Illinois history, applications for all of these programs can be submitted completely online. Service providers can go directly to the ABE website (abe.) to assist individuals in signing up for these programs.

Categories of Coverage

The Affordable Care Act has ushered in a new health insurance coverage environment for Illinois residents. Through an eligibility assessment that looks at citizenship status, household income and family size, individuals are determined eligible for various public healthcare programs, as well as financial assistance in purchasing QHPs on the Marketplace. All U.S. citizens and qualified non-citizens can access any category of health insurance coverage offered on ABE or on the Marketplace. Any lawfully present non-citizen can access coverage through QHPs on the Marketplace and receive assistance in paying for the coverage through tax credits or cost sharing subsidies, if income eligible. Unauthorized non-citizens can still receive insurance coverage through Moms and Babies and All Kids, but are not allowed to access other forms of Medicaid coverage or coverage through the Marketplace.

The ABE website (abe.) assesses eligibility and takes applications for the following healthcare programs: ACA Adult Medicaid (new in 2014), Former Foster Care Children to 26 (new in 2014, FamilyCare, Moms and Babies, AllKids, Aid to Aged Blind and Disabled (AABD) Medicaid, Health Benefits for Workers with Disabilities, and Health Benefits for Persons with Breast and Cervical Cancer).

The Marketplace () assesses eligibility for tax credits and cost sharing subsidies to pay for QHPs and takes applications for QHPs.

Appendix A of this brief provides one-page fact sheets on the main healthcare programs accessed through ABE and the categories of financial assistance available to purchase a private plan on the Marketplace.

Assistance in Accessing Coverage

There are three new initiatives available to assist individuals in signing up for coverage: in-person counselors (IPCs), navigators, and certified application counselors.

The in-person counselors and navigators are distinguishable only by their funding sources. IPCs are funded through the state of Illinois, while the navigators are funded directly by the federal government. But, the roles of these two groups are the same, and they are referred to collectively as “Navigators”. These individuals complete both federal and state specific training to become certified. They conduct outreach activities in order to find individuals and assist them in getting healthcare coverage. They can also assist individuals in signing up for coverage, but they are prohibited from advising or making suggestions as to what plan an individual should choose. Agencies receiving these grants are embedded in the various communities throughout the state. Great care was taken to assure that there are Navigators who can meet the needs of the diverse populations of Illinois.

Certified application counselors (CACs) do not receive any funding to help individuals enroll in health coverage. However, like Navigators, CACs are certified through a federal training to assist individuals in signing up for coverage but cannot advise or make suggestions about particular plans. This initiative was put in place to provide training to entities who work with uninsured populations and want to assist them in getting coverage, such as community health centers, hospitals, medical clinics, or other social services agencies.

Finding help is easy. has a “Get help in your area” section on its home page. An individual or someone assisting him or her can enter their zip code into this section and resources in the person’s area will be provided. In addition, individuals can search for resources that can assist in languages other than English. Individuals may also call 1-866-311-1119.

In addition to the above, a licensed insurance agent or broker who is registered with the Marketplace can also assist an individual in signing up for Marketplace coverage. One key difference between the new initiatives (Navigators and CACs) and agents/brokers is agents/brokers are allowed to advise and make suggestions about specific plans. Brokers/agents do not charge a fee to individuals for their services and are compensated through the insurance companies.

Final Note: Update on Complications with the Website

The news has been full of stories with difficulties in using the federal Marketplace website to secure health insurance. As was explained above, coverage in Illinois is run through , which then directs individuals to ABE (abe.) or the Marketplace (). The initial difficulties were related to not or abe.. Since October 1, the federal government has been working to fix these problems and a revamp of the site was completed at the end of November. Reports since the revamp indicate that the site is working much more effectively and enrollments have increased significantly. In addition, the date to sign up for coverage effective January 1 has been moved to December 23, 2013 in order to give individuals more time to find coverage on the revamped website.

Appendix A

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|ABE Makes Determinations for Each Individual Applicant Based on | |Marketplace Makes Determinations for Each Individual Applicant Based on|

|Citizenship Status, Last 30 days of Income, and Eligibility | |Citizenship Status, Projected Income for the Applicable Year, and Size |

|Determination Group Size.* | |of Tax Filing Unit |

|ACA Adult Medicaid |★ ¶ |133 FPL | |QHPs with No Financial Assistance |★¶ |400+ FPL |

|Family Care |¶ |133 FPL | |QHPs With Tax Credits And Cost Sharing Subsidy (must choose Silver Plan|

|(with or without spenddown) | | | |to receive Cost Sharing Subsidy) |

|Aid to Aged Blind Disabled (AABD) (with or |§ |100 FPL | | |

|without spenddown) | | | | |

|Health Benefits for Workers with Disabilities|§ |350 FPL | | |

|(HBWD) | | | | |

|Health Benefits for Persons with Breast and | |FPL | | |

|Cervical Cancer | |N/A | | |

*Eligibility Determination Group (EDG) is generally based on size of tax filing, but there are important exceptions.

ABE: ACA Adult Medicaid

|Eligibility Criteria |U.S. Citizen or Qualified Non-Citizen |

| |Illinois Resident |

| |19-64 years old |

| |133% Federal Poverty Level |

| |No Resource Test |

|Example(s) | Mary is a 56 year old U.S. citizen. She works and earns $1000 a month in housekeeping at a local |

| |hotel. She lives alone as all of her children are adults living on their own. Her countable income |

| |is below 133% of the Federal Poverty Level. She qualifies for ACA Adult Medicaid. |

| |Jim is 38 year old U.S citizen and father of two children who do not live with him. He earns |

| |approximately $25,000 at a local car repair shop. He pays child support and claims both children as |

| |dependents on his tax return. His Eligibility Determination Group (household size) is 3 and his |

| |countable income is below 133% of the Federal Poverty Level. He qualifies for ACA Adult Medicaid. |

ABE: Former Foster Children Medicaid

|Eligibility Criteria |Aged out of Illinois Foster Care System |

| |Up to Age 26 |

| |No Income Limit |

|Example(s) |Michael is 20 years old and aged out of the Illinois Foster Care system at age 18. He currently |

| |participates in an independence program and has his own apartment. The Program assisted him in |

| |finding a job and he earns approximately $17,000 per year. Michael still qualifies for Medicaid |

| |because of his status as a former foster child. |

ABE: Family Care

|Eligibility Criteria |U.S. Citizen or Qualified Non-Citizen |

| |Illinois Resident |

| |Parent or Caretaker Relative of Child Under 18 |

| |133% Federal Poverty Level |

| |No Resource Test |

|Example(s) |Susana is a U.S. citizen who lives with her two minor children. She works full-time at a local |

| |daycare center and earns $18,000 per year. She claims her two children as dependents on her tax |

| |return. As a parent caretaker of two minor children, Eligibility Determination Group of 3, and |

| |countable income below 133% of the Federal Poverty Level, she qualifies for FamilyCare Medicaid. |

ABE: All Kids

|Eligibility Criteria |Illinois Resident |

| |Age 18 or younger |

| |300% Federal Poverty Level (above 200% FPL must be uninsured for previous 12 months) |

| |No Resource Test |

|Example(s) |Sara and Martin are married, U.S. Citizens, and have 3 minor children. Sara works in the home caring|

| |for the children. Martin earns $50,000 per year as a mechanic. The three minor children are eligible|

| |for All Kids coverage. |

ABE: Moms and Babies

|Eligibility Criteria |Illinois Resident |

| |Pregnant Women up to 60 days after birth of child and children up to 1 years old |

| |200% Federal Poverty Level |

| |No Resource Test |

|Example(s) |Sandra and Alex are married. Alex is a U.S. citizen. Sandra is an unauthorized non-citizen. They |

| |earn a combined income of $35,000. Sandra is pregnant with their first child. Sandra will qualify |

| |for Moms and Babies Medicaid as she has an Eligibility Determination Group of 3 (Sandra, Alex and |

| |the unborn child) and income below 200% of the Federal Poverty Level. Her citizenship status is not |

| |relevant to eligibility for this program. |

ABE: AABD Medicaid

|Eligibility Criteria |U.S. Citizen or Qualified Non-Citizen |

| |Illinois Resident |

| |65 or older, blind or disabled under the Social Security definition |

| |100% Federal Poverty Level |

| |$2000 Single/$3000 Couple Resource Test (excludes home in which you reside and other exclusions) |

|Example(s) |Larry is a 25 year old U.S. Citizen with significant disabilities. His only income is $710 in |

| |Supplemental Security Income. He lives alone and does not file taxes. His only resource is a bank |

| |account with $500 in it. Larry is enrolled in AABD Medicaid for his health insurance. |

| |Lucy and James are married, U.S. citizens, and 79 and 78 years old respectively. They received a |

| |combined $1400 per month in Social Security Retirement. They own their own home and this is where |

| |they both reside. Both Lucy and James are enrolled in Medicare. They are also enrolled in AABD |

| |Medicaid, which provides secondary insurance coverage to their Medicare. This status is often |

| |referred to as “dual eligible” because they are eligible for both Medicare and Medicaid. |

ABE: Health Benefits for Workers with Disabilities Medicaid

|Eligibility Criteria |U.S. Citizen or Qualified Non-Citizen |

| |Illinois Resident |

| |19-64 years old |

| |Working and Paying FICA or SECA |

| |Meet Social Security Administration Disability Criteria (Modified) |

| |350% Federal Poverty Level |

| |$25,000 Resource Test (does not include house in which a person resides or retirement accounts) |

| |Excludes Resources Accumulated While on this Program If Apply for AABD Medicaid in Future |

| |Pay Premium |

|Example(s) |Luther is a 45 year old U.S Citizen. Luther uses a wheelchair and receives $1100 per month in Social|

| |Security Disability Insurance payments. He also works part-time at the local Center for Independent |

| |Living and earns about $1000 per month. He is enrolled in Medicare. He purchases Medicaid through |

| |Health Benefits for Workers with Disabilities for $94 per month. This secondary coverage from Health|

| |Benefits for Workers with Disabilities significantly decreases his monthly medical expenses. |

ABE: Health Benefits for Individuals with Breast and Cervical Cancer

|Eligibility Criteria |U.S. Citizen or Qualified Non-Citizen |

| |Illinois Resident |

| |Age 35-64 |

| |Uninsured |

| |Screened and referred by the Department of Public Health’s Breast and Cervical Cancer Program |

| |Need treatment for breast or cervical cancer |

| |Not otherwise eligible for Medicaid |

|Example(s) |Julia is a U.S. Citizen, 40 years old and married to Jack. She was screened for breast cancer |

| |through her local Public Health department. The screening determined that she had breast cancer. At |

| |the time, she was uninsured so she was connected to Health Benefits for Individuals with Breast and |

| |Cervical Cancer. She continues to receive treatment with this Medicaid insurance. |

Marketplace: Tax Credits

|Eligibility Criteria |U.S. Citizen or lawfully present non-citizen |

| |Not Offered Affordable or Minimum Value Employer Insurance |

| |Not Eligible for Government Insurance (Medicaid, Medicare) |

| |Income Limit to 400% Federal Poverty Level |

| |Access Coverage Through the Marketplace |

|Example(s) |Linda is a U.S citizen and single mother with 2 children. She is self-employed and earns about |

| |$70,000 per year. She claims her two children as dependents on her tax return. She has had |

| |difficulty in the past finding an affordable family health plan. Linda can now choose a plan on the |

| |Marketplace and receive tax credits for this coverage since her income is below 400% of the Federal |

| |Poverty Level. She earns too much money for her children to enroll in All Kids so they will access |

| |insurance through the Marketplace as well. |

Marketplace: Tax Credits and Cost Sharing Subsidy

|Eligibility Criteria |U.S. Citizen or lawfully present non-citizen |

| |Not Offered Affordable or Minimum Value Employer Insurance |

| |Not Eligible for Government Insurance (Medicaid, Medicare) |

| |Income Limit to 250% Federal Poverty Level |

| |Access Coverage Through the Marketplace |

| |Enroll in Silver Plan to receive cost sharing subsidy |

|Example(s) |Mr. and Mrs. Jones are U.S. citizens with three children. Mrs. Jones is pregnant with twins. Mr. Jones earns|

| |$55,000 per year at a job that does not offer health insurance. Ms. Jones does not work outside the home. |

| |Through ABE, Mrs. Jones secures insurance through Moms and Babies and the children are enrolled in All Kids.|

| |Mr. Jones is sent to the Marketplace. On the Marketplace, he is a household of 5 since that is the number in|

| |his tax filing unit. His income is below 250% of the Federal Poverty Level so he qualifies for tax credits |

| |and cost sharing subsidy. He chooses a Silver Plan to utilize all the financial assistance available to him.|

| |Andre immigrated to the U.S. from Mexico three years ago. He is a lawful permanent resident. He works at a |

| |local factory and earns $15,000 a year. He is not offered insurance by his employer. Because Andre has only |

| |been in the U.S. 3 years, he is not a qualified non-citizen and cannot enroll in ACA Adult Medicaid even |

| |though his income is low enough. He can, however, secure insurance on the Marketplace and receive tax |

| |credits and cost sharing subsidy assistance. Andre enrolls in a Silver Plan to utilize all the financial |

| |assistance available to him. |

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To view other MMW materials and resources, including past MMW Bulletin newsletters, fact sheets, and recorded webinars, visit our MMW Coalition webpage at

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