Navigator Manual - 08.29.16

Name:DOB:Social Security #: (include here and on all other attachments)Application ID: INCLUDE ID AND YEAR OF APPLICATIONState: FLTo Whom It May Concerns:I, CONSUMER NAME IN ALL CAPS, am writing this letter in regards to the request of the Marketplace toprovide proof of income. I do not have any source of income. I’m not working or receiving any financialassistance. Thank you for your willingness to help. I have attached a copy of our permanent employmentauthorization cards. Please let me know if anything else is needed. SIGNATURE HERE:____________________________________ CONSUMER NAME TYPED HERE



10/2015Instructions to help you complete the Form ApprovedMarketplace Eligibility Appeal Request Form OMB No. 0938-1213Use the right Complete and mail the correct request form for your appeal.form to requestan appeal • Use this form in the following states: Arizona Kansas New Hampshire South Carolina South Dakota Delaware Louisiana New Mexico Texas Utah Florida Maine North Carolina Virginia Georgia Michigan North Dakota Wisconsin Hawaii Mississippi Ohio Illinois Missouri Oklahoma Indiana Nebraska Oregon Iowa Nevada Pennsylvania • Visit HealthCare.gov/marketplace-appeals to: • Get an appeal request form for other states. • Learn more about Marketplace appeals. • If you have an immediate need for health services and a delay could seriously jeopardize your health, you can ask for an expedited (faster) appeal review. See Section 4. • El Formulario para Apelar la Elegibilidad del Mercado está disponible en español. Para más información visite, CuidadoDeSalud.gov/es/ marketplace-appeals. • To appeal Small Business Health Options Program (SHOP) eligibility, visit HealthCare.gov/marketplace-appeals/shop-decisions/.Timeframe to If you applied in one of the states listed above, you must submit yourrequest an appeal appeal request within 90 days of the date on the Marketplace eligibility determination notice that you’re appealing.How to submit Complete and sign this form, and mail it with copies of any supportingthis form documents to the address shown below.What happens Health Insurance Marketplacenext? Dept. of Health and Human Services 465 Industrial Blvd. London, KY 40750-0061 You may also fax the form to a secure fax line: 1-877-369-0129. You’ll receive all future correspondence about this appeal from the Marketplace Appeals Center. The Marketplace Appeals Center is di erent from the Marketplace which provided your eligibility determination. 1. We’ll send you a notice letting you know that we received your appeal request. If there’s a problem, like if it’s missing information or we need clari cation, we’ll tell you what’s missing and how you can provide additional information. 2. We’ll review your appeal, including all documentation you have provided. We may contact you to request additional information or to discuss your appeal. 3. We may ask if you want to resolve your appeal informally. If you’re satis ed with your informal resolution, you’ll get an informal resolution decision in the mail. 4. If you’re not satis ed with your informal resolution, you can ask us to schedule a hearing for your appeal. Most hearings are held over the phone. If you don’t attend your hearing, your appeal will be dismissed. 5. After your hearing, you’ll get a nal appeal decision.

Additional Language assistance serviceshelp If you need language assistance in a language other than English, you have the right to get help and information in your language at no cost. Call theChoose an Marketplace Call Center at 1-800-318-2596.authorizedrepresentative Accessibility To request an auxiliary aid or service, you can:Questions • Call 1-844-ALT-FORM (1-844-258-3676). TTY users should call 1-844-716-3676. • Send a fax to 1-844-530-3676. • Send an email to: [email protected] • Use this address only to send a letter requesting an auxiliary aid or service: Centers for Medicare and Medicaid Services OYce of Equal Employment Opportunity & Civil Rights (OEOCR) 7500 Security Boulevard, Room N2-22-16 Baltimore, MD 21244-1850 Attn: CMS Alternate Format Team • You have the right to choose an authorized representative to help you with your appeal. This is a trusted person who has your permission to talk with us about your appeal, see your information, and act for you on matters related to your appeal, including getting information about you and signing your appeal request on your behalf. • To appoint an authorized representative, complete and mail the form “Appoint an authorized representative for my appeal,” available at HealthCare.gov/marketplace-appeals/getting-help/. You can also call the Marketplace Appeals Center to request this form. Even if you already completed an authorized representative form for your Marketplace application, you need to complete an additional form for your appeal. If your state isn’t listed above, or to learn more about your appeal, call the Marketplace Appeals Center at 1-855-231-1751. TTY users should call 1-855-739-2231. Hours of operation are Monday through Friday, 7:30 a.m. to 8:30 p.m. Eastern Time (ET); and Saturday, 10 a.m. to 5:30 p.m. ET.Privacy and Use of Your InformationThe Marketplace protects the privacy and security of information about you that you’ve provided. To view the Privacy Act Statement, go to HealthCare.gov/individual-privacy-act-statement/. We’re authorized to collect the information on this form and any supporting documentation, including Social Securitynumbers, under the Patient Protection and Affordable Care Act (Public Law No. 111–148), as amended by the Health Care and Education Reconciliation Act of2010 (Public Law No. 111–152), implementing regulations in 45 CFR part 155, subpart F, and the Social Security Act. For more information about the privacy andsecurity of your information, visit HealthCare.gov/privacy/.Paperwork Reduction Act Disclosure StatementAccording to the Paperwork Reduction Act of 1995 (PRA), no persons are required to respond to a collection of information unless it displays a valid OMB controlnumber. The valid OMB control number for this information collection is 0938-1213. The time required to complete this information collection is estimated toaverage 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review theinformation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Page 1 of 4Marketplace Eligibility Appeal Request Form Form Approved OMB No. 0938-1213 Appeal Request Form – IndividualPlease print in capital letters using black or dark blue ink only.Fill in the circles ( ) like this .SECTION 1: Tell us about the person who’s requesting this appeal (also calledthe “appellant”).1. Name (First name, Middle name, Last name) Date of birth (mm/dd/yyyy)Street address // Apartment or suite numberCity State ZIP code Daytime phone number ()–If other members of your household are appealing, write their names and dates of birth below. Use extra paper, if necessary.Note: The outcome of an appeal could change the eligibility of other members of your household, even if they don’t appeal their owneligibility determinations.2. Name (First name, Middle name, Last name) Date of birth (mm/dd/yyyy)3. Name (First name, Middle name, Last name) // Date of birth (mm/dd/yyyy)4. Name (First name, Middle name, Last name) // Date of birth (mm/dd/yyyy) //SECTION 2: Tell us why you’re appealing.What’s the notice date? (mm/dd/yyyy) (Optional) What’s the Application ID # (printed on the ®rst page of the notice)? (Optional) //Generally, you may appeal the following Marketplace determinations. Check all that apply.The Marketplace determined that I wasn’t eligible for: (Select statements that apply based on your Marketplace eligibilitynotice.) Health coverage through the Marketplace, including Catastrophic coverage Financial assistance (premium tax credits or cost sharing reductions) An exemption from paying the fee for not having health coverage (the individual shared responsibility payment) Enrolling in or changing plans through the Marketplace outside a regular Open Enrollment Period I disagree with the amount of ®nancial assistance (premium tax credits or cost sharing reductions). The Marketplace didn’t provide a timely eligibility determination after I applied for coverage. (Enter the date of your application, if available.) (mm/dd/yyyy) //

Page 2 of 4SECTION 3: Tell us more about why you’re requesting this appeal (optional).Use extra paper, if necessary.SECTION 4: Ask for a faster appeal if you need one.If you have an immediate need for health services, and a delay could seriously jeopardize your life, health, or abilityto attain, maintain, or regain maximum function, you can ask for an expedited (faster) appeal review. I need an expedited appeal. I'll write my reason for this request in the space below.Explain the reason you need an expedited appeal. Use extra paper if necessary. If you're including documents to support yourrequest, send us copies of your documents. Keep all original documents.

Page 3 of 4SECTION 5: SignatureThis information applies for all individuals signing below who are 18 or older.Your approval to let the Marketplace share federal tax information and Social Security Administrationinformation for use during an appeal.During your appeal, we may need to share with you or your authorized representative the information the Marketplace used todetermine your eligibility. This information might include employment income information from a consumer reporting agency,information about income you receive from the Social Security Administration, and federal tax information from the InternalRevenue Service about members of your household, including information from your last ®led federal income tax return. TheMarketplace can’t share federal income tax information or monthly and annual Social Security Bene®t information underTitle II of the Social Security Act from the Social Security Administration to an authorized representative or other individualswithout your consent. Sign below to give your consent.I understand by completing, signing, and dating below, I authorize the Marketplace to disclose to the individuals whosesignatures are provided below as well as any authorized representative any federal tax information in my eligibility record whichwas provided by the Internal Revenue Service. I also consent to the release by the Marketplace of my monthly and annual SocialSecurity Bene®t information under Title II of the Social Security Act to these same individuals along with other information inmy Marketplace eligibility record, collected based on the application I ®lled out (or was completed for me) or that listed me as ahousehold member, and from other data sources like income and employment veri®cation from a consumer reporting agencythat were used to make the Marketplace eligibility determination.I understand I can request a copy of my Marketplace eligibility appeal record during the appeals process.Each adult member of the household must consent to the disclosure of his or her own federal tax information and also consentto the release of monthly and annual Social Security Bene®t information under Title II of the Social Security Act by signing below.The authorization is valid until the earlier of:• The resolution of the appeal; or• My written noti®cation that I want any or all of my authorized representatives removed from this appeal.I’m signing this form under penalty of perjury, which means I’ve provided true answers to all the questions, and I’ve answered tothe best of my knowledge. I know that I may be subject to penalties under federal law if I provide false information. Signature 1. Printed name (First name, Middle name, Last name) Signature Date (mm/dd/yyyy)Signatures of everyone you listed in Section 1 who’s 18 and older //2. Printed name (First name, Middle name, Last name) Date (mm/dd/yyyy)Signature3. Printed name (First name, Middle name, Last name) //Signature4. Printed name (First name, Middle name, Last name) Date (mm/dd/yyyy)Signature // Date (mm/dd/yyyy) //

Page 4 of 4SECTION 5: Signature (Continued)Signatures of any other household members listed on the application for Marketplace coverageEven if they’re not included in this appeal, each adult member of the household who’s 18 and older must consent to thedisclosure of his or her own federal tax information and also consent to the release of monthly and annual Social SecurityBene®t information under Title II of the Social Security Act by signing below.5. Printed name (First name, Middle name, Last name) Date of birth (mm/dd/yyyy)Signature // Date (mm/dd/yyyy)6. Printed name (First name, Middle name, Last name) // Date of birth (mm/dd/yyyy)Signature // Date (mm/dd/yyyy)7. Printed name (First name, Middle name, Last name) // Date of birth (mm/dd/yyyy)Signature // Date (mm/dd/yyyy)8. Printed name (First name, Middle name, Last name) // Date of birth (mm/dd/yyyy)Signature // Date (mm/dd/yyyy) //

Medicare/Medicaid



Medicaid and CHIPFast Facts for AssistersThis Fact Sheet Applies If You: Are a Navigator, non-Navigator assistance personnel (“in-person assister”), or certified application counselor (collectively, an assister) in a state with a Federally-facilitated Marketplace or State Partnership Marketplace Are assisting low-income individuals, families, or children who are uninsured, who are seeking information about health coverage optionsMedicaid and CHIP: OverviewMedicaid and the Children’s Health Insurance Program (CHIP) provide coverage for over 68million low-income individuals, families, and children. Medicaid is a state-administered healthcoverage program for low-income or disabled individuals. CHIP is a state-administered healthcoverage program that provides coverage for low-income children and, in some states, low-income pregnant women who earn too much to qualify for Medicaid and too little to affordprivate health insurance through the Marketplace. Medicaid and CHIP eligibility requirementsand program benefits vary by state. Under the Affordable Care Act, states have the opportunityto extend Medicaid coverage to low-income adults with incomes up to 138% of the federalpoverty level (FPL). As an assister, you should contact your state Medicaid or CHIP agency tolearn about the eligibility requirements and any state-specific rules.Basics of Medicaid EligibilityConsumers’ eligibility for Medicaid depends on several factors including their income level, thenumber of people in their household, their citizenship or immigration status, the state in whichthey live, and, for some people, other factors like whether they are they are disabled, pregnantor have certain medical needs. In all states, Medicaid and CHIP provide health coverage formany low-income families, children, pregnant women, the elderly, and people with disabilities. Insome states the program provides coverage for most adults below a certain income level. In somestates, individuals may still qualify for Medicaid if they are medically needy, even if their incomeexceeds the usual qualifying levels.

The main method for calculating eligibility for Medicaid and CHIP for most populations isModified Adjusted Gross Income (MAGI). This method is generally used to determine theeligibility for children, pregnant women, parents, and single adults enrolled under the new adulteligibility group created by the Affordable Care Act. MAGI is the consumer’s adjusted grossincome plus any tax-exempt Social Security, interest, or foreign income they might have. Forexample, earned wages and unemployment benefits are counted in the MAGI calculation, whilechild support and student loans are not. Household size and composition are important for thepurposes of calculating MAGI and determining Medicaid eligibility. The basic equation forcalculating household size, or the number of individuals in a family, is: Tax Filers + TaxDependents = Household Size.Medicaid ExpansionThe Affordable Care Act helps low-income individuals to obtain health coverage. Under theAffordable Care Act, states have the opportunity to expand Medicaid coverage to low-incomeadults under the age of 65 with incomes of up to 138% of the FPL. There is no deadline forstates to decide if they will expand Medicaid. See Exhibit 1 for more information about who iseligible for Medicaid depending on whether or not a state has expanded Medicaid. Consumersmay still qualify for Medicaid coverage depending on their specific circumstances and shouldapply in order to get an official eligibility determination. Exhibit 1. Medicaid Eligibility Based on Medicaid Expansion, Income, and Household Size Number of people in consumer’s household 123456Medicaid coverage If the state is expanding $15,521 $20,921 $26,321 $31,720 $37,120 $42,520 Medicaid in 2014: Consumer may qualify for Medicaid coverage if their yearly income is below… If the state is not expanding $11,670 $15,730 $19,790 $23,850 $27,910 $31,970 Medicaid: Consumer may not qualify for any Marketplace savings programs if their yearly income is below…Medicaid BenefitsStates establish and administer their own Medicaid programs, and determine the type, amount,duration, and scope of services within broad federal guidelines. Benefits for children must

include the full range of medically necessary services that could be furnished, and, for adults,may vary but generally must be comprehensive in scope.Out-of-Pocket Costs for Medicaid CoverageMedicaid and CHIP offer low-cost or free health coverage for consumers and their families.However, states can impose copayments, coinsurance, deductibles, and other similar chargeson most Medicaid-covered benefits. The amount of these out-of-pocket charges variesdepending on a Medicaid beneficiary’s income. All out-of-pocket charges are based on thespecific state’s defined payment amount for that service. In Medicaid, certain groups, includingchildren, terminally ill individuals, and individuals residing in an institution are exempted fromcost sharing. Refer to your state agency for more specific details about out-of-pocket costsconsumers may have when enrolled in Medicaid. Exhibit 2 details the maximum allowable out-of-pocket costs that beneficiaries at different income levels can expect to pay for certainMedicaid-covered services (unless the state is operating with a waiver of copayment limitationsgranted by CMS). Exhibit 2. Maximum Allowable Copayments Determined by Eligible Population’s Household IncomeServices and <100% FPL 101-150% FPL >150% FPL SuppliesInstitutional Care (e.g., $75 10% of cost 20% of costinpatient hospital,rehab)Non-Institutional Care $4 10% of costs 20% of costs(e.g., physician visits,physical therapy)Non-emergency use $8 $8 No limitof the ER *within 5% aggregate limitPreferred Drugs $4 $4 $4Non-preferred Drugs $8 $8 20% of costApplying for Medicaid

You can help consumers find out whether or not they are eligible for Medicaid in two ways: 1. Through their state's Medicaid website: Help consumers select the specific state in which they are applying for coverage by using the menu at the bottom of this page: HealthCare.gov/medicaid-chip/eligibility/. This menu will direct them to their state’s Medicaid website, and you can help them apply to find out if they qualify for Medicaid. If they qualify, Medicaid coverage can begin immediately and may be effective retroactively. 2. Fill out a Marketplace application: Help consumers complete a Marketplace application to learn about the programs for which they may be eligible. Consumers will include their annual household size and annual income. After filling and submitting the application, the Marketplace will determine eligibility results for both Marketplace and Medicaid coverage. If anyone in the household is eligible for Medicaid or CHIP, the Marketplace will notify the state Medicaid agency. Consumers will be notified by the state Medicaid agency about the next steps that they need to take in order to enroll in Medicaid coverage. It is important to note that if consumers are determined eligible for Medicaid, they are not eligible to receive advance payments of the premium tax credit or cost-sharing reductions, even if they choose to decline Medicaid coverage.Medicaid in Non-Expansion States and the MarketplaceIn addition to being able to apply for Medicaid through the Marketplace, there are other ways inwhich consumers with low or no income can obtain health coverage. In states that have notexpanded Medicaid, a consumer’s coverage options are limited depending on their level ofincome. For example: Most consumers whose income is more than 100% of the FPL will be eligible to purchase a qualified health plan (QHP) through the Marketplace and may be eligible for help lowering the costs of coverage. Consumers who earn less than 100% of the FPL will generally not be eligible for help lowering the costs of a QHP purchased through the Marketplace. They may be eligible for Medicaid, even without the expansion, based on their state’s existing rules. But if they are not eligible, they will not qualify for either of the affordability options under the health care law. See the Medicaid Gap section for more information. Lawfully present immigrants who have an estimated 2014 household income less than 100% of the and who are not eligible for full Medicaid due to their immigration status may be eligible for advance payments of the premium tax credit and lower out-of-pocket costs for QHPs through the Marketplace if they meet all other eligibility requirements. For more information about lawfully present immigrant’s eligibility for Medicaid and other coverage

options, please visit: HealthCare.gov/immigrants/.Medicaid and Minimum Essential CoverageThe Affordable Care Act requires most individuals to obtain minimum essential coverage or topay a fee. Most Medicaid and CHIP coverage is considered to be minimum essential coverage.However, consumers who have certain limited types of Medicaid coverage, such as coveragethat only pays for family planning, emergency medicine, tuberculosis services, or outpatienthospital services, should apply for coverage through the Marketplace, since their Medicaidcoverage is limited and does not qualify as minimum essential coverage. If these consumers donot have coverage through the Marketplace or other complementary coverage, there will belimitations to the health care services that are covered by their Medicaid coverage. Theseconsumers may have to pay a fee for not having minimum essential coverage, but they mayqualify for a hardship exemption. When helping consumers fill out a Marketplace application, ifthey have one of these types of limited Medicaid coverage, make sure that the consumer doesnot check the box saying that they have Medicaid. Instead, the consumer should check “None ofthe above.”Medicaid GapIn states that have not expanded Medicaid, many adults with incomes below 100% of the FPLfall into what is known as a coverage gap. Their incomes are too high to get Medicaid undertheir state’s current rules, but they are too low to qualify for help paying for coverage in theMarketplace. Some populations that may fall into the coverage gap include jobless parents,working parents, and non-disabled, non-elderly childless adults. Below are some options youshould discuss with consumers who fall into this Medicaid gap: Obtain health care services at federally-qualified community health centers. These centers provide services on a sliding scale depending on the individual’s income. Use the following tool to find a community health center near the consumer: HealthCare.gov/lower-costs/low-cost-community-care/. Apply for a hardship exemption from the individual shared responsibility payment (see section below for more information). Purchase catastrophic coverage, which is available for people under 30 years-old and people granted a hardship exemption. Catastrophic plans usually have lower monthly premiums than comprehensive plans, but cover you only if you need a lot of care. They protect you from worst-case scenarios like serious accidents or illnesses. For more information, please see: HealthCare.gov/choose-a-plan/catastrophic-plans/. See what pharmaceutical assistance programs may be available. Some pharmaceutical companies offer assistance programs for the drugs they manufacture. You can help

consumers see if assistance is available for the medications they take by visiting: Medicare.gov Pharmaceutical Assistance Program.Hardship Exemptions from the Individual Shared Responsibility PaymentConsumers who are not eligible for Medicaid because their state did not expand Medicaid maybe eligible for an exemption from the individual shared responsibility payment. If they receive anexemption, consumers will not be responsible for paying a fee for not having health coverage. Aconsumer is eligible for a hardship exemption under the following circumstances: They live in a state that has not expanded Medicaid. They would qualify for Medicaid if the state did expand Medicaid. They would not qualify advance payments of the premium tax credit or cost-sharing reductions on a Marketplace QHP because of their income level.For more information about applying for a hardship exemption, as well as other circumstancesthat would qualify consumers for an exemption, see: HealthCare.gov/exemptions.Medicaid and Immigration StatusImmigrants who are “qualified non-citizens” are generally eligible for Medicaid and CHIPcoverage if they meet their state’s eligibility requirements. See Exhibit 3 for more informationabout the type of immigration statuses that qualify consumers to get Medicaid or CHIPcoverage. Exhibit 3. Qualified Non-Citizens Eligible for Medicaid Lawful Permanent Residents (LPR/Green Card Holder) Asylees Refugees Cuban/Haitian Entrants Paroled into the U.S for at least one year Conditional entrant granted before 1980 Battered non-citizens, spouses, children, or parents Victims of trafficking and their spouse, children, siblings, or parents or individuals with a pending application for victim of trafficking visaHowever, in order to get full Medicaid or CHIP coverage, most LPRs or green card holders havea five-year waiting period. This means they must wait five years after receiving “qualified”

immigration status before being eligible for Medicaid and CHIP. Some lawfully residingimmigrants are exempt from the five-year waiting period, including refugees and asylees. Stateshave the option to remove the five-year waiting period to cover certain lawfully residing childrenand pregnant women who are otherwise eligible for Medicaid or CHIP. In order to see if yourstate has elected to remove the five-year waiting period, please visit:InsureKidsNow.gov/professionals/eligibility/lawfully_residing.html. Individuals who do not havean eligible immigration status and therefore are not eligible for full Medicaid benefits may getlimited Medicaid coverage for emergency services, if they meet all other Medicaid eligibilitycriteria in the state.Some consumers may have been denied eligibility for Medicaid or CHIP because of theirimmigration status. There is a question on the Marketplace application to properly determineeligibility for those individuals with income under 100% of the FPL who are ineligible forMedicaid or CHIP based on immigration status, but who may be eligible for advance paymentsof the premium tax credits. The question is “Were any of these people [individuals applying forcoverage] found not eligible to get Medicaid and the Children’s Health Insurance Program(CHIP), since October 1, 2013?” By answering this question, consumers will be able to continuewith their application and enroll in a plan, if they are otherwise eligible for Marketplace coverage.Tips for Enrolling Consumers in Medicaid or CHIPAssisters can help consumers apply for Medicaid or CHIP using the streamlined Marketplaceapplication available on HealthCare.gov. Consumers can enroll in Medicaid or CHIP year-round,since it is not subject to an annual open enrollment period. The following tips will help to ensurethat consumers and their households receive accurate eligibility determinations and are able toenroll in Medicaid, CHIP or Marketplace coverage. Mixed Eligibility Households: Different members of a household may be eligible for different forms of health coverage (i.e., an applicant may be eligible for a qualified health plan, while the applicant’s child is eligible for CHIP and the applicant’s spouse is eligible for Medicaid due to disability). You should help all household members apply for and enroll in coverage. Income Verification: Make sure that consumers provide accurate income information. Data will be verified with federal sources. If information is incorrect, consumers could owe money back to the government or could be committing fraud. Consumers will receive an eligibility determination or assessment notice from the Marketplace, which may ask consumers to verify and show proof of income. Medically Needy Eligibility: Many states have what are called “medically needy” programs for consumers with significant health needs whose income is too high to otherwise qualify for Medicaid. These consumers can still become eligible by “spending down” the amount of income that is above a particular state's medically needy income

standard. Consumers “spend down” by incurring expenses for medical and remedial care. Once those incurred expenses are subtracted from the person’s annual income and the person’s income is at or below the state’s medically needy income standard, then the person can be eligible for Medicaid. The state Medicaid program then pays for the cost of services that exceed what the individual had to incur in the way of expenses in order to become eligible. Medically Needy and QHP Eligibility: A consumer does not have to accept this type of Medicaid coverage and can instead elect to enroll in a QHP. Consumers are not considered to be eligible for Medicaid and, therefore, do not have minimum essential coverage, until they have met their spend-down amount requirement and Medicaid is picking up the cost of their care. Consumers in this situation should not attest to currently having Medicaid when the Marketplace application asks that question. Medically Needy and Special Enrollment Periods: Consumers have minimum essential coverage once they have met their spend-down amount requirement and Medicaid is covering the cost of their care. However, once the budget period ends, a new spend down cycle will begin with amounts that the consumer will have to reach before Medicaid covers the cost of services. This loss of minimum essential coverage triggers a special enrollment period that consumers may use to enroll in a QHP through the Marketplace. Consumers in this situation should answer “yes” to the Marketplace application question that asks if they recently lost health coverage, and consumers should not attest to currently having Medicaid.Medicaid Enrollees and Special Enrollment PeriodsThere are scenarios in which a special enrollment period may be available for consumers whohave been determined ineligible for Medicaid or CHIP and wish to enroll in Marketplacecoverage outside of the annual open enrollment period. A consumer who applied at either thestate Medicaid agency or the Marketplace, was denied Medicaid, and all three of the followingconditions apply: The consumers’ states did not expand Medicaid. When the consumers first applied, their income was below 100% of the FPL and would have been covered by Medicaid if their state had expanded Medicaid. The consumers experienced an income increase that makes them eligible for a Marketplace plan with advance payments of the premium tax credit or for cost-sharing reductions.The process of accessing these special enrollment periods begins with consumers contactingthe Marketplace Call Center. Once a special enrollment period is activated, consumers have 60

days to select a plan. Coverage effective dates follow the regular effective dates based on thedate of plan selection. For more information, please see: Marketplace.CMS.gov/technical-assistance-resources/seps-for-limited-circumstances.pdf.ScenarioMedicaid Eligibility and Coverage Options in a Non-Expansion State: Michael, a 29 year-old part-time janitor, makes $11,000 per year. He lives in a state that has not expandedMedicaid. Michael is unsure what his options for health coverage are. He is afraid that a QHPthrough the Marketplace will be too expensive, but he does not want to pay the penalty forremaining uninsured. When assisting Michael to find health coverage options, consider thefollowing: If you are not sure what coverage consumers will qualify for, or if their income is close to the eligibility threshold for Medicaid or advance payments of the premium tax credit or cost-sharing reductions, you should help them submit an application through the Marketplace to determine their eligibility. Household size, disability status, and other factors could also make a difference in consumers’ eligibility for Medicaid coverage, even if the state has not expanded Medicaid to low-income, non-elderly adults. Because Michael makes less than 100% of the FPL ($11,670 per year), he does not qualify for financial assistance available through the Marketplace. Michael is eligible for a hardship exemption because he is ineligible for Medicaid based on his state’s decision not to expand. This means he would not be subject to paying a penalty for remaining uninsured. This is because Michael would have been eligible for Medicaid if his state expanded coverage to adults with incomes up to 138% of the FPL. Michael can receive health services at a federally-qualified community health center or the emergency room, if he has an emergency medical condition.Additional ResourcesFor more information visit: Medicaid.gov Available at: https://www.medicaid.gov InsureKidsNow.gov Available at: https://insurekidsnow.gov

CMS.gov: Medicaid in 2014: Background and Tips for Navigators and CACsAvailable at: http://marketplace.cms.gov/technical-assistance-resources/helping-consumers-with-medicaid.pdfHealthCare.gov: Getting Medicaid & CHIP CoverageAvailable at: https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/





Medicare & the Health Insurance MarketplaceThe Health Insurance Marketplace, a key part of the Affordable Care Act, willtake effect in 2014. It’s a new way for individuals, families, and employees of smallbusinesses to get health coverage.If I have Medicare, do I need to do anything?No. Medicare isn’t part of the Marketplace. If you have Medicare, you’re covered anddon’t need to do anything about the Marketplace.The Marketplace won’t affect your Medicare choices or benefits. No matter how youget Medicare, whether through Original Medicare or a Medicare Advantage Plan (likean HMO or PPO), you won’t have to make any changes.Note: The Marketplace doesn’t offer Medicare Supplement Insurance (Medigap)policies or Medicare drug plans (Part D).Does Medicare coverage meet the Affordable Care Act’srequirement that all Americans have health insurance?If you have Medicare Part A (Hospital Insurance), you’re considered covered and won’tneed a Marketplace plan. Having Medicare Part B (Medical Insurance) alone doesn’tmeet this requirement.Can I get a Marketplace plan in addition to Medicare?No. It’s against the law for someone who knows that you have Medicare to sell you aMarketplace plan. This is true even if you have only Part A or only Part B.If you want coverage designed to supplement Medicare, visit Medicare.gov to learnmore about Medigap policies. You can also visit Medicare.gov to learn more aboutother Medicare options, like Medicare Advantage Plans.

Can I choose Marketplace coverage instead of Medicare?Generally, no. As noted above, it’s against the law for someone who knows you haveMedicare to sell you a Marketplace plan. However, there are some situations whereyou can choose Marketplace coverage instead of Medicare: enrolled in it (because you would have to pay a premium, or because you’re not collecting Social Security benefits). and get a Marketplace plan.Before making either of these choices, there are 2 important points to consider:1. If you enroll in Medicare after your initial enrollment period ends, you may have to pay a late enrollment penalty for as long as you have Medicare.2. Generally, you can enroll in Medicare only during the Medicare general enrollment period (from January 1—March 31). Your coverage won’t begin until July of that year.What if I become eligible for Medicare after I join aMarketplace plan?You can get a Marketplace plan to cover you before your Medicare begins. You canthen cancel the Marketplace plan once your Medicare coverage starts.Once you’re eligible for Medicare, you’ll have an initial enrollment period to sign up.For most people, the initial enrollment period for Medicare starts 3 months beforetheir 65th birthday and ends 3 months after their 65th birthday.In most cases it’s to your advantage to sign up when you’re first eligible because: Marketplace plan based on your income. pay a late enrollment penalty for as long as you have Medicare.Note: You can keep your Marketplace plan after your Medicare coverage starts.However, once your Part A coverage starts, any premium tax credits and reduced cost-sharing you get through the Marketplace will stop.

If I have Medicare, can I get health coverage from anemployer through the SHOP Marketplace?Yes. Coverage from an employer through the SHOP Marketplace is treated the sameas coverage from an employer group health plan. If you’re getting health coveragefrom an employer through the SHOP Marketplace based on you or your spouse’scurrent employment, Medicare Secondary Payer rules apply. Visit Medicare.gov tolearn more about how Medicare works with other insurance.If I’m getting health coverage from an employer through theSHOP Marketplace, can I delay enrollment in Part B without apenalty?Yes. You can delay enrollment if you’re getting health coverage from an employerthrough the SHOP Marketplace based on you or your spouse’s current employment.You have a Special Enrollment Period to sign up for Part B without penalty: spouse’s current employment. the coverage ends, whichever happens first.If you don’t sign up during this Special Enrollment Period: from January—March with coverage beginning July 1.Can I get a stand-alone dental plan through the Marketplace?In most cases, no. If the Marketplace in your state is run by the federal government,you won’t be able buy a stand-alone dental plan for 2014. If your state is running itsown Marketplace, you may be able to purchase a stand-alone dental plan for 2014, ifone is available.Will Medicare Advantage plans still be available after theMarketplace starts?Yes. The Medicare Advantage program isn’t changing as a result of the AffordableCare Act.

Is prescription drug coverage through the Marketplaceconsidered creditable prescription drug coverage for MedicarePart D?While prescription drug coverage is an essential health benefit, prescription drugcoverage in a Marketplace or SHOP plan isn’t required to be at least as goodas Medicare Part D coverage (creditable). However, all private insurers offeringprescription drug coverage, including Marketplace and SHOP plans, are required todetermine if their prescription drug coverage is creditable each year and let you knowin writing. Visit Medicare.gov for more information about creditable coverage.How can I get help paying for my Medicare costs? Program. Call your state Medical Assistance (Medicaid) office. To get their phoneWhere can I get more information? explore new health plan options, tell them to visit HealthCare.gov. CMS Product No. 11694 December 2013

A Quick Lookat Medicare

What is Medicare?Medicare is health insurance for:■ People 65 or older■ People under 65 with certain disabilities■ People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)What are the different parts of Medicare?Medicare Part A (Hospital Insurance) helps cover:■ Inpatient care in hospitals■ Skilled nursing facility care■ Hospice care■ Home health careMedicare Part B (Medical Insurance) helps cover:■ Services from doctors and other health care providers■ Outpatient care■ Home health care■ Durable medical equipment■ Some preventive servicesMedicare Part C (Medicare Advantage):■ Includes all benefits and services covered under Part A and Part B■ Run by Medicare-approved private insurance companies■ Usually includes Medicare prescription drug coverage (Part D) as part of the plan■ May include extra benefits and services for an extra costMedicare Part D (Medicare prescription drug coverage):■ Helps cover the cost of prescription drugs■ Run by Medicare-approved private insurance companies■ May help lower your prescription drug costs and help protect against higher costs in the future

What are my Medicare coverage choices?ere are 2 main ways to get your Medicare coverage—Original Medicareor a Medicare Advantage Plan. Use these steps to help you decide whichway to get your coverage. STARTSTEP 1: Decide how you want to get your coverage.ORIGINAL MEDICARE or MEDICARE ADVANTAGE PLAN Part C (like an HMO or PPO)Part A Part BHospital Medical Part CInsurance Insurance Combines Part A, Part B, and usually Part DSTEPS2t:eDpe2c:idDeecifidyeouif nyeoeudnteoed STEP 2: Decide if you need to addtodraudgdcdorvuegracgoev.erage. add drug coverage. Part D Part D Prescription Prescription Drug Coverage Drug Coverage (Most MedicareSTEP 3: Decide if you need to add Advantage Plans cover supplemental coverage. prescription drugs. You may be able to Medicare add drug coverage in Supplement some plan types if not Insurance already included.) (Medigap) policy END END If you join a Medicare Advantage Plan, you can’t use or be sold a Medicare Supplement Insurance (Medigap) policy.

Get the help you need Call 1-800-MEDICARE (1-800-633-4227) to get general or specific Medicare information and important phone numbers. If you need free help in a language other than English or Spanish, say “Agent” to talk to a customer service representative. TTY users should call 1-877-486-2048. Visit Medicare.gov to get detailed information about the Medicare health and prescription drug plans in your area, find participating health care providers and suppliers, get quality of care information, and more. Look at your most recent “Medicare & You” handbook to learn what’s new, find out your Medicare costs, and get information about what Medicare covers. Contact your local State Health Insurance Assistance Program (SHIP) to get free personalized counseling on Medicare coverage, claims, appeals, and help for people with limited income and resources. Visit shiptacenter.org, or call 1-800-MEDICARE to get the phone number for your local SHIP. Visit the Eldercare Locator at eldercare.gov to find local resources, check for benefits, and plan for long-term care. CMS Product No. 11514 Revised August 2015

2016 Medicare CostsMedicare Part A (Hospital Insurance) CostsPart A Monthly PremiumMost people don’t pay a Part A premium because they paid Medicaretaxes while working. If you don’t get premium-free Part A, you pay upto $411 each month.Hospital StayIn 2016, you pay ■ $1,288 deductible per benefit period ■ $0 for the first 60 days of each benefit period ■ $322 per day for days 61–90 of each benefit period ■ $644 per “lifetime reserve day” aſter day 90 of each benefit period (up to a maximum of 60 days over your lifetime)Skilled Nursing Facility StayIn 2016, you pay ■ $0 for the first 20 days of each benefit period ■ $161.00 per day for days 21–100 of each benefit period ■ All costs for each day aſter day 100 of the benefit periodMedicare Part B (Medical Insurance) CostsPart B Monthly PremiumYou pay a Part B premium each month. Most people who get SocialSecurity benefits will continue to pay the same Part B premiumamount as they paid in 2015. is is because there wasn’t a cost-of-living increase for 2016 Social Security benefits. You’ll pay a differentpremium amount in 2016 if: ■ You enroll in Part B for the first time in 2016. ■ You don’t get Social Security benefits. ■ You’re directly billed for your Part B premiums. ■ You have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard premium amount of $121.80.) ■ Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount.

If you’re in 1 of these 5 groups, here’s what you’ll pay:If your yearly income in 2014 was You pay (in 2016)File individual File joint File married & separate tax $121.80tax return tax return return $170.50 $243.60$85,000 or less $170,000 or less $85,000 or less $316.70 $389.80above $85,000 above $170,000 N/Aup to $107,000 up to $214,000above $107,000 above $214,000 N/Aup to $160,000 up to $320,000above $160,000 above $320,000 above $85,000up to $214,000 up to $428,000 up to $129,000above $214,000 above $428,000 above $129,000If you have questions about your Part B premium, call Social Securityat 1-800-772-1213. TTY users should call 1-800-325-0778. If you pay alate enrollment penalty, these amounts may be higher.Part B Deductible—$166 per yearMedicare Advantage Plans (Part C) andMedicare Prescription Drug Plans (Part D)PremiumsVisit Medicare.gov/find-a-plan to get plan premiums. You can alsocall 1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048. You can also call the plan or your State HealthInsurance Assistance Program.

Part D Monthly Premiume chart below shows your estimated prescription drug plan monthlypremium based on your income. If your income is above a certainlimit, you will pay an income-related monthly adjustment amount inaddition to your plan premium.If your yearly income in 2014 was You pay (in 2016)File individual File joint File married & separate tax returntax return tax return$85,000 or less $170,000 or less $85,000 or less Your plan premiumabove $85,000 above $170,000 N/A $12.70 + yourup to $107,000 up to $214,000 plan premiumabove $107,000 above $214,000 N/A $32.80 + yourup to $160,000 up to $320,000 plan premiumabove $160,000 above $320,000 above $85,000 $52.80 + yourup to $214,000 up to $428,000 up to $129,000 plan premiumabove $214,000 above $428,000 above $129,000 $72.90 + your plan premium2016 Part D National Base Beneficiary Premium — $34.10is figure is used to estimate the Part D late enrollment penalty andthe income-related monthly adjustment amounts listed in the tableabove. e national base beneficiary premium amount can changeeach year. See your Medicare & You handbook or visit Medicare.govfor more information.For more information about Medicare costs, visit Medicare.gov.

CMS Product No. 11579Revised December 2015

Helpful Websites: Information on Public Assistance BenefitsIf you have questions about theMedically Needy Program or otherPublic Assistance benefits, want to see alist of our service centers, fax numbersor apply for benefits, visit our website:www.myflorida.com/accessfloridaMedical Coverage for Childrenunder age 19:www.Floridakidcare.orgORwww.healthykids.orgThe following websites provide informationon various programs for free or low costprescriptions for certain medications:www.benefitscheckup.orgwww.medicare.govwww.pparx.orgwww.needymeds.comwww.rxassist.orgwww.aarp.org/flwww.togetherrxaccess.comwww.nacds.orgYou may contact the Elder Helpline at(800) 963-5337. CF/PI 165-7

Department of Children and Families Medically Needy Program An Explanation of “Share of Cost”70, Jul 2015

Department of Children and FWhat is the Medically Needy Program? Some examples of medi be used to meet the “shThe Department of Children and Families (DCF) • Unpaid medical bills owdetermines eligibility for the Medically Needy used to meet the share oProgram. It may also be referred to as the “Share of • Medical bills the individCost” program. The Medically Needy Program three months.assists individuals who would qualify for Medicaid • Health insurance premexcept for having income that is too high. • Medical bills that will n insurance or any other soWhat is a “share of cost”? • Co-pays for medical bill • Medical services prescrIndividuals enrolled in Medically Needy may • Transportation by ambuhave a monthly “share of cost”, which is similar get medical care.to an insurance deductible. The share of cost isdetermined by household size and gross Some examples of medimonthly income. When there are changes to cannot be used to meetthe household size and income, the share of • Premiums for insurancecost amount may change. the individual money for • Over the counter medicHow does the “share of cost” work? bandages, cold remediesSubmit any allowable unpaid or paid medical Whose medical expenseexpenses to DCF to determine if the share of the “share of cost”?cost has been met. Once the allowable medical Allowable medical expenexpenses equal the share of cost, the individual meet the share of cost fois eligible for Medicaid for the rest of that member whose incomemonth. considered to determine even if that individual isExample #1: Your share of cost is $800. You go to the hospitalon May 10 and send us the bill for $1000. You have met your More information aboutshare of cost. If the provider accepts Medicaid, that bill will be Visit our web address bepaid and you will be eligible for Medicaid through the end of information about the MMay. to apply for benefits, or a centers and fax numbersExample #2: Your share of cost is $800. You go to the hospitalon May 10 and receive a bill for $750. On May 12 you go to the www.myflorida.cophysician and receive a bill for $150. You send us both bills.Your share of cost was met on May 12th because the total of thetwo medical expenses were more than the amount of yourshare of cost. If the provider accepts Medicaid, the May 12thbill will be paid and you will be eligible for Medicaid throughthe end of May. (These are only examples.)

Families Medically Needy Program ical expenses that can WHohwat ttoo sduobwmhitepnryoouf omfemeet dthiceal“sehxapreenosefsc?ost” hare of cost” Proof of medical expenses can be submitted by wed that have not been fax, mail, or in person. Be sure to include your of cost before. name and case number on medical expenses. dual paid within the last Some examples of proof of medical expenses are:miums • Medical bills an individual received. not be paid by health • Receipts for medical bills. ource. • Cancelled checks for paid medical bills. ls. ribed by a doctor. Visit www.myflfamilies.com/access-service- ulance, bus or taxi to centers for a listing of service center locations and fax numbers.ical expenses that What services are covered by Medicaid? the “share of cost”e policies that pay For additional information about the Medicaidr hospitalization program, visit: www.ahca.myflorida.com/medicaidcal supplies, such ass, etc. es can be used to meet Important Information nses can be used to Important Information or any household Some medical providers do not accept Medicaid and needs are or Medically Needy. e Medicaid eligibility, not Medicaid eligible. Remember to tell your provider that you are on Medically Needy before making an appointment. t “share of cost” programelow for additionalMedically Needy Program, a listing of DCF service s.om/accessflorida

Immigration



Updated December 3, 2015Key Facts You Need to Know About:Immigrant Eligibility for Health InsuranceAffordability ProgramsMany individuals who are lawfully present in the United States are eligible for healthcoverage through Medicaid, the Children’s Health Insurance Program (CHIP), or subsidizedplans in federal and state marketplaces. All U.S. citizens are eligible for these coverageprograms, but eligibility rules for non-U.S. citizens differ for each program.What are the immigration status • Lawful Permanent Residents (LPRs, greenrequirements for Medicaid and CHIP? card holders)Immigrant eligibility requirements for Medicaid • Refugeesand CHIP originate from the PersonalResponsibility and Work Opportunity • Persons granted asylumReconciliation Act (PRWORA) of 1996. PRWORAcreated two categories of immigrants used in • Persons granted withholding ofdetermining Medicaid eligibility: “qualified” and deportation/removal, or conditional entrants“not qualified” immigrants. In general,immigrants must be in a qualified status to be • Cuban/Haitian entrantseligible for Medicaid and CHIP. However, evenqualified immigrants may not be eligible because • Individuals paroled into the United States, forthey have not met a five-year waiting period after a period of at least one yearthey obtain qualified status. Individuals who arenot eligible for Medicaid because of their • Certain domestic violence survivors and theirimmigration status may be eligible for Medicaid children and/or parentspayment of emergency services, and some maybe eligible for marketplace coverage. Additionally, • Certain trafficking survivors and in somestates have the option to adopt broader eligibility cases their spouses and children (for adultrules for immigrant children and pregnant women. victims) and spouses, children, parents and minor siblings (for child victims).Which categories of immigrants are“qualified” immigrants? All other immigrants are considered not qualified for purposes of Medicaid and CHIP eligibility.Categories of immigrants with qualified statusinclude:

Are qualified immigrants eligible for Can states have less restrictiveMedicaid or CHIP immediately upon eligibility requirements forobtaining a qualified status? immigrants?In general, qualified immigrants who entered the Yes. States have the option to provide MedicaidU.S. on or after August 22, 1996 must wait five and CHIP coverage to “lawfully present” childrenyears after obtaining a qualified status before and/or pregnant women. The term lawfullybecoming eligible for Medicaid or CHIP. This is present includes all qualified immigrants, as welloften referred to as the “five-year bar.” However, as many other types of immigrants who havethere are exceptions. The following qualified permission to live or work in the United States.immigrants do not have to meet the five-year (See Table 1 for a full list of immigration statuseswaiting period requirement: considered lawfully present for the purpose of enrollment in insurance affordability programs). • Refugees States can also use CHIP funding to provide • Asylees prenatal care to women who are otherwise ineligible for Medicaid and/or CHIP under the • Individuals granted withholding of CHIP unborn child option regardless of their deportation/removal immigration status. In addition, some states use state or county funds to provide Medicaid and • Cuban/Haitian entrants CHIP to other groups, such as lawfully present immigrants who do not have qualified status and • Amerasian immigrants to children who are undocumented.2 • Trafficking survivors What are the immigration requirements to enroll in a • Iraqi or Afghan special immigrant status marketplace plan? • Veterans or individuals on active military duty Only lawfully present individuals can enroll in a and their spouse (un-remarried surviving marketplace plan. (See Table 1 for a list of spouse), or child immigration statuses that are considered lawfully present for the purpose of marketplace eligibility). • Certain American Indians born abroad In general people permitted under the law to be in the U.S. meet the requirement, but there are • Individuals receiving Foster Care, and in most some exceptions. An important exception is states, Supplemental Security Income individuals granted deferred action under the recipients Deferred Action for Childhood Arrivals (DACA) program. The U.S. Department of Homeland It is important to note that a few states restrict Security can grant temporary administrative relief eligibility for some qualified immigrant adults even after the five-year wait.1 2 Center for Medicaid and State Operations, State Health Official Letter #09-006, May 8, 2009:1 For more information on how states restrict coverage, www.medicaid.gov/Federal-Policy-see footnotes 6 and 7 on the National Immigration Law Guidance/downloads/SHO050809.PDF.Center document, “Overview of Immigrant Eligibility forFederal Programs, available at:nilc.org/document.html?id=108.2

Table 1: “Lawfully Present” Immigration Categories Eligible for Marketplace Coverage All “Qualified” ImmigrantsLawful Permanent Resident (LPR/green card holder) Battered Spouse, Child and ParentRefugee Trafficking Survivor and his/her Spouse, Child, Sibling orAsylee ParentCuban/Haitian Entrant Granted Withholding of Deportation or Withholding ofParoled into the United States RemovalConditional Entrant Certain American Indians PLUS Other Lawfully Present ImmigrantsGranted relief under the Convention Against Torture (CAT) Individual with Nonimmigrant Status (includes workerTemporary Protected Status (TPS) visa; student visas; U visas; citizens of Micronesia, the Marshall Islands, and Palau; and many others)Deferred Enforced Departure (DED) Administrative order staying removal issued by theDeferred Action* Department of Homeland Security Lawful Temporary Resident*EXCEPTION: Individuals granted deferred action under the Deferred Action for Childhood Arrivals (DACA) programare not eligible to enroll in coverage in the Marketplace Applicant For Any Of These StatusesLawful Permanent Resident (LPR/green card holder) Victim of Trafficking VisaSpecial Immigrant Juvenile Status Withholding of Deportation or Withholding of Removal,Asylum* under the immigration laws or under the Convention Against Torture (CAT)**Only those who have been granted employment authorization or are under the age of 14 and have had anapplication pending for at least 180 days are eligible With Employment AuthorizationApplicant for Temporary Protected Status Applicant for Cancellation of Removal or Suspension of DeportationRegistry ApplicantsOrder of Supervision Applicant for Legalization under IRCA Legalization under the LIFE ActSource: Health Insurance Marketplace, www.healthcare.gov/immigrants/immigration-statusfrom deportation, which is referred to as deferred What are the immigrationaction, for a variety of reasons. While individuals requirements for premium tax creditsgranted deferred action are generally eligible to and cost sharing reductions in theenroll in marketplace coverage, DACA recipients marketplace?are excluded and not eligible to enroll in amarketplace plan. People who are lawfully present are eligible to purchase marketplace coverage. Once these requirements are met, individuals who don’t have other minimal essential coverage may also qualify3

for premium tax credits and cost sharing portion of income he will contribute is the same asreductions if they meet financial requirements. for individuals with incomes at 100 percent of the poverty line, which is 2.03 percent of income3.In general, only individuals with incomes between For example, if his income is $10,000, then his100 and 400 percent of the poverty line are expected premium contribution is $203 per yeareligible for premium tax credits. However, an (2.03 percent of $10,000). His premium taxindividual who is lawfully present and not eligible credit will be the cost of the second-lowest silverfor Medicaid because of her immigration status plan available to him minus his expectedcan qualify for premium tax credits even if her contribution.income is below the poverty line (for example, alawfully present immigrant who is not qualified or Because he is treated as if his income is at 100is qualified but in the five-year waiting period). percent of the federal poverty line, he wouldWhile Medicaid income eligibility differs in states qualify for a cost sharing reduction, which wouldthat expand and those who do not, eligibility for raise the actuarial value of his plan to 94 percent.premium tax credits for lawfully present He would need to purchase a silver plan to receiveimmigrants with incomes below the poverty line is the cost-sharing reduction, which wouldnot affected by a state’s decision on Medicaid significantly lower his deductible, copayments,expansion (see Figure 1). and other out-of-pocket costs. (For more information on premium tax credits and costHow are premium tax credits sharing reductions, please see Key Facts Youcalculated for lawfully present people Need to Know About: Premium Tax Credits andwith incomes below the poverty line? Key Facts You Need to Know About: Cost-Sharing Reductions.)For the purposes of determining a person’sexpected contribution to the cost of coverage, the Figure 1:Coverage Landscape for Families That Include ImmigrantsIn States Expanding Medicaid In States Not Expanding Medicaid3 This percentage is indexed and will change eachenrollment year.4

What options for coverage doundocumented individuals have?Undocumented individuals and individualsexcluded from insurance affordability programsuch as those in the DACA program are eligible forMedicaid payment for services in situationsdefined as emergencies in the Medicaid law,including labor and delivery. They are not eligibleto purchase health insurance through themarketplace, but they may obtain privatecoverage outside the marketplace with nogovernment-sponsored subsidy.There are no immigration status requirements forcertain public health services includingimmunizations as well as services provided byFederally Qualified Health Centers, migrant andrural health centers, and hospital charity care. Inaddition, some states provide coverage ofprenatal services to women regardless ofimmigration status, and a few states and localgovernments extend health coverage toundocumented children and/or some non-citizenadults using state funds.Undocumented individuals also can sign up foremployer-sponsored insurance if their employeroffers it.5



NATIONAL IMMIGRATION LAW A Quick Guide to Immigrant Eligibility for AC JANUARYFOR MORE DETAILED INFORMATION: immigrant eligibility for federal programs, www.nilc.org/table_ofunded food assistance, www.nilc.org/state_food.html; state-funded TANF replacements, www.n PROGRAM LAWFUL PERMANENT LAWFUL PERMANENT LAW RESIDENTS RESIDENTS PERMACA – Health Care RESIReform Subsidies (age 18 and over) (under age 18) (pregna(premium tax credits and cost-sharing If entered the U.S. on or after Aug reductions) Eligible Eligible Eli SNAP Not eligible Eligible Not MEDICAID until after 5-year waiting State option3 until after 5 CHIP period or have credit for 40 period or h to provide without a TANF quarters of work 5-year waiting period 2 40 quart SSI Not eligible State option State until after 5-year waiting to provide without a to provid period 2 5-year waiting period 5-year wa Not eligible Not eligible State until after 5-year waiting until after 5 year waiting to provid period period 5 5-year wa Not eligible Not eligible Not until after 5-year waiting until after 5-year waiting until after 5 period 5 period and pe Not eligible have credit for 40 Not quarters of work or meet until after 5-year waiting until after 5 period and have credit for another exception period an for 40 qua 40 quarters of work or meet another exception1 Also includes Cuban/Haitian entrants, Amerasian immigrants, Iraqi or Afghan special immigrants,2 In a few states, remain ineligible after 5 years unless have credit for 40 quarters of work history or3 Eligible if receiving federal foster care.4 A few states terminate Medicaid to humanitarian immigrants after a 7-year period, and/or TANF a5 At least a dozen states use their maintenance of effort funds to provide TANF without a waiting p

W CENTER | WWW.NILC.ORGCA and Key Federal Means-tested ProgramsY 29, 2013 ovrw_fedprogs.html; medical assistance programs, www.nilc.org/document.html?id=159; state- nilc.org/guide_tanf.html; state-funded SSI replacements, www.nilc.org/document.html?id=475. WFUL REFUGEES, LAWFULLY PRESENT UNDOCUMENTEDMANENT INDIVIDUALS IMMIGRANTS IDENTS ASYLEES, VICTIMS Eligible (including children andant women) OF TRAFFICKING, pregnant women) OTHERS1 Not eligible Not eligiblegust 22, 1996: State option Also not eligible forigible Eligible for children under 21 and full-priced health pregnant women only insurance in the eligible Eligible Exchange marketplace State option 5-year waiting Eligible4 Not eligiblehave credit for for children under 21 andters of work Eligible pregnant women Eligible only for emergencye option Eligible4 Not eligible Medicaid Not eligiblede without a Only eligible Not eligibleaiting period 2 Not eligible during first 7 yearse option after status is granted Not eligiblede without a aiting period eligible 5-year waitingeriod 5 eligible 5-year waitingnd have creditarters of work and individuals granted withholding of deportation or removal. r are a veteran, active duty military, or his or her spouse/child. after a 5-year period.period.