Update, September 13. The Centers for Medicare and Medicaid Services issued more new and revised guidance during the second week of September, 2014. First, CMS released a series of slides describing the streamlined application process that it is phasing in for the 2015 open enrollment period. Under this system, all applicants (including for now special enrollment period applicants) will be asked a series of initial screening question.
Those who are identified as having a simple household situation will be directed to a streamlined process with fewer screens and clicks. For example, an early question about income range will help individuals who are unlikely to get financial assistance to decide whether or not to apply for financial assistance, and avoid further financial assistance questions if they decide not to request assistance. Those with more complex situations will be directed to the traditional process. The streamlined process is also only available to first time applicants, not to individuals reporting a change, who will use the traditional application.
The new process is not only shorter, but also has backward navigation capability and is optimized for mobile users. CMS expects 70 percent of applicants to use the streamlined application; 30 percent the traditional. The new process is being phased in beginning the first week of September and will be fully rolled out for the 2015 open enrollment period in November.
CMS also, on September 12, released revised versions of Guidance Bulletin 10 on grace periods when individuals are terminated for non-payment of premiums and their enrollment through the federally facilitated marketplace spans two benefit years, and Guidance Bulletin 11 dealing with individuals terminated because of data matching errors. The original versions of Bulletin 10, issued on July 16, and Bulletin 11, issued on August 13 were discussed in earlier posts.
In general, an individual terminated from coverage through the federal exchange for non-payment of premiums is closed out of coverage until the next open enrollment period unless he or she qualifies for a special enrollment period. The individual may enroll in coverage for the next coverage year, however, if he or she reenrolls and pays the first month’s premium. Any premiums paid for coverage for the next year are credited to that year and cannot be claimed by the insurer to cover premiums owing for the previous year.
This much is clear. But problems arise when the three-month grace period that an individual is afforded to catch up on unpaid premiums spans two years; for example, the individual ceased paying premiums in November and is either auto-enrolled or chooses a plan for 2015 but is not caught up with paying premiums by the end of December. The Bulletin works through a number of possible situations that can arise involving grace periods that span two years or that end on December 31. The revised Bulletin is generally consistent with the original bulletin, but clarifies what transactions are classified as renewals and how the grace period interacts with enrollment transactions that meet the definition of renewal.
Bulletin 11 deals with individuals who are terminated from federally facilitated exchange coverage because they fail to produce documentation to resolve inconsistencies involving their citizenship or lawful alien status. Individuals affected by data matching issues had until September 5 to submit required documentation, and will be terminated from coverage on September 30 if they failed to do so. Under the original Bulletin 11, individuals who attested that they had in fact submitted documentation before September 5 that did in fact resolve the inconsistency could qualify for a special enrollment period and retroactive coverage even if that documentation was not received. Individuals who submitted required documentation that resolved inconsistencies within 60 days after termination would qualify for a special enrollment period, but only for prospective coverage, with a likely gap in coverage.
Under the revised Bulletin 11, any individual terminated because of data matching issues may re-enroll in coverage by producing sufficient documentation to resolve the inconsistency. If found eligible, the individual’s coverage may be reinstated retroactively to avoid gaps in coverage. Alternatively, the individual may request prospective coverage. If the individual selects the same coverage that he or she had previously, any amounts paid out-of-pocket will be credited toward deductibles or out-of-pocket limits. This change effectively allows any individual terminated from coverage for data matching issues to resume coverage if the individual provides appropriate documentation.
Original post. The decision of the full D.C. Circuit to review the panel decision in Halbig v. Burwell en banc was clearly the big Affordable Care Act (ACA) court decision of the first week in September, but a September 2 decision of the federal district court of the Middle District of Tennessee, Gordon v. Wilson, is also worthy of note.
The Medicaid law has long required state Medicaid programs to determine eligibility for Medicaid with “reasonable promptness,” defined by the regulations to mean within 90 days for applicants with disabilities and 45 days for everyone else. Applicants whose applications are not determined reasonably promptly are entitled by the Medicaid law and by the Due Process Clause of the Constitution to a fair hearing.
Medicaid Eligibility and Tennessee
Tennessee, like all states, was required by the ACA to begin calculating Medicaid eligibility for most recipients using modified adjusted gross income, or MAGI as of January 1, 2014. Tennessee attempted to establish a new computer system for doing this, but when it was not ready by January 1, Tennessee asked the federal exchange to determine Medicaid eligibility until it could get its system operational. Read the rest of this entry »