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Transcript of Navigating TennCare & the Marketplace Tennessee Justice Center 301 Charlotte Ave | Nashville, TN,...
![Page 1: Navigating TennCare & the Marketplace Tennessee Justice Center 301 Charlotte Ave | Nashville, TN, 37201 615-255-0331 Day 2: Puttin’ it to the Test 10/9/2014.](https://reader036.fdocuments.us/reader036/viewer/2022062422/56649de45503460f94adb054/html5/thumbnails/1.jpg)
Navigating TennCare & the Marketplace
Tennessee Justice Center301 Charlotte Ave | Nashville, TN, 37201
615-255-0331
Day 2: Puttin’ it to the Test
10/9/2014
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AgendaDay 1• Pre-Test• Counting Income• Counting Household
Size• TennCare Categories
Day 2• Scenarios• Marketplace Basics• Scenarios• Wilson v. Gordon• Scenarios• Post-Test
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Scenario: Wally “Whitey” White• Whitey became disabled in his
late 20’s and has no children. • He used to receive SSI, but
started getting Social Security at $751/month when he turned 62 in November of 2013.
• He has $500 in a savings account. He rents his home and has no other assets.
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What is Wally
eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
What is the household size for each person for Marketplace purposes?
Same household counting as above.
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Whitey is in a household by himself.
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Step 3: IncomeIncome for household of 1 is $751/month.
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So who’s eligible for what?• Whitey?– Gap– …or… maybe… could it be…
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Pickle Eligibility
$751 x .985 = $739.74
-$20 unearned income disregard = $719.74!
Whitey can get TennCare through Pickle!
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Advocacy Tips• Apply on the Marketplace and follow-up with
THC.• Many folks who are on Medicare don’t know
that they are eligible for pickle.
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Scenario: Lamar• Lamar is a 62 year old widow who retired
early. He gets a Social Security check of $950 per month. This is his only source of income.
• He has a Qualified Income Trust (QIT) worth $40,000. Also, he has a burial fund worth $5,500.
• Soon after he retired, he learned that he has progressive bone cancer. He’s getting some treatment through a hospital charity program, but he continues to deteriorate quickly.
• His daughter, Tandy, has moved in with him to take care of him.
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What is he eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
What is the household size for each person for Marketplace purposes?
Same household counting as above.
Lamar (poor fella, all on his own!)
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Step 3: IncomeIncome for household of 1 is $950/month.
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So who’s eligible for what?• Lamar?– Maybe CHOICES – what else do we need to
know?
• Resources?QIT and burial fund (up to $6000) are non-countable resources.• Needs help with activities of daily living?Lamar says he needs help with mobility and transfer.
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How do you apply for CHOICES?• Call local Area Agency on Aging and Disability.• Need to go through an evaluation. Many
times, people “fail” this the first time. If that happens…
•Appeal!–Appeal form in back of toolkit.
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Practice Tips• CHOICES is a common alternative for people who are
in the Gap, because it is a doorway to Medicaid. If you have a client who needs help with even 1 activity of daily living and is within income and resource limits of CHOICES, he/she could qualify for CHOICES 3.
• If you’re denied the right to an assessment for CHOICES, you have the right to appeal.
• Counting resources for CHOICES can be tricky. Sometimes, folks may want to speak to an elder law lawyer about their resources.
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Marketplace Basics
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What’s my role?• Unless you are a CAC or Navigator, you cannot
hold yourself out as one.• You also cannot recommend a specific plan. • This is training does not provide you with any
type of certification (just tons of helpful info!).
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Premium Tax Credits
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Who is Eligible?Individuals and families with income between 100% and 400% FPL
• Must be lawfully present in the U.S.• Must not be eligible for other “minimum essential
coverage”
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FPL and Eligibility
FPL Affordability Program
Annual Income by Household Size
1 2 3 4
100% FPL Medicaid (?) $ 11,670 $ 15,730 $ 19,790 $ 23,850
138% FPL Medicaid (?) $ 16,105 $ 21,707 $ 27,310 $ 32,913
150% FPL PTC & CSR1 $ 17,505 $ 23,505 $ 29,685 $ 35,775
200% FPL PTC & CSR2 $ 23,340 $ 31,460 $ 39,580 $ 47,700
250% FPL PTC & CSR3 $ 29,175 $ 39,325 $ 49,475 $ 59,625
300% FPL PTC $ 35,016 $ 47,184 $ 59,376 $ 71,556
400% FPL PTC $ 46,680 $ 62,920 $ 79,160 $ 95,400
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Second-cheapest Silver plan –– expected contribution
____________________________________________
Premium Tax Credit amount
How is the Amount of the Tax Credit Determined?
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How is the Amount of the Tax Credit Determined?
Your PTC is based on your expected premium contribution. Everyone in the same FPL has the
same expected premium contribution.
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Annual Household Income Expected Premium Contribution% of FPL Income Amount % of Income Annual Dollar Amount
100-150% $11,490 - $16,755 2 - 4% $230 - $670
150-200% $16,755 - $22,340 4 - 6.3% $670 - $1,407
200-250% $22,340 - $27,925 6.3 – 8.05% $1,407 - $2,262
250-300% $27,925 - $33,510 8.05 – 9.5% $2,262 – $3,183
300-400% $33,510 - $44,680 9.5% $3,183 - $4,245
> 400% > $44,680 n/a n/a
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2nd cheapest Silver plan, $5,000
Gunnar, Age 26 Coleman, Age 62$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$1,448 $1,448
$3,552
$13,552 Tax CreditContribution
2nd cheapest Silver plan, $15,000
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Why is this important?The expected premium contribution doesn’t change
with age, even though the cost of the plan does.
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Offers of Employee Coverage & Eligibility
An individual is not eligible for premium tax credits if he is eligible
for other minimum essential coverage (MEC)
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Minimum Essential Coverage
• Most employer sponsored coverage is MEC
• An offer of coverage - even if it’s not taken - can make someone ineligible for premium tax credits
But wait…10/9/2014
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Exception
An employee may be eligible for premium tax credits if the employer plan is
unaffordable or inadequate, and if the employee does not enroll in it
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Jumping the “Firewall” Between Employer Coverage and Premium Tax Credits
If unaffordable or inadequate
Offer of EmployerCoverage
Premium TaxCredits
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Is it Affordable?
• Affordable = employee contribution for self-only coverage is less than or equal to 9.5% of household income• Yes, that’s right! Cost of self-only coverage
used to determine affordability for both employee and dependents!!??!
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Affordability of Family Coverage (Conrad Family) Mom works at Edgehill. She earns $35,000. Dad is anpolitician and earns about $12,000.
Family Income: $47,000Premium Cost to Employee for Employee-Only Plan:$196/mo ($2,350/yr) 5% of incomePremium Cost to Employee for Family Plan: $509/mo($6,110/yr) 13% of income
Employee Only Family0%2%4%6%8%
10%12%14%
5% 5%
13%9.5% - - - - - - - - - - - - - - - - - - - - -
Bottom Line:No one is eligible for premium tax creditsbecause family coverageis considered affordable.
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Jumping the Firewall:When is Coverage Adequate?
Coverage is adequate if it has a minimum value (MV) of 60% o This generally means that the plan pays
at least 60% of spending for coverage of essential health benefits for a typical population, after accounting for cost-sharing charges required under the plan.
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How Will an Employee Know if his Offer is Affordable or Adequate?
• Application has an appendix to be completed by the applicant (with help from his employer to indicate value and cost of the plan)
• If your employer does not tell you, you can print off the Employer Coverage Tool from healthcare.gov.
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Cost-Sharing Reductions
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Marketplace Plans – Metal LevelsPlan Level Actuarial
Value Platinum 90%
Gold 80%
Silver 70%
Bronze 60%
Lower enrollee cost-sharing
Higher enrollee cost-sharing
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Same, but differentSILVER # 1(enrollee pays)
SILVER # 2(enrollee pays)
Deductible (individual) $2,000 $2,500
Maximum OOP Limit (individual)
$5,500 $6,350
Inpatient hospital (After deductible)
$1,500/admission 30%
Office visit(After deductible)
$30 $35
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Sample Cost-Sharing Reduction (CSR) PlansStandard Silver
Actuarial Value
70%
Deductible (Indiv)
$2,000
Max. OOP limit(Indiv)
$5,500
Inpatient hospital
$1,500 per admiss.
Office visit $30
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CSR for up to 150% FPL
94%
$0
$1,000
$100 per admiss.
$10
CSR for 151-200% FPL
87%
$250
$2,000
$250 per admiss.
$15
CSR for 201-250% FPL
73%
$1,750
$4,000
$1,500 per admiss.
$30
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Go Silver!If your client falls between 100-250% of
FPL, she should pick a silver plan.
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Rule: No reconciliation at end of the year (for cost-sharing reductions)
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Scenario: Luke and Rayna• Rayna and Luke are married
with three children: ages 12, 7, and 2.
• Luke makes $3,000/mo.; Rayna $1500/mo.
• They have savings of $15,000.• Luke is insured with his
employer, who just announced that they will be offering healthcare for employees’ children next month.
• Luke pays $255/mo. for health insurance.
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What is everyone
eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Luke Rayna Maddie Daphne Taylor
Luke
Rayna
Maddie
Daphne
Taylor
✔ ✔ ✔
What is the household size for each person for Marketplace purposes?
Same household counting as above.
✔
✔ ✔ ✔✔
✔ ✔ ✔✔
✔ ✔ ✔✔
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✔
✔
✔
✔
✔ ✔ ✔✔ ✔
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Step 3: Income: WaylonIncome for household of 5 is $4500/month.
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Kids
Rayna
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So who’s eligible for what?• Luke?– Not eligible to get PTCs, because he has an offer of
coverage.• Rayna?– Eligible for PTCs and CSRs!
• Kids?– CoverKids!
But, Luke wants to look at all his options… he doesn’t trust this “CoverKids” deal…10/9/2014
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Luke is skeptical…• Luke currently pays $255/mo (8.5% in income) for
his healthcare.• To add his kids, it would be $510 (17% of his
income).
And Rayna is still uninsured…
A silver plan, with PTCs, could cost $167/mo
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The Family Glitch• Because of the family glitch, Rayna and Luke
would end up spending about $677/mo. (17% of their income) on healthcare without CoverKids.
• So… get those girls on CoverKids!
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Take-Aways and Practice Tips• Family glitch: health insurance that is
“affordable” can still be very expensive for the family.
• If one spouse has employee coverage, but the other spouse gets covered on the Marketplace, the employee coverage premiums do not count towards expected contribution.
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Scenario: Juliette• Juliette is a single mother. • Her son Garth is 12 years old. Juliette’s 61 year
old long-lost father, Waylon, lives with them. • Juliette earns $1,900/month. Waylon makes
$100/month working weekends at a hardware store.
• Juliette claims Waylon as a dependent, but Garth is claimed by his dad. Garth stays with his dad every other weekend.
• Garth has severe intellectual disabilities, and Waylon had diabetes. No one has insurance right now.
10/9/2014
What is everyone
eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Juliette Garth Waylon
Juliette
Garth
Waylon
✔
What is the household size for each person for Marketplace purposes?
Juliette and Waylon: Juliette, WaylonGarth: self, dad
✔ ✔
✔
✔
10/9/2014
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Step 3: Income: Juliette & GarthIncome for household of 2 is $1900/month.
10/9/2014
Juliette
Garth
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Step 3: Income: WaylonIncome for household of 1 is $100/month.
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What about his income for PTC purposes?
Since he is in Juliette’s household for PTC purposes, his income is high enough!
10/9/2014
Step 3: Income: Waylon
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So who’s eligible for what?• Garth?– CoverKids– Maybe Medically Needy Spend Down?– Get on DIDD waiting list
• Juliette?– PTCs and CSRs!
• Could get a Silver plan at $35.37/month, with a $141.56 subsidy, and 94% CSRs.
• Waylon?– CHOICES?– PTCs and CSRs!10/9/2014
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Practice Tips• Remember the exceptions for household
sizes!• Remember to look at someone’s household
for both PTCs and TennCare.• A quick note about insulin: CoverRx is a
resources for folks under 100% FPL.
10/9/2014
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Coffee Break!!!
10/8/2014
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TennCare Updates
10/9/2014
It took TennCare 8 months to process the application for Rusty and his family. During that time, Rusty couldn’t get on the list for a life-saving liver transplant, and his two
sons went to the ER without insurance: one for a broken arm, and one for an illness.
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Wilson v. GordonOn July 27th, TJC, the Southern Poverty Law Center, and the National Health Law Program filed suit against TennCare on behalf of all Tennesseans who have been waiting for more than 45 days for TennCare to tell them whether or not they are eligible.
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“Reasonable Promptness”Federal law requires TennCare to determine an applicant’s eligibility “with reasonable promptness,” defined as no longer than 45 days (or 90 days for the CHOICES program).
10/9/2014
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Applicants’ Right to a Hearing
Federal law requires TennCare to provide an opportunity for a fair hearing to anyone whose application is “denied or is not acted upon with reasonable promptness.”
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Wilson v. Gordon Class“All individuals who have applied for Medicaid (TennCare) on or after October 1, 2013, who have not received a final eligibility determination in 45 days (or in the case of disability, 90 days), and who have not been given the opportunity for a ‘fair hearing’ by the State Defendants after these time periods have run.”
http://www.tnjustice.org/tenncare-suit/class/
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Wilson v. Gordon Order“The Defendants are ordered to provide the Plaintiff Class with an opportunity for a fair hearing on any delayed adjudication. Any fair hearing shall be held within 45 days after the Class Member requests a hearing and provides Defendants with proof that an application was filed.”
If the application is for CHOICES, the hearing must be held within 90 days of the request.
http://www.tnjustice.org/tenncare-suit/order/
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4 Advocacy Tips from TJC1. Appeal! Appeal! Appeal!2. Refer to the Legal Aid Society for
representation at the hearing.– Refer to TJC for advocacy, if the state says they
are closing the applicant’s appeal.
3. Document the person’s application & eligibility
4. Be encouraging!
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Advocacy Tip #11. Help the class member appeal.
• Call Tennessee Health Connection: 1-855-259-0701 OR• Fax delayed appeal form to HCFA Eligibility Appeals: 1-844-563-1728 OR• Certified Mail, Return Receipt Requested, the delayed
appeal request form to: HCFA Eligibility Appeals:
P.O. Box 23650 Nashville, TN 37202-3650
10/9/2014
**Keep the fax/certified mail receipt, or write down date and time of phone call and who you spoke to.**
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Advocacy Tip #1
• The appeal request form asks for proof of date of application.– If the applicant has correspondence from the Marketplace with the
date, send that. If not,– Call the Marketplace to ask for help with written proof.
• If the consumer applied over the phone and never received an eligibility notice in the mail: – Help him/her create an online account.– Link the application to the online account using the application ID
number. – Print the eligibility notice.
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2. Have the class member call her local Legal Aid Society if she is in East Tennessee (1-800-821-1309) or in Middle Tennessee (1-800-238-1443). They may be able to help.
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Advocacy Tip #2
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Advocacy Tip #2• Refer to TJC if TennCare says they are closing
your client’s appeal because he/she could not provide the requested information.
• We do not believe this should happen! We will help advocate for families who have no means to prove their application date.
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3. Help him/her gather documents• Other documents that they should bring if they have
them:– Anything that the Marketplace or TennCare has sent to
him/her– Anything that he/she has sent to the Marketplace or
TennCare
• But, at the end of the day, the most important thing is that they show up.
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Advocacy Tip #3
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Advocacy Tip #3• The state will use an “administrative process”
to adjudicate applications before going to hearing. TennCare’s goal is to resolve eligibility without the need for a hearing.
• If you can provide documents to help the state process the application, then a hearing might not be necessary.
• This is good news!!!
10/9/2014
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Be encouraging! We don’t want folks to be intimidated by this process.
Things are always changing: please check our website for updates
www.tnjustice.org/tenncare-suit 10/9/2014
Advocacy Tip #4
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Scenario: Dolly & Travis• Dolly and Travis are married with two
kids, Porter (5) and Cash (11). Dolly has a child from a previous marriage, Zoey (20), who is a full-time college student living at school during the year.
• Dolly and Travis file taxes jointly, and claim all the kids.
• Travis makes $3400/month, and that is their only income. He does not have access to insurance through work.
10/9/2014
What is everyone
eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Dolly Travis Porter Cash Zoey
Dolly
Travis
Porter
Cash
Zoey
✔ ✔ ✔ ✔ ✔
✔ ✔ ✔ ✔ ✔
✔ ✔ ✔ ✔ ✔
✔ ✔ ✔ ✔ ✔
✔ ✔ ✔ ✔ ✔
What is the household size for each person for Marketplace purposes?
Same as above – 5 people in the household for each member.
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Step 3: IncomeIncome for household of 5 is $3400/month.
10/9/2014
Porter
Cash
Cash
Zooey
Dolly &Travis
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So who’s eligible for what?• Porter? – TennCare
• Cash? – CoverKids (or Medically Needy Spend Down if the family has
a log of medical bills)• Zoey? – Medically Needy Spend Down if the family has a lot of
medical bills, and few resources. – If not, PTCs and CSRs
• Dolly and Travis? – PTCs and CSRs
10/9/2014
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But then, reality strikes.• On March 30, 2014, Dolly and Travis applied
on the Marketplace by phone for the whole family.
• Dolly, Travis, and Zoey are on a silver plan with PTCs and CSRs!
• …but the kids still haven’t been enrolled in TennCare or CoverKids.
What should they do now?
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Appeal!• Call TNHC to ask to file a delay appeal.• The state may ask for more information:– If they ask for proof of application, send in any
information that the family has from the Marketplace with the application date.• If they have nothing in writing, they can try connecting
their application ID# with an online account.
– If they ask for income verification, send in pay stubs (month of application, and month before application).
• Go to covertn.gov to apply to CoverKids directly for Cash.
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Uh-oh… Dolly & Travis Split• Dolly and Travis had one too many
fights about who could eat the last pickle in the jar, so they got divorced.
• Travis has custody of Porter and Cash, and makes their day-to-day decisions. Zoey is still living at school, but stays with her mom when she’s home.
• Dolly claims all three children as tax dependents.
• Travis’s income is still $3400/month.• Dolly gets a job making
$1900/month.10/9/2014
What is everyone
eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Dolly Travis Porter Cash Zoey
Dolly
Travis
Porter
Cash
Zoey
✔ ✔ ✔ ✔
✔
✔ ✔ ✔
✔ ✔ ✔
✔ ✔ ✔ ✔
What is the household size for each person for Marketplace purposes?
Dolly, Porter, Cash, Zoey: Dolly, Porter, Cash, ZoeyTravis: Travis
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Step 3: Income – Porter & CashIncome for household of 3 is $3400/month.
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Cash & Porter
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Step 3: Income – Zoey & DollyIncome for household of 4 is $1900/month.
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Step 3: Income – TravisIncome for household of 1 is $3400/month.
10/9/2014
Travis
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So who’s eligible for what?• Porter?
– CoverKids (or Medically Needy Spend Down if the family has a lot of medical bills)
• Cash? – CoverKids (or Medically Needy Spend Down if the family has a lot of
medical bills)• Zoey?
– Medically Needy Spend Down if the family has a lot of medical bills. – If not, Coverage Gap
• Dolly?– Coverage Gap
• Travis? – PTCs
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Practice Tips• If kids are eligible for CoverKids, do a quick screen to
see if they might be Medically Needy Spend Down (high medical bills? resources?)
• If someone is in the gap:– If they are close to 100% FPL, see if they can pick up a few
extra hours– Refer them to Health Assist Tennessee for help getting
care– Encourage them to share their story: 615-900-GAP3– If their income has any chance of going up this year, have
them apply on the FFM anyway!10/9/2014
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Scenario: Gunnar & Scarlett
• In July, Gunnar started working 4 nights a week at the Bluebird Cafe. He makes about $1800 in wages and tips each month.
• In July, Scarlett started working a part-time job, making $580/month.
• Their jobs don’t offer insurance, and neither of their parents’ have employer insurance.
• Gunnar and Scarlett are 22, graduated college in May, and just got married in June!
10/9/2014
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
10/9/2014
Probably not eligible for TennCare!
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Gunnar Scarlett
Gunnar
Scarlett✔
What is the household size for each person for Marketplace purposes?
Same household counting as above.
✔
✔ ✔
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Step 3: IncomeWhen we count income for TennCare purposes, we want monthly income. But on the Marketplace, we estimate
yearly income.
Gunnar estimates that his gross income in 2014 will be $10,800.Scarlett estimates hers will be $3,480.Combined income = $14,280: under 100% of FPL
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So who’s eligible for what?• Gunnar and Scarlett?– They can buy insurance on the FFM, but they
aren’t eligible for PTCs or CSRs since they are under 100% FPL.
– The lowest cost silver plan would cost them about $284/month – they can’t afford this.
10/9/2014
Gunnar and Scarlett are in the Coverage Gap.
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Practice Tips• For purposes of getting PTCs, the FFM looks at
yearly income. • TennCare looks at monthly income.• Remember, for folks in the gap:– Can they pick up extra hours if they’re close?– Health Assist Tennessee– 615-900-GAP3– Apply anyway!
• Young adults can stay their parents’ employer insurance – even if they are married.
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Woohoo—Scarlett Gets Preggo!• Scarlett finds out that
she’s pregnant!• Income stays the same:– Combined monthly
income: $2,380– Income for 2014: $14,280
Now who’s eligible for what?
10/9/2014
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Gunnar Scarlett
Gunnar
Scarlett✔
What is the household size for each person for Marketplace purposes?
Gunnar and Scarlett are in a household by themselves. (Unborn babies don’t count on the FFM!)
✔
✔ ✔ ✔
Until the baby is born, Gunnar is in a household of 2, and is not considered a parent!
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Step 3: Income – ScarlettIncome for household of 3 is $2380/month.
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Scarlett
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So who’s eligible for what?• Scarlett?– TennCare!
• Gunnar?– Same position he was in before… in the Gap.
What should Scarlett do now?Go to her local Health Department to get Presumptive
Eligibility, and apply on the FFM.
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Look who’s here…Dierks pops out!• On March 14, 2015, Gunnar &
Scarlett have their first baby, Dierks!• Gunnar is still uninsured, and Scarlett
had TennCare when Dierks was born but will lose it at the end of May.
• Gunnar still makes $1800/month.• Scarlett worked in January and 2
weeks in February (made $580 in January, and $290 in February). She plans to go back to work on June 1, and will be making $580/month again.
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What is everyone eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Gunnar Scarlett Dierks
Gunnar
Scarlett
Dierks
✔
What is the household size for each person for Marketplace purposes?
Same household counting as above.
✔
✔ ✔ ✔
✔
✔ ✔ ✔
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Step 3: IncomeIncome for household of 3 is currently $1800/month.
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Step 3: Income for the year• Gunnar will be making $1800/month
($21,600)• Scarlett made $870 in the beginning of the
year, and will make $580/month from June-Dec ($7,830)
• Combined income for 2014: $29,430 (under 150% FPL)
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So who’s eligible for what?• Dierks?– TennCare!– Call Tennessee Health Connection to get him on.
• Gunnar and Scarlett?– PTCs and CSRs!– Gunnar and Scarlett could get a plan that costs
$88/month.
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Practice Tips• A pregnant woman’s household includes herself and
all her unborn children – but only for her household.• A pregnant woman must complete her TennCare
application before her PE ends.• A baby born to a mom on TennCare should get
TennCare for 1 year, even if the family’s income changes.
• If a family doesn’t know if their income will change, they should think about taking less APTCs, so they won’t have to pay back at the end of the year.
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Scenario #5: Layla & Will• Layla and Will are married with 1 daughter,
Miranda. • Layla is 3 months pregnant and an undocumented
Canadian immigrant. Will has had his green card for 3 years and is also a Canadian immigrant.
• Miranda is 2 years old and was born in the U.S. • Layla is a stay-at-home mother. Will works full-time
as a bartender. He makes around $24,000 (gross) a year. This is the family’s only source of income.
• Layla and Will are uninsured. Miranda has had TennCare since birth, and she gets food stamps.
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What are Layla and
Will eligible for?
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Step 1: Quick ScreenQuick mental screen: who are we looking at?
ChildrenPregnant women
Parents/Caretaker RelativesFolks with disabilities and Medicare recipients
Women with breast/cervical cancer
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TennCare is only available for
folks who have had legal status in the US for 5 years. Will is in
the “5-year-bar.”
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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?
Counted in HH (for Medicaid)Will Layla Miranda Baby
Will
Layla
Miranda
✔ ✔
What is the household size for each person for Marketplace purposes?
Will, Layla, and Miranda are all in each other’s households.
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✔ ✔✔
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Step 3: IncomeIncome for household of 3 is $24,000/year, or $2,000/month.
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Layla
Will
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So who’s eligible for what?• Layla?– CoverKids!– She should apply on covertn.gov
• Will?– PTCs and CSRs!
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Advocacy Tips• When Layla’s baby is born, she should call
CoverKids to get the newborn on CoverKids for one year from when Layla got on CoverKids. – The newborn’s coverage will date back to date of birth. – CoverKids will determine whether the child should be
on TennCare or CoverKids, and will facilitate the enrollment in either category.
• Layla will lose her CoverKids 60 days after delivery. She should contact HAT for assistance getting affordable medical services and prescriptions.
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Y’all are amazing.Thank you all for joining us.
Post-test time!Then, stick around for lunch, and to ask any extra burning
questions.
We’re here to help!Katie: [email protected]: [email protected]: [email protected]: [email protected]: [email protected]
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