HealthSource RI Policy Manual 2018-2019 TABLE OF CONTENTS Chapter 1: Introduction: Provides an overview of the HealthSource RI Policy Manual Chapter 2: Eligibility for Qualified Health Plans: Lays out the eligibility criteria that individuals must meet to qualify to purchase private insurance coverage (“Qualified Health Plans” or “QHPs”) through HealthSource RI. Chapter 3: Open Enrollment, Special Enrollment, and Enrollment Effective Dates: Explains when individuals may apply for and enroll in Qualified Health Plans through HealthSource RI. Chapter 4: Eligibility for Premium Tax Credit and Cost Sharing Reductions: Lays out the eligibility requirements individuals must meet to receive a premium tax credit and cost sharing reductions to help purchase and use a Qualified Health Plan through HealthSource RI. Chapter 5: Advance Premium Tax Credit Reconciliation: Explains the reconciliation process that will occur at federal tax filing time for individuals who elect to take their premium tax credits “in advance” based on their estimated annual income. Chapter 6: MAGI Medicaid Eligibility: Reviews the eligibility criteria individuals must meet to obtain coverage under Medicaid based on modified adjusted gross income. Chapter 7: Verification of Eligibility for Insurance Affordability Programs: Explains the rules and procedures that HealthSource RI will use to verify information that individuals provide to complete an application to purchase health insurance through HealthSource RI. Chapter 8: Mid-Year Eligibility Updates and Renewals: Lays out the rules for mid-year eligibility changes (“change reporting”) and renewing coverage and eligibility for insurance affordability programs. Chapter 9: Individual Eligibility and Appeals: Explains the rules governing how individuals and employees of small businesses may appeal certain eligibility determinations made by HealthSource RI Chapter 10: Shared Responsibility Payment & Exemptions: Explains the federal requirement to have minimum essential coverage, the responsibility payment, and the criteria that must be met to be eligible for an exemption from either requirement. Chapter 11: HealthSource RI SHOP Eligibility: Lays out the options for small businesses and their employees to participate in the SHOP component of HealthSource RI. Chapter 12: QHP Termination and Disenrollment: Explains the circumstances under which HealthSource RI can terminate individuals’ enrollment, or how individuals may voluntarily disenroll from a Qualified Health Plan (QHP). Chapter 13: HealthSource RI Account Creation & Maintenance: Explains how individuals can create and maintain a HealthSource RI account, provides an overview of the application and enrollment process, describes how HealthSource RI provides eligibility and enrollment notices to account holders, and provides a summary of applicant rights and responsibilities. 1 1 Chapter 1: Introduction The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010. The ACA makes the following major changes to how individuals, families and businesses secure health coverage: • Providing funding to the states to establish state-based health benefits exchanges to facilitate households’ purchases of affordable health insurance coverage through an exchange. • Creating new federal advanced premium tax credits (APTCs) to help low and moderate-income households purchase coverage. • Creating new federal cost sharing reductions (CSRs) for individual and families purchasing through an exchange to reduce the out-of-pocket costs households below 250 percent of the Federal Poverty Level (FPL) face when using their health insurance plans. • Expanding Medicaid for adults without children up to 133% of FPL,1 and making other changes to Medicaid and Rite Care. • Creating new ways for consumers to shop for health insurance coverage. • Making important reforms to the private insurance market so that, for example, people cannot be denied coverage solely because they have a pre-existing condition. • Requiring households to have health coverage or make a shared responsibility payment, or obtain an exemption from the shared responsibility payment if eligible. In June of 2015, the Rhode Island General Assembly submitted, and Governor Gina Raimondo approved, an operating budget containing a provision establishing HealthSource RI as a division of the Rhode Island State Department of Administration (DOA). HealthSource RI’s organic statute is codified at Rhode Island General Laws, Chapter 42-157, Rhode Island Health Benefit Exchange. HealthSource RI’s operations will be supported by a combination of budgetary allocations and an assessment on carriers, and may be supplemented by a general revenue allocation. In September of 2011, Governor Lincoln Chafee codified some of the major components of the ACA into Deleted: f Rhode Island law through an Executive Order establishing HealthSource RI as the state’s first ever health insurance exchange. HealthSource RI allows households to apply for and purchase health insurance, apply for advanced premium tax credits (APTCs) to lower the costs of insurance, apply for an exemption from the shared responsibility payment, or apply for MAGI Medicaid coverage. Small businesses can purchase coverage for their employees through HealthSource RI’s Small Business Health Insurance Options Program or SHOP. Since the establishment of HealthSource RI, Rhode Island has developed an integrated approach to health reform under the ACA, incorporating HealthSource RI with the state Medicaid program. In the months and years to come, other human services programs operated through the Executive Office of Health and Human Services (EOHHS) and the Department of Human Services (DHS) will also become integrated into this new approach to health care. This work is being done to serve a broad customer base, including Medicaid-eligible individuals and families, subsidy-eligible households, Rhode Island residents purchasing coverage without 1 The effective eligibility level is 138% FPL. 2 2 subsidies, small employers and their employees, and employees of large employers. HealthSource RI supports health reform efforts aimed at promoting the well-being of Rhode Islanders and providing enhanced access to high quality, coordinated care at a reasonable, predictable cost. The mission of HealthSource RI is to serve as a robust resource for Rhode Islanders and Rhode Island businesses to learn about and easily compare the quality of affordability of their health insurance options, enroll in coverage and, if eligible, access federal tax credits for coverage. The implementation of the ACA in Rhode Island, and establishment of HealthSource RI, has created the need for new policies and procedures at the state level. Such rules and procedures have been promulgated pursuant to the authority set forth in RIGL §23-1-1 and Executive Order 11-09, pursuant to RIGL. §§ 42-62-16 et. seq. The purpose of this document is to provide a public resource to clarify the operational policies of HealthSource RI, including, but not limited to: • Determining eligibility for Qualified Health Plans (QHPs), • Determining eligibility for APTCs and CSRs, • Guidelines for enrolling and dis-enrolling from coverage, • Enrollment and payment deadlines for health coverage, and • Rules concerning exemptions from the shared responsibility payment. 3 3 Chapter 2: Eligibility For QualiFied Health Plans A. Overview of QualiFied Health Plans Individuals may enroll in a health insurance plan through HealthSource RI. All health insurance plans offered through HealthSource RI are certified, provide a comprehensive set of health benefits, follow established limits on cost sharing, and meet other requirements set by state and federal law. The health insurance plans offered through HealthSource RI are referred to as Qualified Health Plans (QHPs). To be certified, QHPs must include a set of comprehensive health care services referred to as essential health benefits (EHBs) in 10 categories: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care. QHP coverage may include benefits in addition to the above essential health benefits. Individuals are also able to buy dental-only coverage. Coverage through a QHP is available to all individuals who meet the eligibility standards, regardless of their health status and any pre-existing medical conditions. All individuals who meet the QHP eligibility standards described below are eligible for coverage regardless of their income. However, applicants that anticipate having annual household income of 100% to 400% of the Federal Poverty Level (FPL) may be eligible to receive financial help from the federal government if they lack other affordable coverage options. Applicants that anticipate having annual household income of 100% to 250% of the FPL may also be eligible for cost sharing reductions that reduce the out-of-pocket costs applicants pay for health coverage, such as deductibles, co-payments, and coinsurance for covered services. Applicants who project an annual household income above 400% of the FPL are not eligible for financial assistance but still may purchase a QHP plan at full price. For more information about financial