Reference Guide for Indiana Navigators

2015
Reference Guide for Indiana Navigators
Version 2.0
July 2015
Developed by:
Indiana Primary Health Care
Association
429 N. Pennsylvania Street, Ste 333
Indianapolis, Indiana 46204
www.indianapca.org
With generous support from
The Health Foundation of Greater
Indianapolis
Table of Contents
About IPHCA………………………………………………………………………………….…2
In-Person Assistant Certification Procedures……………………………….…………....4
Data Management & Personally Identifiable Information (PII)…………………………10
Health Insurance Literacy…………………………………………………………………….16
Outreach Best Practices………………………………………………………………………22
Assisting Immigrants and Refugees………………………………………………………..26
Guide to Tax Rules……………………………………………………………………………..34
The Federally-Facilitated Marketplace……………………………………………………...40
The Small Business Health Options Program (SHOP Marketplace) ……………….....57
Indiana Health Coverage Programs (Medicaid)…………………………………………...62
1
About IPHCA
Organized in 1982, Indiana Primary Health Care Association (IPHCA) advocates for quality
health care for all persons residing in Indiana and supports the development of communityoriented primary care initiatives (including Community Health Centers, or CHCs) that are:
 Affordable (based on income),
 Available (services delivered when needed),
 Accessible (services delivered where needed),
 Appropriate (emphasizing continuous, comprehensive, prevention-oriented primary
care), and
 Acceptable (to everyone residing in the community regardless of cultural heritage,
financial status, or personal circumstances).
Included in IPHCA’s comprehensive definition of primary care are medical, dental, and
behavioral health services. IPHCA has a diverse membership that includes CHCs, interested
individuals, and organizations that support IPHCA's important mission.
State-based Primary Care Associations exist in every state and U.S. territory. IPHCA receives
funding from a number of sources, including the Health Resources and Services
Administration's Bureau of Primary Health Care (part of the US Department of Health and
Human Services) to monitor and advocate for access to primary care services throughout
Indiana and to provide technical assistance to Federally Qualified Health Centers in the state.
IPHCA also receives funding from The Indiana State Department of Health and other
organizations such as The Health Foundation of Greater Indianapolis.
Outreach & Enrollment Department
IPHCA’s Outreach & Enrollment (O/E) department consists of two full-time employees who both
work with FQHCs, state-funded health centers, and other organizations across Indiana to
expand access to health care through application assistance, patient education, and community
outreach. IPHCA strengthens the statewide O/E network by providing technical assistance,
guidance, and training to Indiana Navigators, Certified Application Counselors (CACs) and other
O&E professionals.
Please consider checking out the IPHCA website (www.indianapca.org) for more information!
Here’s what you can find online:
 “HIP 2.0 Hub”—news & updates, resources for consumers and enrollment
professionals, a listing of key documents and information from each Managed Care
Entity (MCE), FAQs about HIP coverage, and more
 “How to Apply” section—Step-by-step Marketplace and Medicaid enrollment
procedures for consumers
 “Resources for Assisters”—two-page fact sheets about each Marketplace Qualified
Health Plan (QHP) issuer, toolkits, manuals, educational trainings and resources, free
outreach tools, consent forms, contact cards, certification and recertification steps,
Marketplace topic-specific pages, privacy and security information, and more
 “Trainings”—listing of upcoming webinars and face-to-face trainings and archived
IPHCA webinars and presentations
 “Updates and News”—the latest news and updates in O/E
2
How We Can Help You
 Technical assistance—IPHCA staff are available to help members with troubleshooting
issues, resolving casework, and answering questions about health coverage enrollment
on the Marketplace and Indiana Health Coverage Programs.
 Event support—Need an extra set of hands at a large enrollment event you have
planned? IPHCA can assist in planning events, advertising efforts, and even enrollment
services.
 Training—IPHCA hosts periodic webinars about all things O/E, can speak at coalition or
group meetings, and offer face-to-face instruction.
Meet the IPHCA Outreach and Enrollment Staff
Jessica Ellis received her Bachelor of Science degree in Retail
Management and an associate degree in Organizational Leadership and
Supervision from Purdue University. Since joining IPHCA in Mid-2009,
Jessica has been a part of many aspects of IPHCA and has enjoyed working
with our members. As the Outreach and Enrollment Program Director,
Jessica works with Community Health Centers on growing, educating, and
developing their Outreach and Enrollment staff.
Email: jellis@indianapca.org
Phone: (317) 630-0845, ext. 120
Emily Daw received her Bachelor of Liberal Arts from Indiana University at
Indianapolis with a concentration in English Arts and Humanities and is
currently pursuing an MBA. Since joining IPHCA in January 2014, Emily has
played a role in assisting with all Outreach and Enrollment initiatives--most
importantly serving as support to health centers as they work diligently to
ensure all Hoosiers have access to quality, affordable health insurance.
Email: edaw@indianapca.org
Phone: (317) 630-0845, ext. 116
About This Guide
This guide was created, developed, and distributed through generous funding from The Health
Foundation of Greater Indianapolis (THFGI). THFGI is a private foundation that serves the
community's most vulnerable citizens by funding health-related projects and organizations not
easily supported by other means.
Download a hyperlinked copy of this guide online:
https://indianapca.site-ym.com/?page=OEResources
3
Becoming an Indiana Navigator and Certified
Application Counselor
Introduction to Consumer Assistants
With the launch of the Patient Protection and Affordable Care Act (PPACA, or
ACA), Consumer assistants such as Indiana Navigators and Certified
Application Counselors (CACs) were introduced and designed to serve as
unbiased, informed resources for consumers seeking health coverage.
The ACA established basic training guidelines for assisters to follow
regarding addressing the needs of underserved and vulnerable populations,
eligibility and enrollment procedures, the range of public programs and qualified
health plan (QHP) options available, and proper handling of tax data and personal
information.
Main Types of Consumer Assistants in Indiana
Indiana Navigators
All individuals doing Medicaid and Marketplace enrollments are required to become an
Indiana Navigator. Indiana Navigators are certified to help consumers complete applications
for health coverage including Medicaid and QHPs, and insurance affordability programs like
Premium Tax Credits (PTCs) and Cost-Sharing Reductions (CSRs) in Indiana.
Responsibilities
Consumer
outreach and
education
Assessing the
level and type of
consumer need
Assisting with
eligibility appeals
Assisting with
enrollment
Checking
consumer
enrollment status
Certification Steps
1. Complete online New Application for Indiana Navigator Certification. ($50 and $14.40
processing fee for Indiana residents) *Licensed insurance producers and consultants are
excluded from this requirement and must submit the Designation Form for Licensed
Producers and Consultants.* Applicants may check the status of their application online
at: www.sircon.com/login.html. Application submissions will remain "Pending"/"Under State
Review" until all 6 Steps are complete. Application submissions still pending/incomplete
after 90 days from the submission date will be withdrawn.
2. Complete and submit a Background Check ($7-17 for Indiana residents) *Licensed
insurance producers and consultants are excluded from this requirement.*
3. Review the Conflict of Interest Policy, then complete and submit the Conflict of Interest
Disclosure Form.
4. Review, sign, and submit the Privacy and Security Agreement.
5. Complete Precertification Training and Continuing Education from an IDOI-approved
Navigator precertification education (PE) provider. *IPHCA recommends
www.IndianaNavigators.org for only $4.95.*
6. Pass certification exam. Follow the Certification Examination Procedure and Guidelines.
*Licensed insurance producers and consultants are excluded from this requirement.*

4



All forms/documents may be attached electronically to the end of the online
application. They may also be submitted to IDOI by either:
o Email: Navigator@idoi.in.gov
o Fax: 317-232-5251 ("attn: Navigator Director"), or
o Mail: Indiana Department of Insurance, c/o Navigator Director, 311 W.
Washington St., Ste. 300, Indianapolis, IN 46204.
Applicants may check the status of their application online
at: www.sircon.com/login.html.
o Application submissions will remain "Pending"/"Under State Review" until all six
steps are complete. Application submissions still pending/incomplete after 90
days from the submission date will be withdrawn.
All Navigators receive a unique ID number upon successful completion of all steps. A
certificate may be requested by emailing Navigator@idoi.in.gov.
Renewal Steps
Sixty (60) days prior to the renewal deadline, Indiana Navigators will receive a notice to renew
no later than the last day of the anniversary month of the original certification date; the following
steps must be completed:
 Complete 2 hours of continuing education through an IDOI-approved Navigator CE
provider annually.
 Complete shorter application and pay filing and processing fees.
 Review the Conflict of Interest Policy and sign and submit new Conflict of Interest
Disclosure Form and Privacy and Security Agreement.
 Submit all materials to Navigator@idoi.in.gov.
Reporting Requirements
Navigators must inform the Indiana Department of Insurance (IDOI) of changes within 30 days:
Legal Name
Address
Criminal
History
Deliquent state
tax and/or child
support
payments
Security breaches or
improper disclosure of
consumer's PII no later
than 5 days following
the discovery
Conflict of Interest Policy
Conflicts of interest include personal or business interests that may influence the advice and
assistance the Indiana Navigator or AO provides to a consumer.
Financial
Receiving direct or indirect financial compensation or incentive for the enrollment of an
individual into a particular health coverage plan.
Loyalty
Having a direct or indirect relationship, through business or family, an
interest or relationship with a third party that forbids or prevents the
individual or organization from exercising unbiased judgment in the best
interest of consumer.
Tips for Protecting Personally
Identifiable Information (PII)
● Do not leave computer screen
open
● Securely destroy and dispose of
personal information
● Inform consumer of any security
breach
Privacy, Security and Confidentiality Standards
Indiana Navigators and AOs have access to some very personal
information. Due to the sensitivity of this information, Navigators
5
and AO must agree to maintain the confidentiality of and protect any information provided by the
consumer in the process of applying for and enrolling in a qualified health plan (QHP) or public
health insurance program like HIP. Please see page 10 for more information about complying
with privacy and security requirements.
Application Organization (AO)
An AO is an organization such as a Community Health Center (CHC) or Federally Qualified
Health Center (FQHC) that has employees and/or volunteers assisting consumers with
applications for Marketplace-based health plans, insurance affordability programs and statebased health coverage programs like HIP and Hoosier Healthwise.
Initial Application Steps
1. Complete the New Application for Application Organization Registration.
 Pay the online filing ($50) and processing fees ($14.40).
 Applicants may check the status of their application online
at: www.sircon.com/login.html. (Only one application is needed for an entity with
multiple locations.)
2. Multi-location organizations registering as AOs must submit to IDOI the: (1) name, (2)
address, (3) telephone, (4) email, (5) website (if applicable), and (5) contact person;
for each physical location of the Application Organization.
3. Review the Conflict of Interest Policy, then complete and submit the Conflict of Interest
Disclosure Form and Privacy and Security Agreement.
4. Submit all documents online at end of online application or to Navigator@idoi.in.gov
Annual Renewal Process
AOs have a 30-day grace period following the expiration date to complete all steps.
1. Complete the Renewal Application for Application Organization Registration.
2. Pay the nonrefundable online filing ($50) and processing fees ($7.23).
3. Multi-location organizations registering as AOs must submit to IDOI the: (1) name, (2)
address, (3) telephone, (4) email, (5) website (if applicable), and (5) contact person;
for each physical location of the Application Organization.
4. Review the Conflict of Interest Policy and submit the Conflict of Interest Disclosure
Form and Privacy and Security Agreement
5. Submit all documents at end of online application or to Navigator@idoi.in.gov
Please view the Indiana Department of Insurance’s (IDOI)
website for more information about becoming an Indiana
Navigator and/or Application Organization and the
recertification process: www.in.gov/idoi/2823.htm.
Federal Navigators
Federal Navigators are selected and funded by the federal government
to serve in Federally-Facilitated (FFM) or Partnership Marketplace
states for one year (minimum). In April 2015, CMS announced the new
funding period will be 36 months; recipients will be announced in early
September 2015.
 Federal Navigators in Indiana are also required to become
Indiana Navigators.
6
Certified Application Counselors
Certified Application Counselors (CACs) provide free, unbiased assistance to consumers
applying for and enrolling in health coverage. There is no cost associated with becoming a CAC.
The federal government provides the training and certification materials but does not provide
any funding for it. The training is administrated through the Medicare Learning Networks and
is expected to take between 5-8 hours to complete. Many CACs spread the training over the
course of a few days in order to keep up with other assigned duties. Individuals who want to
become CACs must be affiliated with a CAC Designated Organization (CDO), an organization
designated by the Marketplace to oversee individual CACs.
Key Points
• Organizations (FQHCs) receiving HRSA funding must become a Certified Application
Counselor (CAC) Designated Organization and appoint enrollment staff as CACs to
complete any health coverage application.
• CAC organizations (usually the AO) apply to1 and are designated by the Marketplace.
o The organization is responsible for assigning CAC numbers and training their
staff and volunteers as individual CACs.
• CACs may not impose fees for assistance.
Responsibilities
Assist with
Marketplace
applications
Facilitate enrollment
of eligible individuals
in QHPs and
insurance affordability
programs
Disclose any conflicts
of interests and
comply with privacy
and security
agreements
Act in the best
interest of the
consumer
Abide by federal
standards
Annual Training
CMS recommends that individual CACs complete their CAC training prior to the beginning of the
Open Enrollment Period, even if this is prior to the expiration date of their certification. This
ensures that they have received the most up-to-date training to provide application and
enrollment assistance to consumers.
CAC Designated Organization (CDO) Registration Steps
 Complete the application to be a Certified Application Counselor Organization:
https://marketplace.cms.gov/technical-assistance-resources/assister-programs/cac-apply.html
o The individual identified as the authorized representative on the application should hear
back from CMS within a few weeks by email. The email will contain a contract.
 Sign contract and return to CMS
 Once approved, help staff or volunteers become certified as individual CACs.
o The authorized representative must assign each CAC a unique number which will consist
of the organization’s number (e.g. INCACA9401)
 CAC organizations must have these two agreements in place before assisting consumers:
o An agreement between the CAC organization and the Centers for Medicare and
Medicaid Services (CMS)
o Agreement(s) between the CAC organization and individual CAC(s) (staff and/or
volunteers)
1
https://marketplace.cms.gov/technical-assistance-resources/assister-programs/cac-apply.html
7
CAC Certification Steps
 Complete Marketplace-approved training (Available on
https://marketplace.medicarelearningnetworklms.com/Default.aspx) and pass all examinations.
 Enter into an agreement with the designated CAC organization regarding compliance with
federal standards.
 Disclose to the CAC organization any potential conflicts of interest.
 Upon completion of the training, the CAC organization will issue certificates once they have
completed these requirements.
CAC Recertification Steps
 Complete the new training via the Medicare Learning Network.
(https://marketplace.medicarelearningnetworklms.com/Default.aspx)
 Complete the Recertification Request Form (https://marketplace.cms.gov/technical-assistanceresources/recertification-request-form.PDF).
 If necessary, enter into a new CDO-CAC Agreement with your CAC organization.
 Your CAC organization will issue a new certificate which should be displayed when assisting
consumers.
Helpful Tool
Enroll America’s CAC Organization Toolkit:
https://www.enrollamerica.org/resources/toolkits/cac/
Ethical Standards for Assisters
DO
Be honest regarding personal bias or
conflict of interest
Give complete and accurate
information
Admit when you do not know the
answer
Protect personal information
Be sensitive to different cultures
Use professional language
Empower consumer to make educated
choices
DO NOT
Make up or guess an answer to a
question
Ask anyone for more information than
absolutely necessary
Joke about sensitive physical, social or
cultural difference
Use derogatory or profane language
toward or about a consumer
Disclose personal information to
anyone not assisting with the
enrollment of the individual
Serving Different Cultures and Languages
In Indiana, there are more than 100 languages spoken, so it is helpful to know
what resources are available for translation.
• As of 2010, there are 262,198 speaking Spanish, 35,439 speaking
German, 16,473 speaking Chinese, 16,120 speaking Pennsylvania
Dutch and 14,063 speaking French in Indiana.
8
•
•
The Marketplace call center (1-800-318-2596) offers immediate assistance in English
and Spanish with a language line for other options.
It’s suggested to have oral and written notice of language assistance services at
Navigator appointments such as the call center number, existing staff members that
serve as translators, and/or an outside service providing language assistance services.
Serving Persons with Disabilities
In Indiana, it is most likely that consumer assistants will work with individuals that have a type of
disability—approximately 13.1% of Indiana’s population has some type of disability. You should
be prepared to:
• Ensure consumer education materials, websites, etc. are accessible to all (e.g.
providing TTY services)
• Provide assistance in a location & in a manner physically accessible (e.g. wheel
chair access)
• Ensure authorized representatives are able to assist with decisions
• Be able to refer people with disabilities to local, state, and federal support
services
• Be able to work with individuals regardless of age, disability, or culture
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Data Management Protecting
Consumer Information
Tracking Consumer Data

Use contact cards and authorization forms like CMS’ “Appendix E.”
Download this “IPHCA Contact Card” here: http://www.indianapca.org/?page=OETools


Use password-protected and/or encrypted computer files, data management.
websites, or locked storage cabinets.
Limit who has access to the data.
Helpful Tips
 Track only what you care about (age, language, income, etc.).
 Re-evaluate your strategies and data tracking on a regular basis.
 Always have benchmark goals.
o Monthly, weekly, daily
o By geography
o By staff
 Set goals that will be met about ½ the time.
o (e.g. “enrolling 25 people per week”)
 Connect each person’s goal to the big picture –understanding consumers based on the
metrics you track to ensure Hoosiers get enrolled and stay enrolled in health coverage.
 Establish who enters the data.
Where to get Data about Your Community
 Small Area Health Insurance Estimates (SAHIE): www.census.gov/did/www/sahie/
 Public Use Microdata Areas (PUMAs): www.census.gov/geo/reference/puma.html
 State Health Access Data and Assistance Center (SHADAC): www.shadac.org/
 Enroll America—Marketplace data by zip codes: www.enrollamerica.org/researchmaps/maps/changes-in-uninsured-rates-by-county/
 STATS Indiana—Public Data Utility: www.stats.indiana.edu/index.asp
 The State of Indiana Monthly Medicaid enrollment data: www.in.gov/fssa/ompp/4881.htm
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Privacy and Security Standards
Compliance with Personally Identifiable Information (PII) Standards
 Inform consumers of your assister role and the application process; ensure they
understand.
 Obtain documented authorization prior to accessing personally identifiable information
(PII) and assisting with eligibility and enrollment—you can do this in-person, over the
phone, in writing, or electronically.
 Maintain a record of the authorization.
Inform
Obtain
Assist
Maintain
What is PII?
Information that can be used to distinguish or trace an individual’s identity, whether alone or
combined with other information linkable to the individual:
Name
Address
Income
Social Security
Number
Email address
Photographic images
Date and place of birth
Mother’s maiden name
Payment information
Informing Consumers
 Explain to the consumer:
 Your assister duties as a Navigator/CAC
 Their privacy rights
 How the information will be used and stored
 Have client sign the Certified Application Counselor (CAC) Authorization Form
(“Appendix E”) or the authorization form created and approved by your organization.
Make sure you are providing space that is secure and comfortable for the consumer.
Obtaining Authorization
Your authorization should include at least the following:
 Acknowledgement that you informed the consumer of your responsibilities as a
Navigator or CAC
 Consent for you to access and use the consumer’s PII to carry out your assister
functions and responsibilities
 Acknowledgment that the consumer may withdraw any part of the authorization at any
time
 Description of any limitations the consumer wants to place on your access or use of PII
It is recommended to include the following in your standard authorizations:
 Explanation of what PII includes and examples of PII you might request
 Acknowledgment that the consumer is not required to provide you with any PII
 Explanation that the help you provide is based only on the information the consumer
provides
11
 Acknowledgement that you will only ask for the minimum amount of PII necessary for
enrollment purposes and assister responsibilities
IPHCA encourages assisters to utilize CMS’s Model Authorization Form for
CACs, or “Appendix E”. Download it here:
http://www.indianapca.org/?page=OESecurityStandards
Maintaining a Record of Authorization
At minimum, the record of the authorization should include the following:
 Consumer’s name (and the name of the authorized representative if applicable)
 The date of authorization
 Your name, or the name of the assister to whom authorization was given (you can
include multiple names)
 Notes regarding any limitations placed by the consumer
 Notes recording all acknowledgments as previously discussed
 Notes of any changes made to the authorization later
Maintaining Post-Enrollment PII
 You can store PII in a format and process that works best for your
organization.
 You must maintain record of consumer authorization for at least six years.
 CMS expects your organization to establish policies for keeping records of
authorization secure, organized, and accessible if a consumer needs to
update or correct their information or consent
6
years
De-identify information used in presentations or for reporting purposes if
it is not necessary.
If confidential information is used for a success story, commercial, etc.,
obtain consent from the client.
Only provide or compile data which is required to fulfill its purpose.
Password protect and/or encrypt all data files containing sensitive
information.
Methods of Storing PII
Paper
 Use locked file cabinet.
 Shred any unnecessary information.
 Only individuals who need access to
files to complete job duties should have
access.
12
Electronic
 Keep authorization in a passwordprotected and/or encrypted computer
and/or file.
 Do not access PII on an unsecure
network.
Scheduling Appointments
 Receive and document client permission to collect and put PII on outlook calendar or
scheduling system
o CMS permits you to use technology tools to schedule appointments.
 Tips to remember before buying or using scheduling tools:
o Carefully review the software tool’s terms regarding how a consumer’s
information will be used
 Check that the terms do not claim to provide a service on behalf of CMS
or the Marketplace.
o Be sure to inform consumers how the tool will use their data by updating your
organization's Privacy Notice Statement.
o If the tool reports to a third party, you should ensure the consumer permits the
third party to collect, use and store information.
 CMS encourages you to have a separate consent form if this is the case.
Assisting Over the Telephone
• Read your organization’s standard written authorization form or a script that
contains required elements.
• Record in writing that the consumer’s authorization was obtained.
• Read back the content of the record to the consumer.
• Provide a copy of the record to the consumer at earliest available opportunity.
Assisting Via Email
• ONLY email PII through a secure email.
• It is risky to use personal email systems such as: Yahoo, Gmail, MobileMe, etc.
• Identify suspicious emails.
• Do not open suspicious email attachments or respond/forward the message.
• Never save PII on a cell phone device unless it is encrypted.
• Before emailing a consumer, ensure a valid consent is on record.
Tips for Protecting PII
 Be aware of your surroundings and who’s listening.
 Speak softly.
 Close doors whenever possible.
 Lock computer screen when left unattended.
 Password protect any program or document with PII.
 Turn or block computer screens from public view as much as possible.
 Lock-up contact cards.
 Shred documents when necessary and dispose of appropriately when finished.
 When leaving voice messages, only provide your name, contact information, and a
message for callback.
 Try to avoid faxing sensitive PII—scan, encrypt and email.
 If you must fax, arrange transmission with the recipient and use cover sheets.
 Obtain authorization from your supervisor to remove PII from the workplace, and ensure
it is appropriately secured.
13
Password Tips
Don’t tell anyone
your password or
permit your
computer to
remember.
Don’t reuse old
passwords.
Don’t use personal
information (SSN,
Birth dates).
Memorize!
Change on a regular
basis.
Use 6-8 characters
(mix of upper and
lower case, alpha
and numeric).
Security Breaches
• When there is a breach or potential breach (i.e. when equipment or data is lost or stolen),
prompt action is critical
Notify management
immediately.
Notify IDOI no later than 5
days after discovery.
Notify the consumer no later
than 10 days after discovery.
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15
Educating Consumers and Peers
____________________________________________________________________________
about Health Insurance
Health Insurance Literacy Barriers
Only 12 percent of adults have proficient health literacy, according to the National Assessment
of Adult Literacy, and many Americans cannot correctly define common
financial terms related to health insurance like copay or
deductible.2 People of all ages, races, incomes and education
levels struggle with limited health literacy, but the groups who
struggle the most are older adults, recent immigrants, people
with low incomes, and those enrolled in Medicare or Medicaid.
Jargon and technical language make it harder for consumers to
enroll and retain health coverage, and many people also face
linguistic and cultural barriers. These factors are a recipe for missed deadlines and
appointments, misunderstood instructions, and poor understanding and management of chronic
diseases. Low health literacy is associated with reduced use of preventive services and
management of chronic conditions, unnecessary ER visits, and higher mortality. This costs the
US Economy between $106 billion and $236 billion annually!i
Health Insurance Terms to Know
Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The
law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into
law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act
on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended
version of the law.
Authorized Representative (AR): Someone chosen to act on behalf on an individual with the
Marketplace or Medicaid programs. Some ARs may have legal authority to act on behalf of an
individual.
Catastrophic Health Plan: Health plans that meet all of the requirements applicable to other
Qualified Health Plans (QHPs) but do not cover any benefits other than three primary care visits
per year before the plan’s deductible is met. The premium amount paid each month is generally
lower than for other QHPs, but the out-of-pocket costs are generally higher. To qualify for a
catastrophic plan, an individual must be under 30 years old or get a hardship exemption
because the Marketplace determined that he or she is unable to afford health coverage.
COBRA: A federal law that may allow an individual to temporarily keep health coverage after
employment ends, coverage as a dependent is lost, or another qualifying event. If an individual
elects COBRA coverage, he or she pays 100% of the premiums, including the share the
employer used to pay, plus a small administrative fee.
Coinsurance: Percentage of allowed charges for covered services that you are required to pay
after you have fulfilled the deductible.
Copayment: A fixed amount you pay for a covered health care service, usually when you
receive the service. The amount can vary by the type of covered health care service.
2
Source: HHS, Kaiser Health News
16
Cost Sharing Reduction (CSR): A discount that lowers the amount you have to pay out-ofpocket for deductibles, coinsurance, and copayments. CSR subsidies are automatically applied
on the federal Marketplace for individuals and families with income below 250% of the federal
poverty level (FPL). A consumer must select ad enroll in a silver plan for CSR eligibility.
Deductible: The amount you owe for health care services your health insurance or plan covers
before your health insurance or plan begins to pay.
Employer Shared Responsibility Payment (ESRP): The Affordable Care Act requires certain
employers with at least 50 full-time employees (or equivalents) to offer health insurance
coverage to its full-time employees (and their dependents) that meets certain minimum
standards set by the Affordable Care Act or to make a tax payment
called the ESRP.
Essential Health Benefits (EHBs): Marketplace plans must include
health benefits in at least 10 categories (see image on right).
Exemption: If an individual does not have qualifying health
coverage, he or she can apply for one of the many exemptions to
avoid paying the “penalty” or “individual share responsibility
payment.”
Exclusive Provider Organization (EPO): A lot like HMOs; They generally do not cover care
outside the plan’s provider network. Members, however, may not need a referral to see a
specialist.
Explanation of Benefits (EOB): Summary of health care charges that your health plan sends
you after you see a provider or get a service.
Federal Poverty Level: A measure of income level issued annually by the Department of
Health and Human Services (HHS). Federal poverty levels are used to determine eligibility for
certain programs and benefits.
Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance
plan offering prescription drug benefits. Also called a drug list.
Grandfathered Plan: A health plan exempt from certain provisions of the Affordable Care Act.
Health Insurance Marketplace: Also known as just “Marketplace” or “Exchange,” The Health
Insurance Marketplace is a resource where individuals, families, and small businesses can:
learn about their health coverage options; compare health insurance plans based on costs,
benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace
encourages competition among private health plans, and is accessible through
www.healthcare.gov, the CMS call center, and in-person assistance.
Health Maintenance Organization (HMO): A type of health insurance plan that usually limits
coverage to care from doctors who work for or contract with the HMO. It generally will not cover
out-of-network care except in an emergency. An HMO may require you to live or work in its
service area to be eligible for coverage.
17
Health Savings Account (HSA): An HSA is a tax-exempt or custodial account set up with a
qualified HSA trustee (such as bank or insurance company) to pay or reimburse certain medical
expenses.
Individual Shared Responsibility Payment: Also known as the “penalty” for not having health
coverage or an exemption. This is a fee that is collected through the IRS when an individual files
his or her tax return.
Modified Adjusted Gross Income (MAGI): The figure used to determine eligibility for lower
costs in the Marketplace and for Medicaid and CHIP. Generally, MAGI is adjusted gross income
plus any tax-exempt Social Security, interest, or foreign income.
Minimum Essential Coverage (MEC): The type of coverage an individual needs to have to
meet the individual responsibility requirement (individual mandate) under the Affordable Care
Act (ACA). A person without coverage may have to pay the individual shared responsibility fee
for each month they are without coverage or do not have an exemption.
Open Enrollment Period: An annual period of time designated for the purchase of health
coverage. The 2015-2016 Open Enrollment Period is November 1, 2015 - January 30, 2015.
Out-of-pocket Maximum: The most you pay during a policy period (usually a year) before your
health insurance or plan begins to pay 100% of the allowed amount.
2016 Out-of-Pocket Maximums
Individuals
$6,850
Families
$13,700
Point of Service (POS): Plans vary, but POS plan are often a sort of hybrid HMO/PPO.
Members may need a referral to see a specialist, but they may also have coverage for out-ofnetwork care, though with higher cost-sharing.
Preventive Services: Most health plans cover a set of preventive services like shots and
screening tests with no cost-sharing—including copayments and coinsurance even if the
deductible has not been met for the year. This includes Marketplace private insurance plans.
Provider Organization (PPO): A type of plan that contracts with medical providers, such as
hospitals and doctors, to create a network of participating providers. You pay less if you use
providers that belong to the plan’s network, and you can use doctors, hospitals and providers
outside of the network for an additional cost.
Premium: The amount that must be paid monthly, quarterly or yearly for health insurance. A
consumer must pay the first month’s premium by the insurer’s deadline to avoid plan
termination. Monthly premiums are based on several factors including age, tobacco status,
location, how many people are enrolling on the same plan, and the insurance company.
Premium Tax Credit (PTC)
Consumers between 133-400% of the federal poverty level qualify for the Premium Tax Credit
(PTC), which is a subsidy available only through the Marketplace to help
pay for a Qualified Health Plan (QHP). Consumers can elect to have all
or some of the PTC paid directly to the plan on a monthly basis, or they
can choose to claim the full amount on their tax return.
18
Qualifying Life Event: A change in life that can make and individual eligible for a Special
Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to
a new state, certain changes in your income, and changes in family size (marriage, divorce, or
having a baby) and gaining membership in a federally recognized tribe or status as an Alaska
Native Claims Settlement Act (ANCSA) Corporation shareholder.
Special Enrollment Period (SEP): A time outside of the open enrollment period during which
you and your family have a right to sign up for health coverage. In the Marketplace, you qualify
for a special enrollment period 60 days following certain life events that involve a change in
family status (for example, marriage or birth of a child) or loss of other health coverage. Jobbased plans must provide a special enrollment period of 30 days.
TRICARE: A health care program for active-duty and retired uniformed services members and
their families.
Explaining Health Insurance Processes to Consumers
Appealing an Insurance Company’s decision
Insurers must tell consumers why they’ve denied any claim or ended coverage, and they must
inform about the appeals process. There are two ways to appeal a health plan decision:
1. Internal Appeal: a consumer may ask their insurance company to conduct a full and fair
review of its decision. If the case is urgent, the insurance company must speed up this
process.
2. External Review: a consumer has the right to take their appeal to an independent third
party for review. The insurance company no longer gets the final say over whether to pay
a claim.
Appealing the Marketplace’s Decision
A consumer may file an appeal for the following types of Marketplace decisions:
Eligibility to buy a
Marketplace plan
Eligibility for a
special enrollment
period
Eligibility for lower
costs based on
income
The amount of
savings the
consumer is
eligible for
Eligibility for
Medicaid or CHIP
Eligibility for Eligibility
for an exemption from
the individual
responsibility
requirement or CHIP
He or she can write a letter to the Marketplace or use an appeal request form for Indiana3;
appeal decisions are made within 90 days.
Appeals can be mailed to:
Helping Consumers
Health Insurance Marketplace
Understand Health Coverage
465 Industrial Blvd.
London, KY 40750-0061
 Use familiar language
Reporting Life Changes
It is extremely important to remind consumers that they must report
changes such as:
 Marriage, divorce or death of a spouse
 Becoming pregnant
 Birth, adoption or placement of a child
 A permanent move outside insurer’s coverage area
3
https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf
19
 Check for understanding
 Use visuals and keep the
conversation interactive
 Facilitate healthy decisionmaking
 Involuntarily losing health coverage from events such as end of job-based coverage,
losing eligibility for Medicaid or CHIP, aging off a parent’s policy, COBRA expiration,
decertification of a health plan
 A change in income or household status that opens up eligibility for premium tax credits
or CSRs
 Change in citizenship status
 Change in filing status
 Incarceration or release from incarceration
 Corrections to name, date of birth, or Social Security number
Choosing a Health Plan
Encourage consumers to compare plans based
on what is covered and their needs, preferences
(hospitals, doctors, etc.), costs, and actuarial
value. Someone expecting to have a lot of health
care visits or regular prescriptions may be better
off with a Gold or Platinum plan that pays a
higher percentage of the costs. On the other
hand, a healthy individual who does not expect to
have many health care bills may be comfortable choosing a Bronze or Silver plan.
Educating Our Peers on Assister Roles
Explaining Your Role
Of course you are explaining what a Navigator is to your clients, but both clinical and nonclinical staff in your health center can benefit from knowing more about your position and
responsibilities as a Navigator and CAC. You can tell both colleagues and partners that you are:
 A trained and certified professional through the Indiana Department of Insurance (and
Centers for Medicare and Medicaid Services if applicable)
 Prepared and capable to determine coverage eligibility, assist with coverage
applications, answer questions about health insurance, and plan or participate in
outreach events
 Willing to connect individuals to different resources and information in the healthcare
system and your community
Educating and Utilizing Your Organization’s Staff
It is important to let your colleagues know how low health literacy
impacts your community and how you can work together to improve
access to affordable health care. Capitalize on individual staff expertise
by building an internal referral system for consumer questions and
concerns—know who to ask! Advocate for health insurance literacy in
your organization by incorporating health literacy in staff training and
orientation, posting and sharing relevant resources, or by creating a
presentation on health literacy at your next staff meeting. Other ideas include:
 Hosting a workshop or panel discussion about health insurance literacy
 Creating flashy, informative bulletin boards in an area with a lot of foot traffic
 Promoting a contest for developing a catchy phrase for encouraging consumers to enroll
in coverage
 Involving the entire organization in planning a health literacy outreach event.
20
Did you know October is Health Literacy Month? You can use this month to build awareness
about the open enrollment period, educate about health coverage options, and encourage
consumers to commit to enrolling! There are many community festivals and events during
October as well as other health-related events and awareness weeks to partner with such as:
 National Breast Cancer Awareness Month
 National Health Education Week: October 19-24, 2015
 National School Lunch Week: October 12-16, 2015
 National Child Health Day: October 6, 2015
 Red Ribbon Week: October 10-21, 2015
Remember that consumers who understand health care information may:
• Follow more fully instructions on medications
• Call back less often
• Visit less often
• Have fewer hospitalizations
• Have better health outcomes
• Have increased patient satisfaction
Helpful Resource:
Enroll America’s Health Insurance Literacy Resource Hub:
https://www.enrollamerica.org/hil/
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Effective Outreach & Enrollment
Tips for Providing Effective Outreach & Enrollment
Strengthen Your Team
 Reflect and debrief on what worked and what did not work in 2015.
 Recruit volunteers.
 Utilize receptionists and other staff to assist with setting up appointments
and answering questions.
 Attend trainings, conferences and networking events.
 Involve the entire health center staff in ACA awareness and inreach strategies.
 Assign a lead Navigator.
 Recruit, hire and train bilingual Navigators.
Strengthen Your Community
 Form community partnerships with local organizations and coalitions such as:
o Faith-based organizations
o Immigrant and refugee organizations
o Indiana Minority Health Coalition
o Local universities, community colleges and technical schools
o Food pantries and shelters
o Child care centers
o School districts and school nurse workgroups
o Head Start programs
o WIC
o Unemployment offices
o Health departments
o Tax preparation sites like VITA
o Hospitals and hospital associations
 Attend community events like health expos, county fairs, job
fairs, ethnic and multicultural fairs, parades, and holiday
celebrations.
 Develop relationships and build a referral network with other
consumer assister organizations
Collaborate and Brainstorm
 Hold weekly meetings
o Share new resources, tools, and updates
o Dispel myths and miscommunication
o Reveal best practices and strategies
 Identify and capitalize on your strengths
 Support staff with time-management
o Prioritization and data can help
 Help others develop individual work plans
Strategize and Plan
 Prepare for logistics of next open enrollment period
o How will you address high demand?
22
o What population gaps do you need to reach, and how will you reach them?
 Research and implement new strategies:
o Host a phone-a-thon
o Lease storefront space
o Use signage and buttons
 Develop an outreach work plan
Continue Educating and Assisting Consumers
 Educate about the benefits of the ACA.
 Help consumers navigate the health insurance and health care system, including:
o Understand, maintain and use their coverage
o Understand their rights as health care consumers
o Appeal eligibility and coverage decisions
o Report a change in circumstance and navigate subsequent eligibility
redeterminations
 How these changes may affect APTC and eligibility for coverage
o How and when to pay premiums (if applicable)
o The annual redetermination and open enrollment process
 Assist American Indians, Native Alaskans and other members of tribal organizations.
o Documented members of federally-recognized tribes can enroll for the first time
any time during the year and may change plans once per month throughout the
year through an SEP.
 Help small business owners wanting to enroll employees in SHOP.
o SHOP is open all year.
23
Relaying the Important of Health Coverage
Key Messages for Consumers:
• Consumers should apply for insurance because plans available in the Marketplace and
Indiana Health Coverage Programs (Medicaid) provide free preventive care like
vaccines, screenings and check-ups. They also cover some costs for prescription drugs.
• Having insurance is having peace of mind knowing that if a serious medical situation
arises, they are covered.
• Health care without insurance is expensive—in Indiana the average cost per inpatient
stay is $2,025.ii
• “Apply before the deadline!”
• “You may be eligible for financial assistance to help pay for your health insurance.”
• “If you do not enroll in health coverage, you may be fined when you file your taxes.”
Promising Best Practices
Look at the patient
list for the next day
and identify possible
clients
Prescreen your
clients
Take advantage of
free advertising like
school newsletters
and IN-211
Partner with
schools, libraries
and other
community
resources
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Assisting Immigrants & Refugees with Health
____________________________________________________________________________
Coverage Applications
Coverage for Lawfully Present Immigrants
Lawfully present immigrants are eligible for coverage through the Health Insurance Marketplace.
The term “lawfully present” includes immigrants who have:
 “Qualified non-citizen” immigration status without a waiting period (see details
below)
 Humanitarian statuses or circumstances (including Temporary Protected Status,
Special Juvenile Status, asylum applicants, Convention Against Torture, victims
of trafficking)
 Valid non-immigrant visas
 Legal status conferred by other laws (temporary resident status, LIFE Act, Family
Unity individuals)
Lawfully Present Immigrants and Marketplace Savings
Lawfully present immigrants can buy health insurance on the Marketplace.
 If their annual income is 400% of the federal poverty level or below: They may be
eligible for premium tax credits and other savings on Marketplace insurance.
 If their annual household income is below 100% federal poverty level: If they’re not
otherwise eligible for Medicaid, they’ll be eligible for premium tax credits and other
savings on Marketplace insurance, if they meet all other eligibility requirements.
Eligible Immigration Statuses
Lawful Permanent Resident
(LPR)
Paroled into U.S.
Asylee
Refugee
Conditional Entrant
granted before 1980
Temporary Protected
Status (TPS)
Lawful Temporary Resident
Resident of American
Samoa
Granted Withholding of
Deportation or Withholding of
Removal, under the
immigration laws or under the
Convention against Torture
(CAT)
Member of a federallyrecognized Indian tribe or
American Indian born in
Canada
Administrative order
staying removal issued
by the DHS
Individual with Nonimmigrant Status
(includes worker visas,
student visas, and
citizens of Micronesia,
the Marshall Islands,
and Palau)
Cuban/Haitian
Entrant
Deferred
Enforced
Departure
(DED)
Deferred Action
Status
Victim of
trafficking and
his/her spouse,
child, sibling,
or parent
Applicant for any of these statuses:
 Temporary Protected Status with Employment Authorization
 Special Immigrant Juvenile Status
 Victim of Trafficking Visa
 Adjustment to LPR Status
 Asylum
 Withholding of Deportation or Withholding of Removal, under the immigration laws or under the
Convention against Torture (CAT)
26
With Employment Authorization:
• Registry Applicants
• Order of Supervision
• Applicant for Cancellation of Removal or Suspension of Deportation
• Applicant for Legalization under IRCA
• Legalization under the LIFE Act
Types of Immigration Documentation
Immigrants applying on the Marketplace may need to have one or more of the following
documents when applying for and enrolling in coverage. The documents they need depend on
their immigration status. The following is a list of immigration documentation types and
examples for some of the most common types.
Administrative order staying removal issued by the Department of Homeland Security
Alien number (also called alien registration
number or USCIS number) or 1-94 number
Arrival/Departure Record (I-94/I-94A)
Arrival/Departure Record in foreign passport
(I-94)
Certificate of Eligibility for Exchange Visitor
Status (DS2019)
27
Certificate of Eligibility for Nonimmigrant
Student Status (I-20)
Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee
Resettlement (ORR)
Document indicating membership in a
federally recognized Indian tribe or American
Indian born in Canada
Document indicating withholding of removal
Employment Authorization Card (I-766)
Foreign Passport
Machine Readable Immigrant Visa (with
temporary I-551 language)
Notice of Action (I-797)
28
Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
Permanent Resident Card, “Green Card” (I551)
Reentry Permit (I-327)
Refugee Travel Document (I-571)
Temporary I-551 Stamp (on passport or I94/I-94A)
Lawfully Present Immigrants and Medicaid
Immigrants who entered the U.S. on or after August 22, 1996 must meet
the five-year waiting period for Medicaid or CHIP coverage after receiving
a “qualified immigrant status.” People who do not have eligible immigration
status are therefore not eligible for full Medicaid coverage, but they may
get coverage for limited emergency services through Medicaid “Package
E” if they meet all other Medicaid eligibility criteria.
29
Medicaid & CHIP Coverage for Lawfully Residing Children and Pregnant
Women
States have the option to remove the 5-year waiting period and cover lawfully residing children
and/or pregnant women in Medicaid or CHIP. Twenty-nine states, plus the District of Columbia
and the Commonwealth of the Northern Mariana Islands, have chosen to provide Medicaid
coverage to lawfully residing children and/or pregnant women without a 5-year waiting period.
Twenty-one of these states also cover lawfully residing children or pregnant women in
CHIP. Indiana has chosen not to provide coverage to either of these groups.
Getting Emergency Care
Medicaid provides payment for treatment of an emergency medical condition for people who
meet all Medicaid eligibility criteria in the state (such as income and state residency), but don’t
have an eligible immigration status.
Undocumented Immigrants
The estimated 11 million immigrants living in the U.S. illegally are not eligible for federal
public benefits through the Affordable Care Act or Medicaid, and subsequently cannot buy
coverage through the Marketplace. They may continue to buy coverage on their own outside the
Marketplace and get limited services for an emergency medical condition through Medicaid, if
they are otherwise eligible. In addition, they are not subject to the individual shared
responsibility requirement.
Citizens or lawfully present children of undocumented parents are eligible to purchase from the
Marketplace with advanced premium tax credits and cost-sharing reductions as well as
Medicaid and CHIP.
Disclosure of Immigration Status
The Marketplace and state Medicaid and CHIP agencies cannot require applicants to provide
information about the citizenship or immigration status of any family or household members who
are not applying for coverage. Only those applying are required to provide their Social Security
Number (SSN) and immigration/citizenship status. States cannot deny benefits to an applicant
because a family or household member who is not applying has not disclosed his or her
citizenship or immigration status. People who are not seeking coverage for themselves will not
be asked about their immigration status.
A Social Security Number of a non-applicant may be requested to electronically verify
household income. If unavailable, other proof of income can be provided. Information about
immigration status may be used only to determine an individual’s eligibility.
Identity Verification on the Marketplace
When ID verification cannot be completed online a unique reference ID is provided.
Consumers may call the Experian Help Desk directly (1-866-5785409) or with the Marketplace on a three-way call. If language
assistance is needed, then consumers can call the call center first
and request language assistance to call the Experian Help Desk.
When ID verification cannot be completed over the phone
consumers are required to mail or upload documents to their
Healthcare.gov account (manual process) to be verified by the
Marketplace in order to have access to and use their online account.
30
Be sure to include the reference ID number when mailing to: Health Insurance Marketplace, 465
Industrial Blvd., London, KY 40750.
Required Documentation for ID Verification
Consumers can mail or upload copies of documents from the chart on the next page to verify
their identity on the Marketplace.
One of these:
OR two of these:
• Driver’s license
• U.S. Public Birth Record
• School ID card
• Social Security Card
• Voter Registration Card
• Marriage Certificate
• U.S. Military Card
• Divorce Decree
• U.S. Military Draft Record
• Employee Identification Card
• Military Dependent ID Card
• High School or College
• Tribal Card
Diploma
• Authentic Document from a Tribe
• Property Deed or Title
• U.S.C.G Merchant Mariner Card
• ID card issued by the federal, state, or
local government
• Including immigration document
and US passport
Mixed-Status Families
Mixed-status families are households made up of individuals with different citizenship or
immigration statuses such as an undocumented mom, a “lawfully present” dad, an adolescent
granted deferred action through DACA, and a child who is a U.S. citizen because he or she was
born in the United States. According to the National Immigration Law Center, “As of 2010,
nearly one in four children younger than eight years old had at least one immigrant parent.”
Mixed-status families are less likely to enroll because eligibility rules divide them. Remember
that the Marketplace cannot require applicants to provide information about citizenship or
immigration status of any household members who are not applying for coverage.
Tips for Assisting Mixed-Status Families
 Inform consumers that information obtained on the Marketplace application cannot be
used by the Immigration and Customs Enforcement (ICE) Department of Homeland
Security (DHS) for immigration enforcement purposes.
 Agencies can collect, use and disclose only the information strictly necessary for
enrollment in health coverage.
 Medicaid and Marketplace subsidies are not considered in screening green card
applicants for public charge.
 The Call Center can connect language lines for immediate interpretation into 150
languages.
Individual Taxpayer Identification Numbers (ITINs)
ITINs (Individual Taxpayer Identification Numbers) are issued by the IRS to people who are
ineligible for SSNs but who need to file tax returns. Other lawfully present immigrants who are
ineligible for or who may not have an SSN include people in “nonimmigrant” categories whose
visas do not permit them to work, some children under 14 years old whose application for
asylum or withholding of deportation/removal has been pending for 180 days, and some
children who have applied for Special Immigrant Juvenile status.
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Guide to Tax Rules
Determining Eligibility Based on Income
•Premium tax credits follow tax rules in determining
households
•A premium tax credit household is the same as the tax unit
•Considers projected annual income
Marketplace
Indiana Health Coverage
Programs/Medicaid
•Uses a person’s status as a tax filer, tax dependent, or nonfiler to determine who is in the individual’s household and
whose income is counted
•Considers current monthly income
Tax-Related Elements of the Marketplace Application
Whether the applicant files
taxes:
People receiving the premium
tax credit (PTC) must agree to
file taxes for the year after they
receive advanced payments.
Who is in the applicant’s
household:
Determining who is in a
household requires knowledge
of the filing status used on the
applicant’s tax return and how
many dependents can be
claimed.
What the applicant’s
household income is:
A household’s total income is
the MAGI of everyone in the
household with a tax filing
requirement, including any
dependents required to file.
Who Must File Taxes?
Minimum Income Requirements to File a Federal Tax Return
If filing status is…
Single
Head of Household
Married, Filing Jointly
Married, Filing Separately
Qualifying Widow(er) with
Dependent Child(ren)
And age at the end of
2014 was…
Under 65
65 or older
Under 65
65 or older
Under 65 (both spouses)
65 or older (one spouse)
65 or older (both spouses)
Any age
Then Required to file a return if gross
income was at least…
$10,150
$11,700
$13,050
$14,600
$20,300
$21,500
$22,700
$3,950
Under 65
$16,350
65 or older
$17,550
Please note that at the time of this publication, the 2015 numbers were unavailable. Please refer to IRS.gov for updates.
Tax Elements Defined
Deductions
An expense from gross income that can be deducted from one’s taxable income. Examples
include:
34




Moving expenses (can only be deducted if the taxpayer moved due to a change of
employment or business location or to start a new business.)
IRA contributions (not Roth IRA)—The maximum IRA deduction is $5,500 ($6,500 if over
age 50), or twice that amount if Married Filing Jointly.
Student loan interest—The deduction of student loan interest is capped at $2,500 per year.
Tuition and fees—The maximum amount of the tuition and fees deduction that can be
claimed is $4,000 per year. This deduction is not available for married couples who file
separate tax returns.
Earned Income
Includes salaries, wages, tips, professional fees and taxable scholarship and fellowship grants.
Head of Household
Unmarried or considered unmarried for tax purposes and pays more than half the costs of
keeping up home for a qualifying dependent. A married person can file as Head of Household if
he or she can answer YES to each of the following questions:
1.
2.
3.
4.
Will you file taxes separate from your spouse in the year which the PTC is received?
Will you live separately from your spouse from July 1 to December 31 in that year?
Will you pay more than half of the cost of keeping up your home in that year?
Do you have a child, stepchild, or foster child (of any age) who lives with you more than
half the year?
5. Will either you or the child’s other parent claim the child as a dependent?
Gross Income
All income received in the form of money,
goods, property and services that is NOT
exempt from tax. It includes earned income,
unearned income, and gains but not losses.
It does not include Social Security benefits
unless the person is married and filing a
separate return and lived with the spouse at
any time during 2015 OR half of the
person’s Social Security benefits plus other
gross income and any tax-exempt interest is
more than $25,000 ($32,000 if married filing
jointly).
35
Married Filing Jointly
Legally married, living together or apart. This may occur because one spouse is not available to
sign the return, the couple is separated and unwilling to file taxes jointly, or the couple is
together but they do not want to be held jointly liable for each other’s taxes. These individuals
cannot claim the premium tax credit, but there are two exceptions: survivors of domestic
violence and abandoned spouses.


Non-resident aliens: In general, a couple cannot file jointly if one spouse is a nonresident
for any portion of the year. However, they can choose to file jointly if one spouse is a U.S.
citizen or resident and the non-resident spouse agrees to be treated as a U.S. resident for
the year; in that case, both spouses would be taxed on worldwide income.
Same-sex marriage: As of June 2015, same-sex couple is considered married for federal
and state tax purposes.
Married Filing Separately
Legally married, living together or apart. There is joint responsibility for any tax, interest or
penalty due on the return, including responsibility for the premium tax credits, even if only one
spouse qualifies for the credits.


Abandoned Spouses: A taxpayer is still eligible for premium tax credits if he or she has
been abandoned by a spouse and certifies on the tax return that they are unable to locate
the spouse after “reasonable diligence.”
Victims of Domestic Abuse: A married individual who is living apart from his or her spouse
at the time of filing an income tax return, and is unable to file a joint return as a result of
domestic abuse, will be permitted to claim a premium tax credit while filing a tax return with a
filing status of married filing separately.
Modified Adjusted Gross Income (MAGI)
The universal method used for calculating income
eligibility for all insurance affordability program. It is
adjusted gross income + tax excluded foreign earned
income + tax exempt interest + tax exempt Title II Social
Security Income.
Single
Unmarried, or legally separated or divorced on the last day of the tax year.
 Living apart: Married people cannot claim to be “Single” if they are still married, even if they
have been living apart from their spouse for a long time or their spouse is in another country.
 Legal separation: Indiana residents who are legally separated must still file as married
(either jointly or separately) until their divorce is finalized. Indiana Code 31-15-3-9 specifies
that a legal separation cannot last longer than one year.
 Divorce: A divorce decree must be final in order for the tax filer to be considered “Single”. An
interlocutory decree — a temporary court judgment — is not final and does not qualify a
person to be “Single.”
Unearned Income
Includes interest, ordinary dividends, capital gain distributions, unemployment compensation,
taxable Social Security benefits, pensions, annuities, cancellation of debt, and distributions of
unearned income from a trust.
36
Qualifying Child
In general, a child can be claimed as a qualifying child if he or she is:
 A U.S. Citizen or resident of the U.S., Canada, or Mexico
 Lives with the tax filer for more than half the year
 Is under the age of 19 at the end of the year (or 24 if a full-time student or any age if
disabled)
 Does not provide more than half of his or her own support
Rules for Claiming a Qualifying Child
Relationship—child must be:
 Biological, adopted, foster, or stepchild of the taxpayer
 Brother or sister (including half- and step-siblings of the taxpayer)
 OR niece, nephew, or grandchild of the taxpayer
Age—at the end of the tax year, the child must be:
 Under age 19 and younger than the taxpayer
 Under age 24, if a full-time student for at least five months of the year and younger than the
taxpayer
 Any age if permanently and totally disabled
Residence—child must live with the taxpayer for more than half the year
 Temporary absences, such as a child who attends college and is living away from home, are
considered time in the parents’ home
 There are exemptions for children of divorced, separated parents, or parents who live apart:
o Parents may agree that the noncustodial parent will claim the child, even if the child
lived with the custodial parent for the majority of the year
o The custodial parent must agree and sign a tax form to allow the noncustodial parent
to claim the child
Support—child must not provide more than half of his or her own support
 Total support includes rent or fair rental value of the home, food, utilities and home repairs,
with costs equally divided between family members to decide the child’s portion.
o Expenses related to the child’s clothing, education, medical, travel and other
expenses are included
o State benefits such as TANF or food support are not included
 Includes all of the child’s taxable and nontaxable income such as wages, Social Security
benefits, student loans, and other income
Qualifying Relative
In general, a person can be claimed as a Qualifying Relative if he or she is:
 A U.S. Citizen or resident of the U.S., Canada, or Mexico
 Receives more than 50% of his support from the tax filer
 Cannot be claimed as a Qualifying Child
 Is related to the tax filer or lives in the tax filer’s home all year
 Makes less than $3,900 (in 2014). Generally does not include Social Security.
Rules for Claiming a Qualifying Relative
 NOT a Qualifying Child
 Relationship—prospective dependent must either be related to the taxpayer or live in the
taxpayer’s home for the entire year
 Income—The prospective dependent must not have gross income greater than $3,900
 Support—The taxpayer must pay more than half the support of the prospective
dependent.
37
Qualifying Widow(er) with Dependent Children
Has a spouse that passed away in the previous two tax years with a qualifying child. If a spouse
dies during the tax year, the surviving spouse is considered married for the entire tax year. He
or she can file jointly or separately from their deceased spouse
What should an assister tell a consumer whose marital status will change
during the year?
A person’s marital status is determined by whether he or she is single, married,
legally separated or divorced on the last day of the calendar year for which the
person is filing a tax return. Applicants for premium tax credits should provide their
current filing status on their application.
Counting a Dependent’s Income
Premium tax credit and Medicaid rules require a tax dependent’s income to be included in the
household income if the tax dependent is required to file a tax return. In general, individuals
claimed as dependents on someone else’s tax return must file taxes if they receive at least
$6,200 in earned or $1,000 in unearned income (for 2014 tax year).
Medicaid Rules for Determining Household
38
Rules for All Dependents—To be a dependent, three tests must be met:
 The person claiming the dependent cannot be a dependent of another taxpayer.
 If the prospective dependent is married, he or she can still be claimed as a dependent.
However, if the married dependent files a joint return with his or her spouse, the return
must be filed only to claim a refund of taxes paid during the year through wage
withholding.
 The prospective dependent must be a U.S. citizen, resident or national or must be a
resident of Mexico or Canada.
Helpful
Resources
CBPP’s The Assister’s Guide to Tax Rules
In The Loop’s Tax Resource Center
IRS Tax Tips Newsletters
Health Coverage and Federal Income Taxes
Most tax filers, about 75%, just need to check a box on their tax return to indicate that they had
coverage all year. Marketplace consumers receive a Form 1095-A that includes all the
information they need about their coverage to file their return. Consumers will use the
information included on Form 1095-A to complete Form 8962, which they will file with their tax
returns to claim the premium tax credit or to declare premium assistance they received through
advanced payments made to their insurance provider. Read more about the Form 1095-A
online: https://marketplace.cms.gov/technical-assistance-resources/1095a-faqs.PDF.
Exemptions
Consumers who obtained a coverage exemption from the Marketplace or qualify for an
exemption that can be claimed on the tax return will file Form 8965.
NOTES:
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39
Navigating the Federal Marketplace
____________________________________________________________________________
____________________________________________________________________________
Basics of Patient Protection and Affordable Care Act (ACA)
The Patient Protection and Affordable Care Act (ACA) was passed on March 23, 2010 under the
President Barack Obama administration. This created a new avenue to purchase health
insurance coverage—the Marketplace, or Exchange which is managed by the U.S. Centers for
Medicare & Medicaid Service (CMS) and accessed through www.healthcare.gov. In addition,
the law allows for tax subsidies to help individuals afford coverage, enacted tax penalties
associated with not having health insurance, and restricted the time coverage is available for
purchase. Other benefits of the ACA include:
Eligible young adults
can be covered
under a parent’s plan
until age 26
Individuals with preexisting conditions
are no longer
excluded from
coverage offers
Lifetime and annual
maximums are
eliminated
Preventive and
wellness services are
mandated benefits
without any costsharing requirements
Common Terms Defined
Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA gives workers and their families who lose their health benefits the right to choose to
continue group health benefits provided by their group health plan for limited periods of time
under certain circumstances such as voluntary or involuntary job loss, reduction in the hours
worked, transition between jobs, or death, divorce, and other life events. Qualified individuals
may be required to pay the entire premium for coverage up to 102% of the cost to the plan.
Catastrophic Coverage
What is it?
Plans with high deductibles and lower
premiums
Consumer pays all medical costs up to a
certain amount
Includes 3 primary care visits per year and
preventive services with no out-of-pocket costs
Who is eligible?
Young adults under 30
Those who qualify for a hardship exemption
Those whose plan was cancelled and believe
Marketplace plans are unaffordable
Cost-sharing Reduction Program (CSR)
 Reduces out-of-pocket costs for consumers
 Increases the Actuarial Value (AV) of health coverage plans for low-income consumers
(below 250% FPL)
 Consumer must select at least a Silver plan
 Members of federally recognized tribes may qualify for additional cost-sharing benefits.
40

Quick Facts about
American Indians and
Alaska Natives
Members of federally recognized tribes and Alaska Native
Claims Settlement Act (ANCSA) Corporation shareholders:
 Can enroll in the Marketplace any time
 Can change plans up to once a month
 Can be exempt from the penalty for not having
health coverage
 Do not have any out-of-pocket costs for Indian
health programs
 Do not have any out-of-pocket costs if their income
is below 300% FPL
Excepted Benefit Plans
Plans that cover a specific service or condition and do not provide comprehensive health
coverage. They are not subject to many of the ACA market reforms. The most common is
stand-alone vision. Stand-alone dental plans are the only excepted benefit plans offered on the
Marketplace. They are:
x Not offered in the metal tier levels of QHP
 Subject to a maximum out of pocket amount
 May be purchased using the APTC
x Not eligible for cost-sharing reductions
Exemptions
Individuals may seek an exemption from the shared responsibility requirement by applying for
one or more of the exemption types. To be eligible for an exemption in any month, the individual
must meet the criteria for the exemption for at least one day in that month.
Reason for Exemption
Where to apply
When to apply
Length of
exemption
No health insurance for less than
3 months in a row (short coverage
gap)
No application
needed; this will be
handled on tax
return
Tax return or
automatically
exempt if not
required to file a
tax return
Tax return
2015 Application
Tax filing
The months without
coverage, up to 3
months
N/A
Calendar year
Tax filing
Calendar year
IRS will provide
guidance
IRS will provide
guidance
Marketplace
application, tax
return, or this form
Marketplace
application, tax
return, or this form
Anytime within the
year
Until the first full
month that
immigration status
has changed
Month(s) in prison or
jail after a conviction
Anytime within the
year
Months of
membership
Income below tax filing threshold
Insurance is more than 8% of
household income (income from
all members of household listed
on taxes)
Not lawfully living in the US, do
not have permanent residency, or
considered a “nonresident alien”
In jail or prison after a conviction
Member of a recognized health
care sharing ministry that pays
the health expenses of its
41
members
Member of a federally recognized
Indian tribe or ANCSA corporation
Marketplace
application, tax
return, or this form
Anytime within the
year;
documentation
must be submitted
Anytime within the
year
Member of a religious sect that is
opposed to insurance, such as
the Amish
Marketplace
application or this
form
Eligible for services through an
Indian health care provider
Marketplace
Anytime within the
application or this
year
form
Hardship Exemptions
Marketplace
Right away when
application or this
hardship begins
application for
exemption form

Unexpected increase in basic
expenses that prevents
purchase of coverage
 Cost of coverage would
deprive individual of food,
shelter, clothing or other
necessities
 Homelessness, eviction,
foreclosure, damage from
natural disaster
 In a plan that cannot be
renewed and cannot afford
other plans (See complete list
here)
Insurance would cost more than
8% of household income for the
upcoming year
Income is below 100% of poverty,
but cannot get Medicaid (Hoosier
Healthwise, HIP, etc.
Marketplace
application
Marketplace
application
Before February
15, during a
special
enrollment
period, or when
eligible for a jobbased plan
Anytime within
the year
Continues unless a
change is reported
For adults, continues
until a change is
reported
For children,
continues until age
21, at which time a
separate application
is required
Until ineligibility for
services is reported
At least three
months; might need
to be renewed
The rest of the year
after an exemption is
granted
Calendar year
Grandfathered Plans
Health plans in existence prior to the passage of the ACA that do not have to comply with some
provisions related to benefits, cost-sharing, pre-existing condition exclusions and annual
maximums. Plans may only maintain grandfathered status if they do not make substantial
changes to their policies. Individuals offered grandfathered coverage through an employer may
choose to not accept the coverage and purchase coverage that meets ACA requirements
instead. Grandfathered plans may be renewed up until October 1, 2016.
42
Individual Mandate (Individual Shared Responsibility Requirement)
Affordable Care Act (ACA) condition requiring individuals to maintain health coverage for
themselves and their dependents; health coverage must be considered Minimum Essential
Coverage (MEC) as determined by the federal government. All Qualified Health Plans (QHPs)
on the Marketplace must cover certain the 10 Essential Health Benefits (EHBs) set for 20152016.
Minimum Essential Coverage
Coverage for one day in the month is considered to be coverage for the entire month.
Types of MEC
Coverage under a government sponsored program including:
 The Medicare Program
 The Medicaid Program
 The Children’s Health Insurance Program (CHIP)
 Veteran’s Administration programs including TriCare and CHAMP VA
 Coverage for Peace Corps Volunteers
 Coverage under an employer-sponsored health plan
 Coverage under a health plan offered in the individual market within a state
 Coverage under a grandfathered health plan
 Additional coverage as specified such as Refugee medical assistance and Medicare
advantage plans
Metal Levels (Actuarial Value)
The Marketplace offers four categories of Qualified Health Plans (QHPs), known as “Metal
Levels” which are distinguished by the share of health care costs QHP are expected to cover.
These four levels are indexed to actuarial value, or the percentage that insurance companies
will pay on average for the health services consumers use.
Metal Level
Bronze
Silver
Gold
Platinum
AV target
AV Band
60%
70%
80%
90%
58-62%
68-72%
78-82%
88-92%
Modified Adjusted Gross Income
Modified Adjusted Gross Income or MAGI is the figure used to determine eligibility for lower
costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income
is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income
you have.
Items NOT Counted for MAGI Income Eligibility
American Indian and Alaskan Native tribal income
Child support
Educational income (used for tuition and books)
SSI
Nominal cash support for dependents
Veterans’ benefits
Assets such as homes, stocks or retirement accounts
Workers’ compensation
Income disregards (except tax deductions and non-taxable income
43
Open Enrollment Period
Annual timeframe when consumers can purchase health coverage on the Marketplace. The
open enrollment period for 2015-2016 is November 1, 2015—January 30, 2016.
Premium Tax Credit (PTC)
 Lowers the monthly premium amount
 Can be used to purchase any plan on the federal Marketplace
 Can be paid directly to insurer (Advanced Payment)
 Available to consumers 138-400% of the Federal Poverty Level (FPL).
The amount of the premium tax credit (PTC) and the level of cost-sharing reductions (CSR) is
based on the applicant’s income. Income is expressed as a percentage of the federal poverty
level (FPL), which is updated each year and published by HHS.
PTC Eligibility
Must be a citizen, national,
or legal resident of the U.S.
Household income between
138% and 400% of FPL
No other MEC is available;
or available coverage has
individual premium ≥ 9.5%
household income or does
not provide minimum value
Individuals can have the full amount of the PTC sent directly to the insurer as an advanced
payment option, elect to have partial payment with the potential of a tax credit at filing time, or
claim the entire amount later on their tax return. The amount that an individual may owe the IRS
due to an overpayment of the APTC is capped, so individuals between 100% and 400% FPL for
the 2015 tax year may owe no more than the amounts due to excess APTC payments
2014 APTC Repayment Caps
Household income
Single Individual
Family
< 200% FPL
$300
$600
200% to 300% FPL
$750
$1,500
300% to 400%
$1,250
$2,500
400% and above
Full Amount
Full Amount
Please note that at the time of this publication, the 2015 numbers were unavailable.
Please refer to IRS.gov for updates.
Qualified Health Plans (QHPs)
Plans sold on the Marketplace must be certified and accredited as QHPs and provide Minimum
Essential Coverage (MEC), cover Essential Health Benefits (EHBs), and meet Actuarial Value
(AV) and provider network standards. QHPs are the only plans that an individual can purchase
that are eligible for the Premium Tax Credit (PTC) or Cost-Sharing Reductions (CSRs).
Rating Rules
The ACA limits the factors that major medical plans can base the price of their plan on to age,
location and tobacco use.
44
Rating for Age
Limited to a 3 to 1 ratio—older adults may be charged no more than three times
the premium as younger adults.
3x
Rating for Location
The ACA allows insurers to adjust their premiums depending on enrollee’s location; there are 17
rating areas in Indiana.
Rating for Tobacco
Up to 1.5 times the premium for individuals that use tobacco. Tobacco use is
defined as use of any tobacco product on average four or more times per week
over the past six months. At no point may a rate increase for tobacco based on
age contradict the three-to-one age rating limit.
1.5x
Shared Responsibility Payment
Those who do not have MEC or an exemption will be required to pay a shared-responsibility
payment to the IRS upon tax filing. It is calculated on a monthly basis, or one-twelfth (1/12) of
the annual penalty amounts, for each month without coverage.
45
Special Enrollment Period (SEP)
A time outside of the open enrollment period when a consumer can sign-up for health coverage.
In the Marketplace, an individual qualifies for a special enrollment period 60 days following
certain life events that involve a change in family status.
SEP Event
Details/Examples

Loss of Minimum
Essential Coverage (MEC)













Loss of eligibility for employer coverage (e.g., loss
of a job,
Voluntarily quitting a job, or a reduction in work
hours that causes
Loss of availability of employer-sponsored plan
Loss of Medicaid or CHIP eligibility (including loss
of pregnancy-related and medically needy
Medicaid)
Expiration of COBRA
Cancellation of non-group plan
Loss of eligibility for student health plan
Divorce or legal separation resulting in loss of
coverage
Cessation of dependent status
Death (i.e., of another person in the family)
resulting in loss of coverage
Decertification of current Marketplace coverage
No longer living, working, or residing in the area of
the plan
Termination of employer contributions to
employee’s health coverage
Newly eligible for the premium tax credit due to
discontinuation or change to employer-sponsored
plan resulting in plan no longer being considered
MEC


IF PLAN SELECTED
AFTER DATE OF
LOSS OF COVERAGE:
1st day of the month
following plan selection
The plan year ends for a non-calendar year plan
in the individual (non-group) or group market (i.e.,
the plan year ends in a month other than
December)
Applies even if there is an option to renew the
non-calendar year plan
1 of the next month
following plan selection
IF PLAN SELECTED
BEFORE OR ON DATE
OF LOSS OF
COVERAGE: 1st day of
month following loss of
previous coverage
Death: Enrollee or enrollee’s dependent dies
Divorce
IF PLAN SELECTED
AFTER
DATE OF LOSS OF
COVERAGE: 1st day of
the
month following plan
selection
Date of birth, adoption,
placement of adoption or
placement in foster care
1st day of month
following plan selection
Birth, Adoption, Foster Care
Losing a dependent or no
longer considered a
dependent
IF PLAN SELECTED
BEFORE OR ON
DATE OF LOSS OF
COVERAGE: 1st day of
month following loss of
previous coverage
st
Marriage
Expiration of noncalendar year plan
QHP Effective Date


46



Loses a dependent due to divorce
No longer considered a dependent due to
divorce
Includes losing dependent through a child
support order or other court order
Gaining lawfully present status

Newly eligible or
ineligible for APTC,
change in CSRs


Permanent Move





Regular coverage
effective dates
Change in income or household size leads to
determination that enrollee or dependent is newly
eligible or ineligible for premium tax credits
Change in income or household size changes
eligibility for cost-sharing reductions
Includes moving between cost-sharing reduction
levels and losing or gaining eligibility
Move within the same city, county, or state as
long as there is a different set of qualified health
plans available
Move to another state
Return to the U.S. after living outside the country
A child or other dependent moves back to parent’s
home
Released from incarceration
Native American or
Alaska Native status
Is or becomes a member of a federally recognized
Native American or Native Alaskan tribe
Exceptional
Circumstances

Demonstrate to the Marketplace that an individual
meets exceptional circumstances
 Serious medical condition or natural disaster kept
person
 from enrolling during open enrollment (e.g.,
unexpected
 hospitalization or temporary cognitive disability; an
earthquake, hurricane, or massive flooding)
 Survivors of domestic violence or abuse or
spousal abandonment
 Medicaid/Marketplace transfers that kept a person
from enrolling in coverage during open enrollment
 System errors related to immigration status
 Unresolved casework that kept a person from
enrolling in
 coverage during open enrollment
NOTE: Many complex situations may trigger an SEP
under exceptional circumstances. For more
information on this SEP and how to access it, see
Healthcare.gov: www.healthcare.gov/sep-list
47
Regular coverage
effective dates
IF PLAN SELECTED
BEFORE DATE OF
MOVE: 1st day of month
following
permanent move
IF PLAN SELECTED
AFTER DATE OF
MOVE: Regular
coverage effective dates
Regular coverage
effective dates (May
enroll in or change
QHPs one time per
month)
Effective date
appropriate to
circumstances
Error/Inaction/Misconduct
Error, misrepresentation, or inaction by the
Marketplace or HHS, its instrumentalities, or other
entity providing enrollment assistance (e.g., assisters,
navigators, insurers, brokers) resulted in the person
not being enrolled in a plan, being enrolled in the
wrong plan, or not receiving advance payments of
premium tax credits or costsharing reductions for which the person was eligible
NOTE: For more information on this SEP and how to
access it, see Healthcare.gov:
www.healthcare.gov/sep-list
Effective date
appropriate to
circumstances
Health plan violation
Demonstrate to the Marketplace that QHP
substantially violated a material provision of its
contract
Effective date
appropriate to
circumstances
Student Health Insurance
Only self-funded student health coverage qualifies as MEC. Effective May 12, 2014, student
health plans are not required to be offered as a calendar year plan. Student health insurance is
exempt from the requirement to establish open enrollment period and coverage effective dates
based on a calendar policy year.
Assisting Consumers with Marketplace Applications
Screening Consumers
First of all, make sure you do these three things:
Introduce
yourself as a
Navigator
Explain your
role and how
you can help
Reveal any
potential
conflicts of
interest
Then you can proceed to determine their coverage options by:
Assessing knowledge:
Are the familiar with
ACA? Tax penalty?
PTCs?
Asking about:
- Household size
- Household income
- Plan to file taxes
- Coverage preferences
Answering questions:
Direct consumer to
additional resources
while keeping the focus
on the application
To purchase coverage on the Marketplace, individuals must:
 Be U.S. citizen or legal resident
 Reside in the state they are applying in
 Not be incarcerated
48
Reporting Household Size
Include
Do NOT Include

Consumer
x

Consumer’s spouse
x

Children who live with the consumer, even
if they make enough money to file a tax
return themselves
Unmarried partner needing health
coverage
Anyone claimed as a dependent on a tax
return, even if they do not live with the
consumer
Anyone else under 21 who the consumer
lives with and takes care of
x



x
Unmarried partner who does not need
health coverage
Unmarried partner’s children, if they are not
consumer’s dependents
Parents living with the consumer, but file
their own tax return and are not
consumer’s dependents
Other relatives who file their own tax return
and are not the consumer’s dependents
Estimating Income









Include
Consumer’s and their spouse’s gross
income, if they are married and will file a
joint tax return
Any dependent’s gross income who is
required to file a tax return
Wages
Salaries
Tips
Net income from any self-employment or
business
Unemployment compensation
Social security payments, including
disability payments—but not SSI
Alimony
x
Do NOT Include
Child support
x
Gifts
x
x
x
x
Supplemental Security Income (SSI)
Veterans’ disability payments
Workers’ compensation
Proceeds from loans (like student loans,
home equity loans or bank loans)
Disability Questions
The consumer should answer “yes” to the Marketplace disability question if he or she and/or
other household members is blind, aged, or hard of hearing;
Activities of daily living
receives SSDI or SSI; has a physical, intellectual or mental health
Bending
Eating
condition causing: serious difficult completing activities of daily
Hearing
Lifting
living, difficulty doing errands, serious difficulty concentrating,
Thinking
Breathing
remembering or making decisions, and/or difficulty walking or
Sleeping
Standing
climbing stairs.
Seeing
Walking
Employer-Sponsored Coverage Questions
The Marketplace may require consumers who are currently employed with access to employersponsored coverage to enter additional information about who (with employer) to contact about
employee health coverage (usually HR); amount employee pays for premium cost; any known
changes in future employer coverage; and whether employer-sponsored coverage meets
minimum value (whether the policy covers at least 60% of healthcare costs for the covered pool,
on average, after premiums).
49
Coverage Effective Dates
The start date for federal Marketplace coverage is based on the date a consumer completes
enrollment in a QHP. A consumer is not considered enrolled in a QHP until they pay their
portion of the first month’s premium. In general coverage purchased by the 15th of the month is
effective the 1st of the next month, and coverage purchased after the 15th is effective the 1st of
the following month.
Helping Consumers Maintain Coverage
There are many reasons adults and children lose coverage despite their eligibility such as
administrative barriers, cost, or not knowing how to navigate the health coverage system. As an
assister, you should help consumers understand their responsibilities as insured.
As an assister, you might help consumers with the following tasks:
Choosing a
health
coverage plan
How and when
to pay
premiums
How the annual
redetermination
process works
How and when
to report life
changes
Terminating a
plan
Appealing a
decision
Choosing a plan
Individuals can select a plan based on quality, covered benefits, covered providers, and
expected cost-sharing level. Remember to remain neutral as your help the consumer compare
plans and weigh their options for health coverage.
Reporting Life Changes
Once a consumer has Marketplace coverage, they are responsible for reporting certain life
changes which may change the coverage or savings they’re eligible for. These changes include:
Marriage or divorce
Having or adopting child or
placing child for adoption
Change in income
Changing place of
residence
Change in disability status
Gaining or losing a
dependent
Changes in tax filing status
Change in citizenship or
immigration status
Incarceration or release
Correction to name, date
or Social Security number
Getting health coverage
through Medicare or
Medicaid
Becoming pregnant
Change in status of
America Indian, Alaska
Native or tribal status
Other changes affecting income or household size
Reporting a change can occur through two methods:
Online
Log-in to account. Select the
application and report the life
change.
A new eligibility notice will be
generated that will explain
eligibility for a SEP.
By phone
Contact the Marketplace Call
Center (1-800-318-2596), and a
representative will authorize the
SEP.
Paying Premiums
If consumers do not pay their premiums, qualified health plans (QHPs) can cancel their
coverage. Consumers receiving the advanced premium tax credit (APTC) have a three-month
grace period before their coverage can be cancelled (as long as they have paid their premiums
50
for at least one month). Consumer must repay all outstanding premiums by end of grace period,
or QHP may cancel the coverage. Consumer may have to pay for all health care services
received during the second and third months of the grace period.
Annual Redeterminations
2015 coverage ends December 31, 2015 for all Marketplace plans!
Historically, coverage loss at renewal is all too common in public health coverage programs like
Medicaid and CHIP. Millions of consumers will experience the Marketplace renewal process this
fall for the second time. Consumers should be strongly encouraged to use the open enrollment
period as an opportunity to update their information and reevaluate their health coverage needs
for the coming year. The consumer’s insurer will send information prior to November 1st about
updated premiums and benefits. If a consumer is happy with his or her current plan, and income
or household size HAVE NOT changed, then he or she does not need to do anything. The
Marketplace will auto-enroll the consumer in the same plan for 2016.
If a consumer wants to change plans, he or she can:
1. Choose any other Marketplace plan within the same insurer and service area if she or he
wants to stay with same company.
2. Choose a new health plan from a different insurance company through the Marketplace.
3. Buy a new private plan outside the Marketplace. (Will not be eligible for PTC or CSR)
In some cases, 2015 plans will not be offered in 2016 (e.g Assurant enrollees). These
individuals will be automatically enrolled in a similar plan unless he or she chooses another plan
and enrolls. These individuals will also be eligible for an SEP because their plan is ending.
For an enrollee who did not authorize the Marketplace to request updated tax return
information for use in the annual redetermination process:
• For those receiving APTC and CSR, a notice will be mailed that states something like:
Unless the individual contacts the Marketplace to obtain an updated eligibility
determination by December 15th for coverage effective January 1, 2016, then APTC and
CSR will end on December 31, 2015.
• The Marketplace will renew the enrollee’s coverage in a QHP for 2016 without APTC
and CSR if coverage is otherwise renewable.
For individuals found in excess of 500% FPL:
Individuals who are enrolled in a Marketplace QHP with APTC or CSR who authorized the
Marketplace to request updated tax information will receive the standard notice, and they will be
told that if they do not contact the Marketplace to update their information they will be
terminated from PTC and CSR and reenrolled in their QHP without assistance if the plan is
renewable. Individuals must report eligibility changes by December 15, 2015 to receive an
updated eligibility determination.
51
Tips for Educating Consumers about the Renewal Process
Establish a systematic way for staff to remind consumers about their coverage renewal
date and/or the open enrollment period
Add an alert to medical records that staff can see when patients come in for appointments
Use social media to promote messages that inform about reporting life changes and
renewal processes
Use appointment cards, posters and mailings to communicate with patients at time of
renewal
Develop materials geared toward your clients that highlight the key aspects of the renewal
process
Terminating a Health Coverage Plan
Individuals may terminate their enrollment in a QHP at any time. To terminate enrollment in a
QHP the individual should contact their qualified health plan directly. QHPs may terminate
enrollees for non-payment of premiums, enrollment in another QHP, or fraud.
Appealing a Health Coverage Decision
Individuals that believe their eligibility determination for a QHP, or eligibility for APTC or CSR is
incorrect should contact the federal Marketplace to file an appeal. Individuals may file appeals
for up to three years after they experienced the triggering event.
Individuals that believe they have been denied a provider or service they should have had
access to through their QHP, should contact the plan administrator as soon as possible.
Individuals who do not feel their situation is resolved through the QHP grievance procedure may
request an appeal from the QHP issuer.
Same-Sex Spouses
Effective January 1, 2015, a health insurance issuer cannot deny coverage options to same-sex
spouses under the same terms and conditions as coverage offered to opposite sex-spouses if
the marriage was legitimately entered into in a jurisdiction where the laws permit the marriage of
two individuals of the same sex, regardless of the jurisdiction in which the insurance policy is
issued or where the policyholder resides. Same-sex spouses will also receive premium tax
credits and cost-sharing reductions, as applicable. As of June 2015, same-sex marriage is
legally recognized on both state and federal levels.
2016 Qualified Health Plan (QHP) Issuers
Ambetter (CeltiCare; formerly MHS—both of Centene Corporation)
Ambetter is an HMO network which services 28 counties in Indiana.
Member Benefits: My Health Pays program—members who stay up-to-date
with preventive care services can earn rewards, wellness program
reimbursement, discounts on gym memberships, and special health
management and pregnancy programs.
Ambetter Phone Number
Member Services: 1-877-687-1182
Website: www.ambetter.mhsindiana.com
52
Anthem
Anthem is Indiana’s largest health insurance company with approximately four million enrolled
Hoosiers as of November 2014. Anthem services all counties in Indiana and contracts with over
1,500 primary care providers and over 9,000 specialty care providers. As an open access HMO
Network, Anthem Marketplace members
Anthem Phone Numbers
do not need to select a Primary Care
 Broker Service Center (helps Navigators): 1-800-742-8199
Physician (PCP) and do not need a
 Customer Service: 1-855-330-1095
referral to access services that are in Provider Service: 1-855-854-1438
network.
Website: www.anthem.com
Member Benefits: Special member-only savings on fitness center memberships, hearing aids,
LASIK eye surgery, vitamins, health and beauty products, and massage therapy.
CareSource
CareSource is an HMO that does not require referrals for in-network services. All
Indiana University (IU) Health providers are in-network (4,000 as of November
2014) for a total of 10,000 in-network providers in 23 counties.
Member Benefits: Free generic prescriptions with Silver and Ultra Gold plans,
healthy living programs, and optional dental coverage.
CareSource Phone Numbers



Customer Service: 1-877-806-9284 or 1-800-429-9502
Provider Service: 1-866-286-9949
Nurse Advice Line: 1-866-206-4240
Website: www.CareSourceJust4Me.com
Indiana University (IU) Health Plans
IU Health is Indiana’s largest healthcare system which will service 45 counties in 2016. The
HMO provider network includes all IU Health physicians and other non-employed physicians at
all Indiana Health Hospitals, including Riley Hospital for Children. Referrals are needed for a
specialist provider.
IU Health Phone Numbers
Member Benefits: Local customer solutions
center and personal case and disease
management
MDwise
MDwise is an Indiana-based, not-for-profit
company that will service all 92 counties in
2016. Members select a Primary Medical
Provider (PMP) by calling the MDwise
customer service line; PMPs provide referrals
to specialists.


Direct enrollment: 1-888-820-1275
Member Service: 1-855-413-2432
o Existing member service: #1
o Enrollment information: #2
Website: www.iuhealthplans.org
MDwise Phone Numbers


Customer Service: 1-855-417-5615
o Provider Service: #1
o Member Service #2
NURSEon-call: 1-855-417-5615
Website: www.mdwise.org
Member Benefits: Rewards program for receiving preventive care, completing health risk
screening, maintaining healthy weight, etc. (MDwise Rewards—earn points to receive free gift
cards).
53
Physicians Health Plan of Northern Indiana (PHP)
PHP is an Indiana-based health insurance company headquartered in Fort Wayne. PHP is
available in 28 counties in northern Indiana with approximately 12,000 providers to choose from.
Plans offered are HMO open-access with HSA options available.
Member Benefits: Health clubs (e.g. YMCA and Anytime Fitness and
health class (e.g. CPR) discounts, game and activity discounts (e.g. Fort
Wayne Children’s Zoo)
PHP Phone Numbers


Customer Service: 1-800-982-6257
o Pharmacy: #14
o Billing: #16
o All other calls: #11
MyNurse 24/7: 1-800-931-4714
Website: www.phpni.com
Southeastern Indiana Health Organization (SIHO)
SIHO is an HMO network that services six counties in southern Indiana
(Bartholomew, Brown, Decatur, Jackson, Jennings, and Scott).
SIHO Phone Numbers


Member Services: 1-812-378-7070 or
1-800-443-2980
o Provider: #1
o Member: #2
Marketplace Enrollment Support: 1-844-378-7103
Website: www.siho.org
UnitedHealthcare (UHC)
UHC is licensed under All Savers Insurance Company (ASIC) on FFM and covers all 92
counties with all Indiana hospitals in-network.
Member Benefits: myHealthcare costs
calculator to estimate prices of doctor visits,
inpatient procedures, and medications and
a variety of other digital and mobile tools.
UHC Helpful Phone Numbers


Navigator Hotline: 1-866-698-1739
Member Services: 1-877-512-9947
Website: www.uhc.com/
Key Changes From 2015
MDwise is expanding from 71
counties to statewide
coverage of all 92 counties.
Time (Assurant) is
discontinuing its
plans and will not be
a QHP issuer in
2016
54
IU Health Plans will expand
coverage from 17 to 45
counties
Resources for Addressing Consumer Needs
Need or Concern
The Affordable Care Act
Health plan details
Plan recommendations
Plan quality
Complaints about a
Consumer Assistant
Complaints about Health
Insurance Plan
Find another Navigator
Resource(s)
Federal Marketplace call center: 1-800-318-2596
Health plan summary of benefits, insurance carrier, Employer’s
Human Resources of Benefits Manager
IDOI—research “Find agent/broker”
Federal Marketplace researching, “Consumer Experience”
IDOI:
 On-line Form (click here)
 Printable Fillable Form (PDF)
1st : Contact health insurance company
2nd: If unable to resolve the issue with health insurance company,
contact IDOI
IDOI—”Find an Indiana Navigator or AO in Your County”
Enroll America locator tool
Filing Complaints with Indiana Department of Insurance (IDOI)
IDOI accepts complaints and compiles reports so you and other members of the public can
evaluate the companies and agents who conduct insurance business in Indiana. Once the
complaint information has been collected, IDOI thoroughly investigates all circumstances and
take any appropriate action to prosecute or fine the company or person if found to be at fault.
If the insurance company has not followed the terms and conditions of your policy, you may
submit a consumer complaint form. Examples of appropriate issues include:
 Coverage Concerns
 Claim Disputes
 Premium Issues
 Policy Cancellations
 Refunds
You may submit a consumer complaint online using the on-line forms below or via the mail. Mail
all complaints to:
Indiana Department of Insurance
Consumer Service Department
311 West Washington Street, Suite 300
Indianapolis IN 46204-2787
Fax to:
317-234-2103
Types of Issues Handled by IDOI
 Improper denial or delay in settlement of a claim
 Alleged illegal cancellation or termination of an insurance policy
 Alleged misrepresentation by an agent broker or solicitor
 Alleged theft of premiums paid to an agent, broker, or solicitor
 Problems concerning insurance premiums and rates
 Alleged improper handling of an insurance claim by a company or agent
What IDOI Can Do:
 Forward a copy of your complaint to the insurance company, if appropriate
55





Obtain information or explanations on your behalf from the insurance company or their
representatives. This may involve written and verbal contact with such companies or
persons
Review in detail the information obtained from the company for compliance with statues,
regulations and policy contracts
Explain the provisions of your insurance policy, as appropriate
Suggest to you actions or procedures that you may take which could aid in resolving
your insurance problems
If it is determined that the actions of an insurance company are in violation of a statute,
regulation or policy that the Division enforces we may take corrective action against that
company.
See more information about filing complaints with IDOI here:
http://www.in.gov/idoi/2547.htm.
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Small Business Health Options Program (SHOP)
What is the Small Business Health Options Program (SHOP)?
The SHOP Marketplace (www.healthcare.gov/small-businesses) is an avenue on the federal
Marketplace for small businesses to purchase health insurance coverage for employees. SHOP:
• Simplifies the process of buying health insurance
• Helps curb premium growth and spurs competition based on price and quality
• Provides access to a small business tax credit
Certified enrollment specialists are permitted to assist employers with SHOP. Federal
Navigators are required to assist with SHOP, but CACs are not.
Employer Mandate—Employer Shared Responsibility Provision
Starting in 2015, employers with over 50 full-time equivalent employees or a combination of fulltime and part-time equivalent employees are subject to the employer shared responsibility
provision, or employer mandate. These employers will be subject to a fine collected by the IRS
for each month they have one or more full-time employees receiving a Premium Tax Credit
(PTC).
• Employees can only get PTC if employer-sponsored coverage is not offered or it is
considered unaffordable (greater than 9.5% of the employees’ household income)
• Employers will not be subject to the shared-responsibility payment if employees that
work on average less than 30 hours a week receive a PTC.
Employers offering coverage to at least 95% of
full-time employees
Penalty is the lesser of:
 $250 per month or $3,000 per year for each fulltime employee receiving a Premium Tax Credit,
or
 $167 per month or $2,000 per year for every
full-time employee and full-time equivalent
employee, excluding the first 30 employees
Employers not offering coverage to at least
95% of full-time employees

$167 per month or $2,000 per year for
every full-time employee and full-time
equivalent employee, excluding the first
30 employees
How SHOP Will Work in OE3
The SHOP Marketplace is open to employers that meet the following requirements:
Have at least 1
common-law employee
on payroll (cannot be a
spouse)
Offer coverage to all
full-time employees
working more than 30
hours a week
th
th
Meet the 70%
participation rate of fulltime employees offered
coverage (does not
include spouses or
dependents, if offered)*
* The requirement is waived between November 15 and December 15 of each year
57
Employers interested in SHOP coverage should contact their agent or broker or the Marketplace
directly at http://www.healthcare.gov or 1-800-706-7893.
2015 SHOP Guidelines
In 2015, the employer selects a metal coverage level (bronze, silver, gold, or platinum), as well
as a reference plan within that coverage level. The employer and employees portions of the
premium will go directly to the SHOP Marketplace. The SHOP Marketplace will also offer small
employers an Employee Choice option.
2016 SHOP Guidelines
Beginning in 2016, SHOP will be open to employers with up to 100 FTEs. Employers that enroll
in SHOP coverage and then grow past the small group limit for employees may continue with
their SHOP coverage, and renew their SHOP coverage.
Metal Level
Bronze
Silver
Gold
Platinum
Plan Pays (average)
Employee Pays
60%
70%
80%
90%
40%
30%
20%
10%
Calculating Full-time Equivalent Employees
To calculate full-time equivalent employees (FTEs):
• Use the most recent year
• Exclude seasonal employees (those working <120 day a year)
• Count the number of people who worked an average of 30+ hours a week
• Add this amount to the number of hours worked per week by non-full time employees
divided by 30
Helpful Tool


SHOP FTE Calculator: https://www.healthcare.gov/shop-calculatorsfte/
Guide to Enrolling in the SHOP Marketplace
Minimum Participation Rate for SHOP
What if a business does not reach the minimum participation rate?
1. Change offer of coverage
 e.g. Increase the amount the employer contributes to the employees’ insurance
premiums to encourage more participation
 Change of offer cancels current offer, and the process starts over with a new
enrollment period
2. Enroll between November 15th and December 15th. The minimum participation
requirement does NOT apply during this annual enrollment period.
3. Completely withdraw offer of coverage.
An employer can reapply at any time during the same calendar year if minimum participation
was not met. Mid-year changes in participation do not affect ability to maintain coverage.
58
Benefits of SHOP
 Apply year-round.
 Control the coverage offered and how much is paid toward employee premiums.
 Choose from the four tiers of coverage to find a plan that meets the needs of the
business and employees.
 Start coverage any time.
 Establish own open enrollment period of at least 30 days.
 Same coverage start dates on the individual Marketplace apply in SHOP.
 SHOP coverage for businesses with fewer than 25 employees may qualify for a
small business health care tax credit.
Appealing a SHOP Decision
SHOP eligibility is determined within 3-5 days of receiving a completed application. Employers
have 90 days from the date of the notice to request an appeal and can appeal SHOP decisions
in 2 cases:
1. Receiving a notice that denies SHOP eligibility
2. The SHOP Marketplace has not made a SHOP eligibility determination in a
timely manner
Appeal request form should be mailed, or a letter should be written including name, address,
phone number and explanation. If the appeal determines eligibility for SHOP, the decision must
be retroactive to the date the incorrect determination was made.
Small Business Health Care Tax Credit
Business must have an official eligibility determination from the SHOP Marketplace before the
end of 2015. Employer claims the tax credit when submitting federal income tax returns for 2016
using form 8941. To qualify, 50% of the full-time employees’ premium costs must be paid by the
employer. The tax credit is worth up to 50% of the employer’s premium contribution (up to 35%
for tax-exempt employers). Businesses with < 25 employees making an average of ≤ $50,000
may qualify for tax credits if purchasing through SHOP.
Tips for Assisting SHOP Consumers
Prescreen employers
based on number of fulltime employees or fulltime equivalent
employees and average
incomes
Use the Healthcare.gov
Premium Estimator Tool
with employers which will
show a list of available
plans in their area
Encourage consumers to
keep a copy of SHOP
eligibility determinations
for tax filing purposes
59
Use the HealthCare.gov
Full-time Equivalent
(FTE) Employee
Calculator
Use the HealthCare.gov
SHOP Tax Credit
Estimator
The Role of Agents, Brokers, and Producers in SHOP
The SHOP Marketplace on HealthCare.gov has an Agent/Broker Portal with online enrollment
functions. To work with the SHOP Marketplace, all agents and brokers must keep an active
SHOP registration, an active state insurance license, and National Producer Number (NPN).
Brokers act on behalf of the consumer. They can be compensated by the consumer or receive
compensation from an insurance company.
Agents are loyal to an insurance company and sell, solicit, or negotiate insurance on behalf of
the insurer. They are compensated by the company (or companies) only. An “independent
agent” is affiliated with more than one company. A “captive agent” works for or on behalf of one
insurance company. (When you buy a policy directly from an insurance company, you are
probably going through an in-house agent.)
Producer is a broader term that encompasses both agents and brokers. A producer is defined
as someone who sells, solicits, or negotiates insurance.
SHOP Resources for Assisters
SHOP Small Employer
Call Center
Health Insurance
Marketplace Call
Center
General Inquiries: 1-800-706-7893
TTY: 1-800-706-7915
Hours: Monday – Friday, 9 AM – 7 PM
General Inquiries: 1-800-318-2596
TTY: 1-855-889-4325
Hours: 24 hours a day, 7 days a week
Small employers and
those helping small
employers
Employees and those
helping employees
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61
Indiana Health Coverage Programs
____________________________________________________________________________
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What is Medicaid?
Medicaid is a public health insurance program enacted in 1965 by Title XIX of the Social
Security Act which provides free or low-cost health insurance coverage to low-income children,
pregnant women, and parents and caretakers, former foster children under age 26 receiving
Indiana Medicaid when aged out of the system, and blind, disabled, and aged individuals.
Indiana Medicaid programs are collectively referred to as Indiana Health Coverage Programs
which are administered by the Office of Policy Planning (OMPP) and Family and Social Services
Administration (FSSA). The federal government matches Indiana spending on Medicaid. The
Department of Family Resources (DFR) is the division of FSSA responsible for processing
applications and making eligibility decisions. The County Offices of the DFR administer IHCP at
the local level. Online applications for Medicaid are located on the DFR’s Benefit Portal.
Federal Poverty Level (FPL)
Household Size
Medicaid uses the Federal Poverty Level (FPL) issued by the Department of Health and Human
Services (HHS) as a measure of pre-tax income to determine what is considered poverty in the
United States. Anyone living at 100% or below the FPL is considered living in poverty. FPL
Guidelines are typically released in January each year. The Marketplace will use 2015
guidelines for 2016 coverage. Indiana Health Coverage Programs (IHCP) begins using new
guidelines in March or April of each year. In 2015, an individual with a pre-tax income of
$11,770 or less is living in poverty, and so is a family of 4 with pre-tax income at or below
$24,250.
2015 Federal Poverty Level for The 48 Contiguous States and D.C.
100%
133%
150%
200%
250%
300%
1
2
3
4
5
6
7
8
400%
$11,770
$15,654.10
$17,655
$23,540
$29,425
$35,310
$47,080
15,930
21,186.90
23,895
31,860
39,825
47,790
63,720
20,090
26,719.70
30,135
40,180
50,225
60,270
80,360
24,250
32,252.50
36,375
48,500
60,625
72,750
97,000
28,510
37,785.30
42,615
56,820
71,025
85,230
113,640
32,570
43,318.10
48,855
65,140
81,425
97,710
130,280
36,730
48,850.90
55,095
73,460
91,825
110,190
146,290
40,890
54,383.70
61,335
81,780
102,225
122,670
163,560
For family units of more than 8 members, add $4,160 for each additional member.
Indiana’s Health Coverage Programs
Indiana has a variety of programs with varying criteria with year-round enrollment. The state’s
website, www.indianamedicaid.com, is a great resource that provides information about each
program, eligibility, and more. The following descriptions are brief overviews of the programs.
Hoosier Healthwise
Provides health care coverage for pregnant women (up to 213% FPL), children up to age 19 (up
to 250% FPL), and former foster children up to age 26 at little or no cost. There are three benefit
packages in Hoosier Healthwise. The state determines eligibility and selects the coverage right
for the applicant.
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HHW PACKAGE
A—Standard
C– Children’s Health
Insurance Program
(CHIP)
P—Presumptive
Eligibility for Pregnant
Women (PEPW)
DESCRIPTION
 Full-service plan for children and pregnant women
 No premiums
 May have small copays for pharmacy, transportation, and emergency
services
 Full service plan for children only (under age 19)
 Small monthly premium payment & co-pay for some services based on
income
 Ambulatory prenatal coverage for individuals who are determined
“presumptively eligible” while their Indiana Application for Health
Coverage is being processed
Children’s Health Insurance Program (CHIP)
CHIP is a part of Hoosier Healthwise (Package C) for children up to age 19 with household
income between 158%-250% FPL. A child cannot be
CHIP (HHW Package C) Income Limits
covered by other comprehensive health insurance to
Family Size
Monthly Income Limit
be eligible for this program. Individuals in CHIP are
1
$2,453
responsible for monthly premiums and must pay the
2
$3,319
first premium prior to coverage becoming effectuated
3
$4,186
(there is a 60-day grace period). A child whose
4
$5,053
coverage was dropped voluntarily may not receive
5
$5,919
CHIP coverage for 90 days following the month of
termination with some exceptions. Enrollees of CHIP receive standard HHW benefits like
hospital care, doctor visits, check-ups, lab and x-ray services, mental health care, substance
abuse services, home health care, dental care, vision care, therapies, emergency
transportation, and prescription drugs. There is a three dollar ($3) copayment for generic,
compound, and sole-source drugs and a ten dollar ($10) copayment for brand-name drugs;
over-the-counter drugs are not covered.
Monthly
Premiums
Family FPL
158% up to 175%
175% up to 200%
200% up to 225%
Premium for 1
Child
$22
$33
$42
Premium for 2+
Children
$33
$50
$53
225% up to 250%
$53
$70
Healthy Indiana Plan (HIP)
HIP was created in 2008 and is Indiana’s unique health coverage program for adults between
the ages of 19-64. On January 27, 2015, Indiana Governor Mike Pence announced that Indiana
and the federal government had reached an agreement on HIP 2.0 expansion. HIP 2.0 now
covers Hoosier adults age 19-64 with a household income at or less than 138% of the federal
poverty level who are otherwise ineligible for Medicaid. The program provides full health
benefits including free preventive services, hospital
HIP Income Limits
services, mental health care, physician services,
Family Size
Monthly Income Limit
1
$1,370
prescriptions and diagnostic exams. Other new
2
$1,854
features of the HIP expansion include coverage for
3
$2,338
maternity, dental, and vision services. There are
4
$2,822
several different categories of HIP coverage
5
$3,306
outlined in this guide.
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HIP Plus
The initial plan selection for all members is HIP Plus which offers the best value for members.
For Hoosiers with
incomes up to 138%
FPL
Required POWER
Account contributions
(2% member income)
No other cost-sharing
(except non-ER use
of ER)
Offers dental, vision,
and more
comphrensive
prescription drug
benefit
POWER Account
jointly funded by
member and the state
of Indiana
Covers Maternity
services with no costsharing
Other Benefits:
 100 visit limit for home health
 Coverage for Temporomandibular Joint Disorders (TMJ)
 Bariatric surgery
 75 visits annually of physical, speech and occupational therapies
 100 day limit for skilled nursing facility
 Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds
 Dental—limited to 2 cleanings and 4 restorative procedures per year
 Pregnant women receive transportation and chiropractic services
FPL
<22%
23%-50%
51%-75%
76%100%
101%138%
Maximum POWER Account Contributions
Monthly Income,
Maximum
Maximum Monthly
Single Individual Monthly PAC*, Income, Household
Single
of 2
Individual
Less than $214
$4.28
Less than $289
$214.01 to $487
$9.74
$289.01 to $656
$487.01 to $730
$14.60
$656.01 to $984
$730.01 to $973
$19.46
$984.01 to $1,311
$973.01 to
$1,358.70
$27.17
Maximum Monthly
PAC, Spouses**
$1,311.01 to
$1,831.20
$2.89 each
$6.56 each
$9.84 each
$13.11 each
$18.31 each
*Amounts can be reduced by other Medicaid or CHIP premium costs
**To receive the split contribution for spouses, both spouses must be enrolled in HIP
HIP Basic
HIP Basic is the fallback option for members with household income less than or equal to 100
percent of the federal poverty level (FPL) who don't make their POWER account contributions.
HIP Basic can be much more expensive than HIP Plus.
64
For Hoosiers
with incomes
≤100% FPL
Reduced benefit
package (no
dental or vision)
No required
POWER
Account
contributions
Requires
copayments for
all services
POWER
Account funded
by the state of
Indiana
Covers Maternity
services with no
cost-sharing
Other Benefits:
 100 visit limit for home health
 60 visits annually of physical, speech and occupational therapies
 100 day limit for skilled nursing facility
 Early periodic screening diagnosis and testing (EPSDT) services for 19- and 20-year
olds
 Pregnant women receive transportation, vision, dental and chiropractic services
Service
HIP Basic Copay
Amounts
$4
$75
$4
$8
Outpatient Services
Inpatient Services
Preferred Drugs
Non-preferred Drugs
Non-emergency ED
visit
Up to $25
HIP State Plus
Available to individuals who qualify as low-income parents and caretakers, low-income 19- and
20-year-olds, and individuals with serious and complex medical conditions deemed "medically
frail.” Medically frail individuals have been determined to have one or more of the following:
disabling mental disorder, chronic substance abuse disorder, serious and complex medical
condition, physical, intellectual, or developmental disability, or a disability determination from the
Social Services Administration.
HIP State Basic
If a State Plus member does not make his or her monthly contribution and the member’s income
is at or below 100% of the FPL, the member will be enrolled in HIP State Plan–Basic, which
requires copayments. Members whose incomes are over 100% of the FPL who do not make
their monthly contributions will be subject to a six-month lockout unless they are medically frail
or are residing in a domestic violence shelter or in a state-declared disaster area. There are no
benefit differences between the two HIP State Plan options; however, individuals are required to
either make contributions to their POWER Accounts (HIP State Plan–Plus) or pay copayments
(HIP State Plan–Basic).
HIP State Plan Benefits:
 No visit limit for home health
65







Coverage for Temporomandibular Joint Disorders (TMJ)
Chiropractic services
Bariatric surgery
Requires authorization for physical, speech and occupational therapies—but unlimited
No limit for skilled nursing facility
Early periodic screening diagnosis and testing (EPSDT) services for 19 and 20 year olds
Pregnant women receive access to all pregnancy-only benefits on HIP Plus or HIP Basic
plan and full State Plan benefits
HIP Maternity
HIP Maternity is the Medicaid pregnancy program for women eligible for HIP. Women becoming
pregnant while enrolled in HIP should report their pregnancy within 10 days of knowing to their
MCE and the Department of Family Resources (DFR). With HIP Maternity, all cost-sharing is
eliminated until 60 days post-partum. If annual redetermination occurs during pregnancy, federal
guidelines require the member to be moved to HIP Maternity.
HIP Link
HIP Link is an option for eligible members age 21-64 who work and have access to their
employer's health plan. HIP Link members also have a POWER account and contribute to their
coverage like other HIP members. With HIP Link, the POWER account (valued at $4,000) can
be used to pay insurance premiums and out-of-pocket medical expenses associated with the
member's employer-sponsored plan.
Employers register (http://www.in.gov/fssa/hip/2489.htm) their health plans to participate, then
their employees who are eligible and want to participate in HIP Link sign-up with the state. Once
an employee is enrolled in the employer-sponsored health plan, the employer will deduct the
cost of premiums charged from the employee’s pay, per normal procedures. In turn, the State
will reimburse the employee directly for the amount of the deduction, minus a small contribution
made by the employee. The employer must pay at least 50 percent of the enrollee’s premium.
Most types of employer plans are eligible for HIP Link, so long as the plan meets the minimum
benefits requirements of the Affordable Care Act and is verified as an affordable option for
employees.
Power Account
The program provides a Personal Wellness and Responsibility (POWER) Account valued at
$2,500 per adult to pay for medical costs. Enrollees contribute approximately 2% of gross
income; employers and non-profits can also contribute up to 100% of the contribution amount.
Individuals who fail to make their monthly POWER Account contribution after a 60-day grace
period may be disenrolled for 6 months if their household income is above 100% of the federal
poverty level (FPL); individuals below 100% FPL are kicked to HIP Basic. The POWER Account
cannot be used to pay HIP Basic copays.
Five-percent (5%) of Income Limit
Members are protected from paying more than 5% of their quarterly income toward HIP cost
sharing requirements, including the total of all:
• POWER account contributions (PAC)
• Emergency Room copayments
• HIP Basic copayments
Members meeting their 5% of income limit on a quarterly basis will have cost-sharing
responsibilities eliminated for the remainder of the quarter.
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Account Rollover
HIP Plus: Unused member contributions rollover to offset next year’s required contribution. This
amount if doubled if preventive services are completed—up to 100% of the contribution amount.
Example: Member has $100 of member contributions remaining in POWER account. This is
credited to next year’s required contribution amount. Credit is doubled to $200 if preventive
services were completed.
HIP Basic: If preventative services are completed, members can offset required contribution for
HIP Plus by up to 50% the following year. Members may not double their rollover as in HIP Plus
Example: Member receives preventive services and has 40% of original account balance
remaining at year end. May choose to move to HIP Plus the following year and receive a 40%
discount on the required contribution.
Gateway to Work Program
HIP members who are unemployed or working less than 20 hours a week will be referred to
available employment, work search, and job training programs that will assist them in securing
new or potentially better employment. Gateway to Work is a voluntary program, and HIP
members will be notified if they have been referred to the program. Eligibility for HIP coverage is
not affected if a member chooses to not participate.
Those interested in participating in Gateway to Work should call 1-800-403-0864 and select
Option 1 for the health coverage menu and then Option 6 for Gateway to Work. Once engaged
in the Gateway to Work program, members may receive case management services, participate
in a structured job readiness program and receive help with their job search. Additional training,
volunteer work experiences and/or education may be provided, as appropriate. Gateway to
Work participants will also be invited to attend hiring events with employers.
Managed Care
All benefits in the new HIP program, with the exception of Medicaid Rehabilitation Option (MRO)
services, are provided through the MCEs. This includes dental and pharmacy services, which
were previously carved out of HIP. The MCEs are responsible for providing coverage for these
benefits and issuing payment to providers. MRO services available to qualifying HIP State Plan
members are carved out and reimbursed as fee-for-service claims.
Three Managed Care Entities (MCEs)
Hoosier Care Connect, Hoosier Healthwise, and HIP enrollees select one of the three managed
care entities (MCEs), or they are auto-assigned 14 days after enrollment. In 2015, the MCEs are
Anthem, MDwise, and MHS.
Some factors for beneficiaries to consider when selecting an MCE include:
 Provider network
o Is the individual’s doctor available in the MCE network?
o Are the locations of network providers easily accessible for the enrollee?
o Are the locations convenient to the individual’s work, home or school?
 Special programs and enhanced services
o Is there a service or program offered by the MCE that is particularly important or
attractive to the enrollee?
67
Changing MCEs
Hoosier Healthwise enrollees can change
MCES…
Anytime during the first 90 days with a health plan
Healthy Indiana Plan enrollees can
change MCES…
In the first 60 days or until they make the first
POWER account contribution
Annually at eligibility redetermination
Annually during an open enrollment period
Anytime when there is a “just cause”
 Lack of access to medically necessary services
covered under the MCE’s contract with State
 The MCE does not, for moral or religious
objections, cover the service the enrollee seeks
 Lack of access to experienced providers
 Poor quality of care
 Enrollee needs related services performed that
are not all available under the MCE network
Anytime there is a “just cause” as outlined for
Hoosier Healthwise enrollees
Primary Medical Provider
Once a beneficiary is enrolled in an MCE, he or she must select a Primary Medical Provider
(PMP). Enrollees must see their PMP for all medical care; if specialty services are required the
PMP will provide a referral. Provider types eligible to serve as a PMP include Indiana Health
Coverage Program enrolled providers with the following specialties:
Family
Practice
General
Practice
Internal
Medicine
Ostetrics/
Gynecology
General
Pediatrics
Helpful Tool
IPHCA’s HIP 2.0 Hub
www.indianapca.org/?page=OEHIP2HUB
Hoosier Care Connect
Hoosier Care Connect (HCC) is the program that replaced Care Select and serves as the
state’s program for the aged, blind, and/or disabled (ABD), population, wards of the court or
foster children, or a child receiving adoptive services or adoption assistance. Enrollees must
have one of the following conditions: Asthma, Diabetes, Congestive, Heart Failure Coronary
Artery Disease, Chronic Obstructive Pulmonary Disease, Hypertension, Severe Mental Illness,
Serious Emotional Disturbance (SED) Depression, Chronic Kidney Disease w/o dialysis, comorbidity of Diabetes and Hypertension or other combinations, or other approved serious or
chronic conditions.
HCC includes all covered services that are covered under Hoosier Healthwise Package A.
Members of HCC also receive special services for their personal health needs such as
medication therapy management and health care coordination.
Traditional Medicaid (Fee-For-Service)
The following individuals who meet income and resource requirements are eligible:
 Persons in nursing homes and other institutions, such as intermediate care facilities for
the intellectually disabled (ICFs/ID, formerly ICFs/MR)
68







Immigrants whose alien status is unverified or undocumented
Persons receiving hospice services
Persons with both Medicare and Medicaid (called dually eligible)
Persons with breast and cervical cancer
Refugees who do not qualify for any other aid category
Current and former foster children
Wards of the State
In Traditional Medicaid, beneficiaries are not enrolled in a Managed Care Entity (MCE) or Care
Management Organization (CMO) and can see any Indiana Health Coverage Program enrolled
provider.
TRADITIONAL MEDICAID
BENEFIT PACKAGE
Standard Plan
Medicare Savings Program
Package E
Family Planning
Presumptive Eligibility (PE)
DESCRIPTION
Full Medicaid coverage
QMB: Medicare Part A & B premiums, deductibles, & coinsurance
SLMB/QI: Medicare Part B premiums
QDWI: Medicare Part A premiums
Emergency Services only– for certain immigrants who do not qualify for
full Medicaid coverage
Family planning services only
Services to members determined presumptively eligible for temporary
coverage via the PE process are reimbursed by FFS except for those in
the Adult aid category (HIP Basic) and those found presumptively eligible
under the Presumptive Eligibility for Pregnant Women (PEPW) process.
Medicaid for Employees with Disabilities (M.E.D. Works)
Provides full Medicaid for working people ages 16-64 with disabilities and below 350% FPL.
Enrollees must be disabled according to Indiana’s definition of disability and not exceed the
asset limit (Single: $2,000 or Couple: $3,000). Members pay a small monthly premium and may
also have employer insurance.
MED WORKS PREMIUMS
Monthly Income
$1,472 - $1,716
$1,717 – $1,962
Single
Married
Premium
$48
$69
$1,963 - $2,452
$2,453 - $2,943
$107
$134
$2,944 - $3,433
$3,434
$1,992 - $2,323
$161
$187
$65
$2,324 - $2,655
$2,656 - $3,319
$93
$145
$3,320 - $3,983
$3,984 - $4,647
$4,648
$182
$218
$254
69
590 Program
This program provides coverage for residents of state-owned facilities. It does not cover
incarcerated individuals residing in Department of Corrections (DOC) facilities. Enrollees are
eligible for Package A benefits with the exception of transportation.
Home and Community Based Waivers
These waivers allow provision of long-term care services in home and community based
settings under the Medicaid program.
WAIVER
Aged and
Disabled
Traumatic
Brain Injury
Community
Integration &
Habilitation
Family
Supports
ELIGIBILITY
SPECIFICS
 Income: Up to 300% Supplemental
Security Income (SSI) benefit
(Parental income & resources
disregarded for children under 18)
 Meets ANSA “Level of Care”
 Would otherwise be place in
institution such as nursing home
without waiver or other home-based
services
 Complex medical condition
which required direct assistance
 Diagnosis of Traumatic Brain
Injury
 Diagnosis of intellectual disability
which originates before age 22
 Individual requires 24 hours
supervision
To apply for the Aged and Disabled waiver or the Traumatic Brain Injury Waiver, individuals can
go the local Area Agencies on Aging (AAA) or call 1-800-986-3505 for more information.
To apply for the Community Integration & Habilitation or Family Supports waiver, individuals can
go the local Bureau of Developmental Disabilities Services (BDDS) office or call 1-800-5457763 for more information.
Behavioral and Primary Healthcare Coordination Program (BPHC)
BPHC assists individuals with serious mental illness (SMI) who otherwise will not qualify for
Medicaid or other third party reimbursement Individuals meet the following eligibility criteria:
 Age 19+
 Medicaid Rehabilitation Option (MRO)-eligible primary mental health diagnosis
(e.g. schizophrenia, bipolar disorder, major depressive disorder)
 Demonstrated need related to management of behavioral and physical health
and need for assistance in coordinating physical and behavioral healthcare
 ANSA Level of Need 3+
 Income below 300% FPL
o Single: $2,942/month
o Married: $3,982/month
Individuals may apply for the BPHC program through a Community Mental Health Center
(CMHC) approved by the FSSA Division of Mental Health and Addiction (DMHA) as a BPHC
provider. A list of approved CMHCs can be found at
http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.aspx.
Medicare Savings Program
This program covers low-income Medicare beneficiaries and helps pay for out-of-pocket costs.
Individuals must be eligible for Medicare Part A.
70
Program
Qualified Medicare
Beneficiary (QMB)
Income Threshold
100% FPL
Resource Limit
Single: $7,280
Couple: $10,930
Benefits
 Medicare Part A & B
Premiums
 Co-pays, deductibles,
coinsurance
 Part B Premiums
(Specified Low
Income) SLMB
120% FPL
Single: $7,280
Couple: $10,930
Qualified Individual
(QI)
135% FPL
Single: $7,280
Couple: $10,930
 Part B Premiums
Qualified Disabled
Worker (QDW)
200% FPL
Single: $7,280
Couple: $10,930
 Part A Premiums
Family Planning Program
The Family Planning Program is for individuals wishing to prevent or delay pregnancy who do
not qualify for any other category of Medicaid, meet citizenship or immigration status
requirements, are not pregnant, have not had a hysterectomy or sterilization procedure, and
have income at or below 141% FPL. This program includes, but not limited to:
 Annual family planning visits
 Pap smears
 Tubal ligation
 Vasectomies
 Hysteroscopic sterilization with an implant device
 Laboratory tests, if medically indicated as part of the decision-making process regarding
contraceptive methods
 FDA approved anti-infective agents for initial treatment of STD/STI
Individuals must request to be considered for this program on their Indiana Application for
Health Coverage if not eligible for full Medicaid benefits.
Breast and Cervical Cancer Program (BCCP)
BCCP provides Medicaid coverage to women with breast and cervical cancer diagnosed
through the Indiana Breast and Cervical Cancer Program (BCCP) of the Indiana State
Department of Health (ISDH). Enrollees are also eligible for Hoosier Healthwise Package A
during the course of treatment and must meet the following criteria:
 Must be younger than 65 years old
 Must not be eligible for another Medicaid category
 Must not be covered by any other insurance that includes breast or cervical cancer
treatment
Alternatively, a woman can receive coverage for treatment under the BCCP program if she was
diagnosed with breast or cervical cancer, but not screened through BCCP if:
 She is between the ages of 18 and 65
 She has income at or below 200% of the FPL
 She is not eligible for Medicaid under any other category
 She has no health insurance that will cover treatment
Uninsured or underinsured Indiana residents below 200% FPL (age 40+) may qualify for free
breast and cervical cancer screenings and tests.
71
Age
40-49
50-64
65 and older
Eligible Services
Free office visit & Pap test
Free office visit, Pap test, and mammogram
Free office visit, Pap test, and mammogram only if not enrolled in Medicare
1634 Transition
In June 2014, Indiana transitioned to a 1634 state. Indiana implemented changes to disability
eligibility to the aged, blind and disabled (ABD) Medicaid program. This entails a simplified
disability eligibility process requiring consumers to submit an application to the Social Security
Administration (SSA) for disability benefits as part of the Medicaid for the Disabled application.
Individuals deemed eligible for Supplemental Security Income (SSI) and Social Security
Disability Insurance (SSDI) are automatically enrolled in Medicaid. The State gives precedence
to SSA disability determinations for SSI.
Program for All-Inclusive Care to the Elderly (PACE)
The Program for All-inclusive Care to the Elderly (PACE) was designed and implemented by the
state of Indiana to provide quality community-based care for Indiana Health Coverage Programs
(IHCP) members who:
 Are 55 years old or older
 Are certified by their state to need nursing home care
 Are able to live safely in the community at the time of enrollment
 Live in a PACE service area
Presumptive Eligibility (PE)
Presumptive Eligibility (PE) is a process that allows Qualified Providers (QPs) to make
temporary IHCP eligibility determinations for individuals. PE allows individuals to obtain medical
services from any IHCP provider prior to their Indiana Application for Health Coverage (IAHC) is
processed and a determination by Family and Social Services (FSSA) is complete
Qualified Providers (QPs)
The following entities may make PE determinations:
QP Criteria
QPs must meet the following criteria:
 Be enrolled as an Indiana Health Coverage Program (IHCP) provider
72





Attend a provider training
Provide outpatient hospital, rural health clinic or clinic services
Be able to access HP Web interchange, internet, printer & fax machine
Allow PE applicants to use an office phone to facilitate the PE and Hoosier Healthwise
enrollment process
May include hospitals, pediatricians, family/general practitioner, internist, medical clinic,
rural health clinic among others
Qualifying Individuals
Benefits and Limitations
73
Application Process
Information is entered on Web interChange 24/7 and is based on self-attestation with real-time
responses. QPs are not permitted to ask for supporting documentation to verify eligibility. An
individual can apply for all members in his or her family. An application cannot be completed for
incapacitated individuals until coherent.
The PE period extends from the date an individual is determined presumptively eligible until:
 When an Indiana Application for Health Coverage is filed:
o Day on which a decision is made on that application
 When an Indiana Application for Health Coverage is not filed:
o Last day of the month following the month in which the PE determination was
made
Presumptive Eligibility for Pregnant Women (PEPW)
Eligible women are pregnant, Indiana residents, and U.S. citizens or qualified immigrants with a
household income of less than 213% FPL. PEPW does not pay for hospital stays, hospice, long
term care, abortion, postpartum services, labor and delivery, or services unrelated to pregnancy.
Indiana Application for Health Coverage
The Indiana Application for Assistance includes SNAP, cash assistance and health coverage.
Application methods:
• Online (Recommended)
• Telephone
• Fax
• Mail
• In Person at Division of Family Resources (DFR) office
Medicaid eligibility determinations are made within 45 days or 90 days for determination based
on disability. Applicants can check status of online application using:
• Case number
• Case name
• Date of birth
• Last four digits of SSN
Authorized Representatives (AR)
An AR is an individual or organization which acts on a Medicaid applicant or beneficiary’s behalf
in assisting with the application, redetermination process and ongoing communications with the
state. An AR is commonly a trusted family member, but can also be a third party entity.
Designation must be in writing and signed by the applicant or beneficiary and the authorized
representative—State Form 55366 can be used.
Eligibility Notices
The DFR provides written notice, via mail, to applications and beneficiaries regarding any
decision affecting eligibility. Types of notices include, but not limited to approvals, denials,
terminations, suspensions of eligibility, and changes in benefit packages or aid categories.
The State sends notice within 24 hours + mailing time. Individuals can be determined Medicaid
eligible for up to 3 months of retroactive eligibility from the date of application.
74
Eligibility Appeals
Individuals wishing to challenge disability eligibility decisions appeal to the Social Security
Administration (SSA) or Indiana Medicaid depending on the reason for the denial.
• Regarding an SSA disability on file: appeal to SSA
• Indiana Medical Review Team (MRT) decision: appeal to Indiana Medicaid
Eligibility Redeterminations
Eligibility redeterminations are conducted every 12 months for MAGI categories. The State
renews if there is sufficient information, but if there is not sufficient information, a pre-populated
renewal form will be sent to the enrollee. Eligibility is terminated if the form is not submitted in a
timely manner; if eligibility is terminated but the documents are submitted within 90 days of the
original due date, the documents will be reviewed without the need to submit a new application
Reporting Changes
Enrollees are required to report changes to the state (FSSA) within ten (10) days. Examples of
changes include:
• Change in address
• Income
• Family composition (gaining or losing a dependent; marriage)
• Citizenship
• Residency
• Employment
• Disability status
• Medicaid eligibility
• Incarceration
• Tax filing status
• Babies born to Medicaid enrollees receive coverage for the first year of life without the
need for a separate application—they will be covered under Hoosier Healthwise and
enrolled in the mother’s Managed Care Entity (MCE)
Application Methods
Program
Application Process
Aged & Disabled Waiver
Apply at Area Agencies on Aging (AAA) or call 1-800-986-3505
Breast & Cervical Cancer
Program (BCCP)
Community Integration &
Habilitation or Family
Supports Waiver
Family Planning Eligibility
Program
Healthy Indiana Plan (HIP)
Apply for Medicaid coverage, option 3; Family Helpline: 1-855-435-7178
Hoosier Care Connect
(HCC)
Hoosier Healthwise (HHW)
Traditional Medicaid
Apply at Bureau of Developmental Disabilities Services (BDDS) office or
call 1-800-545-7763
Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in
person at DFR office
Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in
person at DFR office
HIP Helpline: 1-877-GET-HIP9
Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in
person at DFR office
HCC Helpline: 1-866-963-7383
Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in
person at DFR office
Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in
person at DFR office
75
Steps for Resolving Casework
1. Start with verifying information on your Web interChange portal
2. Check Department of Family Resources (DFR) Benefits Portal
https://www.ifcem.com/CitizenPortal/application.do
3. Troubleshoot with your Outreach & Enrollment team
4. Use DFR mailbox to submit question or issue
http://www.in.gov/fssa/dfr/2999.htm
5. Contact local DFR and speak with a representative
Region 1 (Lake): DFR.region1@fssa.IN.gov
Region 2 (St. Joseph): DFR.region2@fssa.IN.gov
Region 3 (Allen): DFR.region3@fssa.IN.gov
Region 4 (Grant): DFR.region4@fssa.IN.gov
Region 5 (Marion): DFR.region5@fssa.IN.gov
Region 6 (Vigo): DFR.region6@fssa.IN.gov
Region 7 (Vanderburgh): DFR.region7@fssa.IN.gov
Region 8 (Clark): DFR.region8@fssa.IN.gov
Region9 (Tippecanoe): DFR.region9@fssa.IN.gov
Region 10 (Wayne): DFR.region10@fssa.IN.gov
6. Ask to speak with DFR Regional Manager (information current as of June 2015)
State Region
E-mail Contact
Regional Manager
Region 1 (Lake)
DFR.region1@fssa.IN.gov
Carlean Gadling
Region 2 (St. Joseph)
DFR.region2@fssa.IN.gov
Kim Teska
Region 3 (Allen)
DFR.region3@fssa.IN.gov
Kim Yann
Region 4 (Grant)
DFR.region4@fssa.IN.gov
Stacey Young
Region 5 (Marion
DFR.region5@fssa.IN.gov
Tim Bolton
Region 6 (Vigo)
DFR.region6@fssa.IN.gov
Felecia Vaccaro
Region 7 (Vanderburgh)
DFR.region7@fssa.IN.gov
Donna Martin
Region 8 (Clark)
DFR.region8@fssa.IN.gov
Nancy Lowry
Region9 (Tippecanoe)
DFR.region9@fssa.IN.gov
Vickie Woody
Region 10 (Wayne)
DFR.region10@fssa.IN.gov
Mary Medler
(as of 6/25/15)
7. Submit question or issue to Jessica (jellis@indianapca.org) or Emily (edaw@indianapca.org (317) 630-0845
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Download a hyperlinked copy of this guide online:
https://indianapca.site-ym.com/?page=OEResources
i
Center for Health Care Strategies, Inc.
KFF
Other resources include: The Indiana Navigator Training Content Manual, Centers for Medicare and Medicaid, and Enroll America.
ii
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