Federal Recognition of Same-Sex Marriage Could Mean Big Changes for Taxes and Health Care Reform

The Supreme Court issued two key rulings today on same-sex marriage, United States v. Windsor (regarding the federal Defense of Marriage Act or "DOMA") and Hollingsworth v. Perry (regarding California's Proposition 8). The Court struck down DOMA as unconstitutional and dismissed the appeal in the Proposition 8 case for lack of standing.

"These momentous decisions certainly have implications for taxes and the Affordable Care Act (ACA)," said Brian Haile, Senior Vice President for Health Care Policy, Jackson Hewitt Tax Service Inc. "Same-sex partners should understand some of the implications of marriage to their health insurance options under the ACA before they tie the knot. Simply put, getting hitched affects their health care."

Haile outlined the following:

1. Same-sex partners may now be able to file as "spouses." Under the federal income tax rules as currently written, taxfilers may be able to claim a same-sex partner as a dependent if they live together for the year, if the partner resides legally in the U.S., if the taxfiler provides at least 50 percent of the total support for the partner and the household, and if the partner has very limited income. This is a murky area – and the Court's decisions only partially clarify the law.

To the extent that the Court's rulings expand the federal definition of marriage, then many of these individuals in jurisdictions that recognize same-sex marriages may now be able to file as "spouses" rather than "dependents." Other same-sex individuals who did not meet the restrictive dependent test may now become part of the taxfiler's household as a spouse in those states that recognize same-sex marriage. (For reference, 12 states and the District of Columbia marry same sex couples.) However, the marital status vis-a-vis federal law of same-sex couples who live in states that do not recognize their marriage remains unclear.

2. Same-sex partners with similar incomes may lose out. For example, same-sex partners who each have an income of $40,000 may be eligible for the premium assistance tax credits under the ACA – but only if they remain single. If they marry (in those states that allow same-sex marriage), then they would lose eligibility because their income would be over the threshold for a household of two.

3. Same-sex partners with different incomes may gain. For example, two persons in a same-sex relationship who had incomes of $30,000 and $80,000, respectively, would not qualify for the tax credits if they were married in states that recognize same-sex marriage (because their combined income is above the limit for a couple). However, the individual making $30,000 would qualify for the tax credits if he or she remains unmarried (as that individual's income is below the threshold for a household of one). Of course, the couple may end up paying a lower marginal tax rate if they marry and exercise a new right to file jointly – so part of the decision about whether and when to marry in states that recognize same-sex marriage may involve a complicated trade-off between minimizing taxes and accessing insurance.

4. Same-sex couples who currently access domestic partner benefits may gain. Under the current federal income tax rules, the value of the benefits that employers provide to opposite-sex spouses is largely excluded from income; however, the opposite is true from same-sex partners – and they have to pay taxes on the full value of the employer's contribution for same-sex partner health insurance, etc. These taxfilers may no longer have to treat the value of the health insurance as imputed income if they get married in states that allow them to do so – meaning that their taxes may go down. The same is true for employers: they may pay lower payroll taxes if the couple marries and no longer has to treat the value of the employer's contribution as imputed income.

5. Same-sex couples who do not have or do not access domestic partner benefits may lose out. If the couple marries (assuming that they live in a state that recognizes same sex marriage) and one employer offers spouse or dependent coverage, then the same-sex spouse may lose eligibility for the ACA tax credits. The ACA limits the tax credits to spouses and dependents who do not have access to coverage. Even if the employer does not subsidize spouse or dependent health coverage, the fact that a spouse has access may disqualify him or her from the tax credit program.

6. Married same-sex couples receiving ACA tax credit will have to file jointly. If a same sex couple were to get married in a state that allows them to do so and claim the new tax credits under the ACA, then the ACA rules require them to file a joint return for the respective tax year (as is the case with opposite-sex married couples).

Even with the Court's decisions, HHS still faces several related policy questions. The final rules about the new insurance marketplaces clarify that the marketplaces and insurers must "…[n]ot discriminate based on race, color, national origin, disability, age, sex, gender identity or sexual orientation."* Consequently, many observers had a number of questions about how HHS would interpret these requirements in the context of the small group marketplace even before the Court's rulings. For example, must the small group marketplace require insurance companies to provide same-sex domestic partner coverage to participating employers and employees?

"To my knowledge," Haile added, "the agency's only requirement in this regard is that insurers in the federal marketplace self-attest that they do not discriminate on this basis."**

Surprisingly, many same-sex couples (particularly lower-income same-sex couples) may be better off if HHS answers "no" to such questions. The reason is simple but not intuitive: the final rule on premium tax credit eligibility states that individuals who have access to "affordable" employer-sponsored coverage are ineligible for premium tax credits. However, "affordability" of employer-sponsored insurance is determined only with regard to the employer contribution to the employee-only coverage. Consequently, a same-sex partner (and for that matter, any dependent) may be ineligible for tax credits if the employer offers same-sex coverage – even if the employer makes no contribution to toward the associated premium. However, if partner or other dependent coverage is unavailable, then a same-sex partner or other dependent may have some hope of qualifying for a tax credit.

The Internal Revenue Service and other federal agencies may issue interpretive guidance later this year to clarify some of the outstanding questions, but the implications of the Court's rulings today certainly complicate both the tax code and health care reform.

* 45 CFR Section 155.120(c)(2); 45 CFR Section 156.200(e).
** Letter to Issuers, April 5, 2013, available at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf.

Brian Haile 
Senior Vice President for Health Care Policy
Jackson Hewitt Tax Service Inc. 

For more information about the Affordable Care Act and its impact on taxpayers, please visit Jackson Hewitt's public website or Brian Haile's Twitter channel.

(This post originally appeared on PRNewswire here)

Provider-Plan-Payer Alliance for Health - Your Input is Needed

Illinois was recently awarded a Model Design grant from the Center for Medicare & Medicaid Innovations (CMMI) for the development of a State Health Care Innovation Plan. Through these grants, CMMI is encouraging states to develop multi-payer approaches that send a consistent signal to providers and consumers incentivizing healthy behaviors, safe environments, and appropriate community supports linked to high quality care through accountable and comprehensive delivery systems. Illinois will develop its models to test over three years in the next round of funding. The grant period officially began April 1, and we must submit the comprehensive plan to CMS by September 30.

Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.

Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.

Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.

Resources
Steering Committee Members
Steering Committee Presentation
State of Illinois Provider-Plan-Payer Alliance for Health
Letter from CMS Center for Medicaid Innovation Awarding Illinois the Model Design Award
CMS State Innovation Model Fact Sheet
Value of an All Payer Claims Database Webinar
Alliance Town Hall Meeting Notes - June 6, 2013

Comments
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here and use the Town Hall Questions as a guide. Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.

NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).

[This was originally posted on the State of Illinois' Health Care Reform Website]

Illinois was recently awarded a Model Design grant from the Center for Medicare & Medicaid Innovations (CMMI) for the development of a State Health Care Innovation Plan. Through these grants, CMMI is encouraging states to develop multi-payer approaches that send a consistent signal to providers and consumers incentivizing healthy behaviors, safe environments, and appropriate community supports linked to high quality care through accountable and comprehensive delivery systems. Illinois will develop its models to test over three years in the next round of funding. The grant period officially began April 1, and we must submit the comprehensive plan to CMS by September 30.

Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.

Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.

Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.

Consumer & Community Feedback Needed!
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here (scroll down to the bottom of the page) and use the Town Hall Questions as a guide.

Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.

NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).
- See more at: http://heartlandpolicy.blogspot.com/2013/06/provider-plan-payer-alliance-for-health.html#sthash.g0hxlRcD.dpuf

Training for In Person Counselors and Navigators in Illinois

The State is preparing to award grants in early July to community based entities who will employ helpers to educate consumers about their new health care options under the Affordable Care Act and to assist people in enrolling in the new Medicaid expansion and Health Insurance Marketplace when open enrollment begins on October 1. These helpers will be called In Person Counselors (IPCs); however, there will also be other enrollment "helpers" called Navigators and Certified Application Counselors. The different names just refer to how the assister is funded; all of the assisters will help people choose and enroll in coverage.

In order to train these assisters, the State has partnered with the University of Illinois at Chicago School of Public Health to develop a curriculum and training program to begin by the end of July and go through the middle of September. The curriculum will consist of both online and in person learning modules. The training will be ongoing and will consist of a testing and certification process as required under state law. There will be continuing education and a backup technical assistance call center for individual questions.

In addition to the state training, IPCs and Navigators will also take a federal online Navigator training by the fall which will inform them about using the federal Marketplace portal. This is important, because all assisters in Illinois must be familiar with both the state Medicaid system as well as the federal Marketplace system since Illinois has chosen to be a partnership state and administer its health care reform programs jointly for the first year with the federal government. We are waiting on federal guidance regarding the Certified Application Counselors' training requirements.

Many other community based providers will help their clients understand and access health care coverage, even if they aren't designated "assisters" or "Navigators." These front line workers also need information on the ACA but may not need as intensive a training program as the certified assisters. There are training materials and presentations available to these organizations/ entities throughout the state including the Starting Strong Webinar Series and other events on the Illinois Health Matters events page.

Stephanie Altman
Health & Disability Advocates

An Ambitious Effort to Get Americans Covered

As the nation’s largest public health philanthropy, addressing the crisis of the uninsured is central to our mission.
 

A 2009 RWJF-funded study by the Institute of Medicine documented severe consequences to the long-term health prospects of people living without health insurance. Put simply, the uninsured live sicker, suffer more, and die younger. And beyond the impact on the individual and their families, high rates of uninsurance strain communities’ health systems, limiting access to quality care for those with insurance.

Sadly, 50 million of our fellow Americans—nearly one in six of us—are uninsured. For decades, RWJF has worked to remedy the crisis of the uninsured, and this week marks an especially important milestone, as “Get Covered America” kicks off across the nation. A grassroots, consumer-driven campaign, “Get Covered America” will educate Americans about new opportunities to obtain affordable health insurance in advance of open enrollment season this fall.

RWJF provided a grant earlier this year to Enroll America to organize the “Get Covered America” campaign, and also pledged an additional challenge grant to encourage other donors to join us in this effort to reduce the staggering number of uninsured Americans.

Our support for this campaign, along with other efforts to educate people about their options, is a continuation of RWJF’s effort over many years to enroll eligible people in health insurance programs. For example, starting in 1997, RWJF made a decade-long investment of nearly $150 million to enroll children and low-income adults in coverage for which they were eligible. During this time the total number of children covered by the Children’s Health Insurance Program doubled, from 2.2 million to 4.4 million, and total Medicaid enrollment increased by 10 million people. (Find more background here.)

Significantly, RWJF did not act alone. We partnered with government officials, as well as major health stakeholders to streamline eligibility and enrollment systems to reach out and enroll eligible people. More recently, expanding participation in the Medicare Part D prescription drug benefit followed a similar model of public-private cooperation. These examples highlight an important role for philanthropy as the Affordable Care Act’s coverage provisions take effect this fall: working closely with the public and private sectors to ensure robust enrollment.

With nearly 30 million of America’s uninsured eligible for new coverage options created under the law, “Get Covered America” has undertaken an ambitious series of goals. Over the summer, campaign volunteers and staff will fan out in communities across the nation to provide people with straightforward information about these new options: their ability to shop for insurance once the state and federal marketplaces open for enrollment in October, the availability of tax credits for which they may be eligible, and for the lowest income people, eligibility for Medicaid in states that have chosen to pursue that option.

To learn more about “Get Covered America” and what you can do to help, visit www.getcoveredamerica.org.

Andrew D. Hyman
Robert Wood Johnson Foundation

(This blog was originally posted on the RWJF "Culture of Health" blog here.)

New Options for States: Facilitating Medicaid and CHIP Renewal & Enrollment in 2014

States must prepare themselves for an efficient enrollment period in order to capitalize on the upcoming changes to Medicaid eligibility under the Affordable Care Act. The Centers for Medicare & Medicaid Services (CMS)/Center for Medicaid & CHIP Services, recently released a letter that identifies enrollment strategies to help with the anticipated increase in applications. These optional strategies may facilitate enrollment while lessening administrative demands on individual states.

Here are the strategies for those states interested in adopting them:

1) Implementing the early adoption of Modified-Adjusted Gross Income, (MAGI)-based rules

Under the ACA, eligibility for all health insurance programs will be determined by MAGI methodology, which uses different income-counting procedures than current Medicaid programs. During the open enrollment period, which begins on October 1st, 2013, individuals applying for coverage in 2013 will determine their eligibility through MAGI methodology. However, individuals renewing and applying for Medicaid during that 4-month period will have their income reviewed by both current rule and MAGI methodology. States can opt to change how they determine eligibility starting October 1st in order to simplify this process.

2) Extending the Medicaid renewal period

Anyone who has a Medicaid renewal which falls in the first quarter of 2013 will also have to have their eligibility determined by both pre-MAGI and MAGI rules. Extending the renewal period will allow the states to use only the MAGI eligibility rules for simplicity.

3) Enrolling individuals into Medicaid based on Supplemental Nutrition Assistance Program, (SNAP), eligibility

The majority of non-elderly, non-disabled individuals who receive SNAP benefits are also eligible for Medicaid. Enrolling individuals in Medicaid who also receive SNAP benefits without a separate, MAGI-based income determination can help ease a state’s administrative burden. This enrollment opportunity can be implemented for a limited amount of time as states handle the demands of the increase in applications.

4) Enrolling parents into Medicaid based on their children’s Medicaid eligibility

A large number of parents with Medicaid-eligible children will also be eligible for Medicaid when changes go into effect. Enrolling parents based on their children’s eligibility can also serve as a temporary way to facilitate enrollment.

5) Adopting 12 month continuous-eligibility for parents and other adults

Many states already have 12-month continuous-eligibility for children, meaning that children are guaranteed their Medicaid coverage for a full year despite changes to their family’s income. Extending this guarantee to families will reduce the amount of “churning” between different plans, and ensure that entire families have more consistent coverage.

States that wish to implement any of these strategies must get authorization from the federal government. CMS also is encouraging states to propose any other creative strategy that will facilitate enrollment.

Illinois should consider whether some or all of these options are optimal. Implementing these strategies could lessen the administrative burden on the state, maximize enrollment of uninsured populations, maximize eligibility for low income families, and increase federal financing for health care in the state.

Stephanie Altman & Kathryn Bailey
Health & Disability Advocates

Medicaid Expansion Passes Both Houses of the Illinois General Assembly

Earlier this week, the Illinois Legislature passed a bill (SB 26) to implement the Medicaid expansion option for adults without minor children on January 1, 2014. This expansion is a cornerstone of the Affordable Care Act and has the potential to cover over 600,000 low income adults in Illinois under the Medicaid program. The bill has overcome many hurdles along the way and now will be sent to the Governor's desk for his signature.

A year ago, the Supreme Court made the Medicaid expansion to adults an option that states did not have to take. However, the expansion is financially advantageous for states because the federal government pays all of the costs of the new Medicaid adult group for the first three years and thereafter, the state pays no more than 10% of the costs - making this the most lucrative Medicaid program in history for state governments. This coverage program will bring needed revenue to Illinois including to local entities such as Cook County and the City of Chicago as well as to hospitals and other safety net providers.

Illinois will begin accepting Medicaid applications for this new adult group on October 1, 2013, and coverage will begin on January 1, 2014.  For residents of Cook County, they can enroll right now and begin getting coverage into the CountyCare program which is an early implementation of the Medicaid expansion. The passage of SB 26 ensures that CountyCare enrollees will be able to continue to be covered under Medicaid along with the rest of the state in 2014.

In addition, SB 26 makes other changes to the Medicaid program including "fixing" some of the SMART Act Medicaid cuts by partially restoring dental care to pregnant women. Some mental health advocates were opposed to an amendment added onto the bill, that allowed a new category of mental health facilities for short term crises. For any questions, you can contact me at saltman@hdadvocates.org.
 
Stephanie Altman
Programs & Policy Director
Health & Disability Advocates

ObamaCare Is Here – But Is It Working for People with HIV?

Read AFC's CountyCare report and press release. 

On January 1, 2014, national health care reform will kick into high gear, providing new health insurance options for millions of people across the country. And thanks to visionary leadership from Cook County Board President Toni Preckwinkle, Cook County Health and Hospitals System Board CEO Dr. Ram Raju, and the Obama administration, the Affordable Care Act (ACA) is already being implemented in Cook County in the form of CountyCare.

This new program implements a provision of national health care reform that allows states to expand Medicaid programs to cover most low-income adults. The federal Center for Medicare and Medicaid Services (CMS) granted Cook County permission to implement the program in October 2012. Previously, as many as 250,000 Cook County residents were excluded from Medicaid because they did not meet the program’s restrictive eligibility requirements, such as being totally disabled. The AIDS Foundation of Chicago (AFC) estimates that 1,800 or more Cook County residents with HIV could benefit from CountyCare.

While CountyCare is a sign of great things to come, it also provides some critical lessons that can be applied later this year when health care reform rolls out statewide. AFC recently released a new report, CountyCare & the Ryan White Program: Working Together to Optimize Health Outcomes for People with HIV, that details the importance of CountyCare and the role it can play in improving access to health care for HIV-affected individuals. It also contains a number of policy recommendations for the city and state departments of public health, Cook County, and the federal government that aim to improve the program for people with HIV and avoid problems in the future.

The most significant issue with CountyCare for people with HIV is that nine HIV clinics  in Chicago are excluded from the primary care network. As a result, 500 or more patients with HIV could be forced to switch doctors to receive care at a clinic that’s already enrolled.

Many low-income people with HIV have connections to the health care system that are tenuous at best. They are facing not just HIV and its paralyzing stigmas, but also homelessness, mental illness, substance use, and chronic physical health conditions, such as diabetes and heart disease. Large numbers live in violence-plagued communities in Chicago, where a trip to the corner store can mean getting caught in turf-war crossfire. In such contexts, HIV care is the last thing on a person’s mind, and something as simple as having to find a new doctor can cause them to drop out of medical care entirely.

Delayed or disrupted health care harms people with HIV and also worsens the health of our communities.  People who are not taking HIV medications face a far greater risk of transmitting HIV to their partners. In fact,research shows that people whose HIV is controlled with medications have a 96 percent lower risk of transmitting HIV to their partners.

If those nine clinics are unable to join the CountyCare network, their HIV-positive clients will be forced to switch to new health care providers. The federal Ryan White Program, which subsidizes medical care for low-income uninsured patients with HIV, is mandated by law to be the payer of last resort, tapped only when people have exhausted all other sources of coverage. In fact, federal law prohibits clinics from serving patients with Ryan White dollars if their insurance could be used. Thus, people with HIV are caught in a bind: They are required to apply for all insurance for which they are eligible, but if they enroll, they might be forced to leave their current health care provider of choice.

The Ryan White Program’s payer-of-last-resort provision is a double-edged sword. Despite being a resource for people without coverage, it has the potential to disrupt existing doctor/patient relationships, something all of us – and especially people with chronic, complex health conditions like HIV and other co-occurring diagnoses – want to avoid.

Such potential disruptions occur because different federal government entities routinely drop the ball in coordinating and communicating their strategies. One of the lessons we have learned as we prepare to implement health care reform nationwide is to closely monitor the interactions and implications of various programs.  We cannot rely on the federal government to communicate across or even within agencies. Sustained advocacy and vigilance will be needed as health reform kicks off.

So what are other lessons we are learning from the CountyCare rollout, and what can we do to avoid situations like this in the future?

It’s clear that the transition to new health care reform programs will be slower than we want. Case managers and other staff at community clinics are already overwhelmed by the flood of clients they see every day; it will be challenging to help thousands more people apply for new ACA programs, connect them important resources, and ensure they’re receiving optimal HIV care. New federal funding for ACA enrollment staff will hopefully help with this task.

Moreover, the HIV community needs to better prepare itself for health reform programs. Most importantly, clinics should aggressively reach out to new Medicaid and private insurance programs to make sure they are part of these new programs, and the insurance companies must do their part and enroll HIV clinics in their networks.  Clients can’t be stripped of medical options because their doctor doesn’t accept their insurance.

Establishing the right enrollment and service systems under CountyCare is paramount for people living with HIV. We have a unique opportunity to improve health care access and services for individuals with this disease. Getting this right is imperative, so we can learn from this rollout and help tens of thousands of other Illinoisans affected by HIV, who will have new insurance options in 2014 when the ACA goes into full swing.

The new report from AFC also details recommendations for service organizations, case managers, government officials, and people with HIV, so that all can take full advantage of CountyCare. It’s available at www.aidschicago.org/countycare.

David Ernesto Munar
AIDS Foundation of Chicago 

(This post was originally published on the AIDS Foundation of Chicago blog).