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Audio (MP3) Listen in New Window Presentation (PDF) Open in new window Meet Your Speaker: Laura Kendall Former Eligibility Consultant for the Hamilton County DFR Office. Current Eligibility Manager for Medicaid Eligibility Policy team—we provide eligibility guidance to the county DFR offices. Contact: Laura Kendall, Eligibility Manager/Program Director FFS, HCC laura.kendall@fssa.in.gov 317.234.6112 So What is Medicaid? JUST THE BASICS So What is Medicaid? -Medicaid was created under TITLE XIX of the Social Security Act and pays for the medical care of persons who meet specific categorical non-financial, income, and resource requirements. -Any person who meets his or her state’s Medicaid eligibility criteria has a federal right to Medicaid coverage in that state. How is it Funded? -Medicaid is funded jointly by the federal government and the states. -Federal law outlines basic minimum requirements that all states Medicaid programs must fulfill. -However, states have broad authority to define eligibility, benefits, provider payments and other aspects of their programs. Who is Covered? Federal law requires states to cover these “mandatory” groups—if financially eligible—in order to receive any federal matching funds: Children Parents/Caretakers of children 18 years or younger Pregnant Women People with Physical and Mental disabilities. Seniors Former Foster Care Children (18-25) Applying for Medicaid THE PROCESS Where to Go The Medicaid application and resources for screening to see whether someone might qualify can be accessed online at www.IFCEM.com Local DFR offices can provide information or a paper application to potential applicants. To find the nearest DFR office clients can go to IN.gov/FSSA/DFR DFR offices also provide computers where people can apply online, for those who may not have internet access at home. Filling out the Application A Medicaid application asks for information such as the applicant’s current address, citizenship status, household size and relationships, monthly income, etc. After an application is submitted, the applicant will get a confirmation number. That number can be used to get updates about the case by calling 1-800-403-0864. Alternatively someone at the local DFR office could look up information. Processing Once a valid application is received, the DFR offices try to process Medicaid applications within 45 days. If an applicant states they are disabled, this process may take up to 90 days. For those who do not indicate a disability on their application no interview is needed, and a form called a 2032 is sent requesting all information that is needed to determine eligibility. Those who indicate they are aged, blind, or disabled will have an appointment scheduled by phone or at the local DFR to gather information in regard to resources, disability status, etc. Non-Financial Considerations Indiana Residency Social security number Citizenship/Immigration status Tax filing status Disability status Age at application Pregnancy SSA/Medicare eligibility Residency in an institution Approval The client is assigned a case number upon application, as well as a separate RID (recipient ID), which is used for Medicaid claims. An approval notice is sent upon authorization, and if the client is a NEW Medicaid beneficiary, a Medicaid will be received within 7-10 days. Some categories of coverage being in the month of application, but others can supply coverage for the three months prior to application if the client is income/resource eligible in those months. Redeterminations A client’s Medicaid is reviewed annually, aside from a few exceptions. Recently we have started an auto renewal program, and some recipients who have recently had an annual review for Food Stamps may be auto renewed. If we cannot auto renew, clients have to fill out a Medicaid Mailer and return supporting documentation of bank accounts, etc. Types of assistance: Our Categories There are more than 30 Categories of Medicaid. They can be broken down into a few smaller benefit groups: TRADITIONAL MEDICAID HOOSIER CARE CONNECT HOOSIER HEALTHWISE HEALTHY INDIANA PLAN (HIP Hoosier Healthwise -Claims are processed by the managed care entity (MCE). -Provides coverage for health care services rendered to the following aid category groups: -Children (not on foster care, receiving adoption services, or wards of the state) -Pregnant Women -Some Low-income Parents MAGP – pregnant women MA X – newborn MA Y – children not yet age one MA Z – children, age 1-5 MA 2 – children, age 6-18 MA 9 - children, age 1-18, (CHIP) MA 14, MA 15 - former foster children MA 10 - children age 1-18, w/premium Healthy Indiana Plan (HIP) Effective February 1, 2015. Cost-sharing health coverage program for qualified Indiana residents with income up to 138% of the FPL. Non-disabled adults ages 19-64 Parents and caretakers (with children ages 0-18) Transitional Medical Assistance (formerly eligible as parents and caretakers) MA RP – HIP Plus MA RB – HIP Basic (no cost-share) MA SP – HIP Plus, State Plan MA SB – HIP Basic, State Plan (no cost-share) Traditional Medicaid This includes the Fee-for-Service coverage for members who are dual eligible for Medicaid and Medicare. This also includes clients who have Medicare Savings Program benefits only. These programs help clients pay for Medicare premiums, deductibles, etc. MA A – Aged (65 or older) MA D – Disabled (SSA or MRT) MA B – Blind (SSA or MRT) MA DW – Disabled Worker MA L – Qualified Medicare Beneficiary MA J – Special Low-Income Medicare Beneficiary MA I – Qualified Individual Hoosier Care Connect Provides care coordination services as well as medical, prescription, and dental to aged, blind, and disabled members who are NOT: Dual eligible (Medicare/Medicaid) Long-term Care Hospice (Institutional setting) HCBS Waiver Program MASI – SSI Recipients MA A – Aged (65 or older) MA B – Blind (SSA or MRT) MA D – (SSA or MRT) MA DW – Disabled Worker Hoosier Care Connect New program that replaced Care Select earlier this year In Hoosier Care Connect you enroll with a managed care entity (MCE) that provides most of your Medicaid-covered benefits. Enhanced benefits like disease management and wellness programs Help from a health plan to connect with healthcare providers and specialists Access to a 24-hour Nurse Helpline Care coordination services based on your needs including: Education on how to better manage your health and any chronic illnesses Help in getting connected to medical, behavioral health and community resources Support after you are discharged from the hospital to help you stay healthy and keep follow-up appointments Other Special Programs 590 (For residents of state-owned facilities) Emergency Services (Package E) Hospital Presumptive Eligibility HCBS Waivers Family Planning Presumptive Eligibility for Pregnant Women Breast and Cervical Cancer Treatment Services 1634 Conversion WHAT CHANGED 1634 Changes: as of JUNE 1, 2014 The Indiana Health Coverage Programs (IHCP) changed the way individuals are determined eligible for Medicaid coverage under the aged, blind, or disabled aid categories. Referencing the section numbers of the Social Security Act, Indiana transitioned from a “209(b)” state to a “1634” state. As a 209(b) state, Indiana required aged, blind, and disabled individuals to be determined eligible based on state-specific applications for Medicaid coverage and utilized state-specific criteria for disability determinations. 1634 Changes -Social Security Income (SSI)-eligible individuals are automatically enrolled in Medicaid under MASI category and do not need to file a separate Indiana Application for Health Coverage. -Individuals who receive Social Security Disability Income (SSDI) are not required to undergo a separate determination of disability from Indiana’s Medical Review Team (MRT). A financial eligibility review is still required, so these individuals do need to complete the Indiana Application for Health Coverage. 1634 Changes IHCP is no longer required to operate a Spend-down program; therefore this program was eliminated effective June 1, 2014. The income eligibility threshold for full aged, blind, or disabled Medicaid coverage increased to 100% of the FPL. All members eligible under the aged, blind, or disabled aid categories with incomes at or below this level are eligible for full Medicaid benefits. Long-term care and Waiver members over 100% FPL have special guidelines in regard to the SIL (Special Income Limit). Long-Term Care Services LEVEL OF CARE State Plan Medicaid (Traditional Fee for Service) State Medicaid programs must cover certain “mandatory services” as required by federal law. Some Mandatory services include: EPSDT services, pregnancy related services and laboratory and x-ray services. States can choose to cover “optional services.” Indiana has chosen to cover Hospice care, Home Health Care, Dental and many other optional services. Long Term Services and Supports The Medicaid program allows for the coverage of Long Term Care Services through several vehicles and over a continuum of settings. This includes Institutional Care and Long Term Services and Supports The Affordable Care Act includes changes that enable states to target home and community-based services to particular groups of people, to services accessible to more individuals, and to ensure the quality of the services provided. Standards for Aged, Blind, Disabled INCOME Single: $981 (current FPL) Couple: $1328 Disabled Worker: $3433 BPHC Limit: $2943 Special Income Limit: $2199 (for long-term care/waivers) RESOURCES Single: $2000 Couple: $3000 For Married Couples where one spouse receives waiver services or lives in long-term care, there are spousal impoverishment rules that provide for a higher resource limit. Special Income Limit (SIL) The SIL only applies to members who are in long-term care or who are eligible for HCBS waivers. The person’s income is compared to the SIL, currently $2199, and if over: -For members who are in long-term care, a client must create a Miller Trust and have all income over the SIL placed into said trust on a monthly basis as a condition of eligibility. -For members receiving waiver services, a Waiver Liability obligation is computed. This is comparable to what used to be called a spend-down. The client will have to incur this amount before Medicaid will pay for claims. Special Income Limit (SIL) Parental income is exempt in the SIL test and if the child passes the SIL test, parental resources are exempt. If Medicaid coverage is needed prior to the start date of waiver services, retroactive coverage can be approved using regular eligibility rules for those months, including parental deeming as appropriate for the child’s category. If the parents request Medicaid coverage to coincide with the waiver start date, the parents are not required to provide any information regarding their income or resources. Miller Trusts Qualifying Income Trusts (QIT) have been developed to allow an individual with income in excess of the SIL to become Medicaid eligible. A Miller Trust must specify the following: It is to be funded only by the income of the individual. It cannot be funded with the individual’s resources, nor the income or resources of other persons; Upon the death of the individual, the State of Indiana will receive all remaining funds in the trust up to the amount of Medicaid expenditures paid on the individual’s behalf; If the right to receive the income is assigned or otherwise transferred in title to the trust, the QIT exception is nullified. Consideration of Resources Resources are not considered for MASI, or for any Hoosier Healthwise (children’s Medicaid) or HIP categories. Resources are reviewed for all aged, blind, and disabled categories, as well as for Qualified Medicare Beneficiary categories. Other Exempt Resources A home that is the principle residence of the client, his spouse or child Income-producing property Life insurance policies with total face value less than $1,500 Life insurance policies with a face value less than $10,000 if the estate or funeral home is the beneficiary Irrevocable Funeral trusts/agreements with a face value less than $10,000 One vehicle for the recipient/household Retroactive lump sum payments from Social Security (for 9 months) Burial plots Valid Special Needs Trusts and Pooled Trusts Non-Exempt Resources Bank accounts and other liquid resources that are available to the client Life insurance policies whose beneficiary is not a funeral or the estate Life insurance policies with a face value over $10,000, regardless of beneficiary Real property that is not a current residence and does not produce income Retirement accounts that are available or can be cashed out within 20 days (excluding accounts of non-recipient spouses) Any extraneous vehicles (not including one exempted vehicle) Collective accounts Home and Community Based Services (WAIVERS) Waiver Service Options State plan services of special interest to HCBS waiver enrollees: -Home health care -Durable Medical Equipment & Supplies -Medical Transportation -Hospice States can choose to operate Home and Community Based programs using different rules -1915(c) HCBS -1915(i) What are HCBS Programs? Permit a State to furnish an array of home and community-based services to assist Medicaid beneficiaries who want to live in the community and avoid institutionalization. Serve a variety of targeted populations groups, such as people with mental illnesses, intellectual or developmental disabilities, and/or physical disabilities. -Services such as respite, case management, and training to caregivers are offered under HCBS programs. -Give person-centered care: The member and/or guardian is directly involved in developing goals, selecting providers, and choosing from available services. -Some allow for a higher income level for Medicaid eligibility. What are HCBS Programs? 1915(c)- HCBS Waiver Provides services to individuals who are eligible for Medicaid (either with or without a higher income standard applied) and meet specific criteria including an institutional level of care but wish to remain in the community instead of an institution. Individual can not be in managed care There is a maximum number of approved member slots/year, once filled there will be a waiting list. Members can only be on one waiver program at a time. What are HCBS Programs? 1915(i)- State Plan Option Provides services to individuals who are eligible for Medicaid with or without certain income limits applied, and meet specific criteria. Individual may be enrolled in Managed Care. There is no maximum number of approved member slots/year Anyone who qualifies will receive services timely. No waiting list. Permissible HCBS Waiver Categories SSI (MASI); Aged (MA A); Blind (MA B); Disabled (MA D); MED Works (MADW, MADI) Low-income Caretakers (MAGF) Foster Care (MA 15) Foster Care Independence (MA14) Children under Age 1 (MA Y) Children Age 1-5 (MA Z) Children Age 1-18 (MA 2, MA 9) Transitional Medical Assistance (MA F) IV-E FC Foster Care children (MA 4) Children receiving Adoption Assistance (MA 8) Examples of HCBS Waiver Services IN ADDITION TO REGULAR FFS BENEFITS Adult Day Service Assisted living Case/Care Management Environmental Modifications Home/Vehicle Modifications Homemaker Habilitation Family and Caregiver Training Music/ Recreation Therapy Home Delivered Meals Non-medical Transportation (not to any medical appts) Personal Emergency Response System Pest Control Respite (relief for caregiver) Rent and Food for Unrelated Live-in Caregiver Workplace Assistance Personal Emergency Response System 1915(c) HCBS Waivers Types of 1915(c) HCBS Waivers Aged and Disabled Waiver (A&D) Traumatic Brain Injury Waiver (TBI) Community Integration and Habilitation Waiver (CIH) Family Supports Waiver (FSW) The Psychiatric Residential Treatment Facility Transition Waiver (Alternative to PRTF) Aged and Disabled (A&D) Waiver This is an alternative to nursing facility admission for adults and persons of all ages with a disability A client must be approved for Nursing Facility level of care. This program currently has no waitlist. Can apply at local Area Agency on Aging (AAA) office. Traumatic Brain Injury (TBI) Waiver Participants meet the minimal requirements for Nursing Facility (NF) or Intermediate Care Facility (ICF/IID) level of care and have a traumatic brain injury Indiana defines a traumatic brain injury as a trauma that has occurred as a closed or open head injury by an external event that results in damage to brain tissue, with or without injury to other body organs. Examples of external agents are mechanical; or events that result in interference with vital functions. This program does have a minimal waitlist. Can apply at local Area Agency on Aging (AAA) office. Community Integration & Habilitation (CIH) Waiver Participants must have the Intermediate Care Facility (ICF/IID) level of care determination. For Individuals of all ages with intellectual or developmental disabilities. This waiver combined previous DD and Autism waivers. Must meet priority criteria: higher level of needs, loss of caregiver, advanced age of caregiver No waiting list. Can apply at Bureau of Developmental Disabilities Services. Family Supports Waiver (FSW) Must have Intermediate Care Facility (ICF/IID) level of care. For individuals of all ages with intellectual or developmental disabilities. This is the primary point of entry for ICF/IID waivers. This program has a limit of $16, 545 per year for any combination of services offered on the program. This program does have a waiting list. Can apply at Bureau of Developmental Disabilities Services. Psychiatric Residential Treatment Facility (PRTF) Waiver For youth age 6-20 with serious mental illness (SMI) or serious emotional disturbance (SED) who have specific diagnosis such as psychosis, anxiety or depression Implemented after the Community Alternative to psychiatric treatment facility grant expired. (CA-PRTF) No new enrollees. This is a transitional program that will end after 2 years. Money Follows the Person Grant (MFP) Federal grant to help states move individuals from institutional settings to home and community-based settings. Participation in Indiana's MFP program lasts for 365 days. On participation day 366, funding for the supports received by the participant will change from the MFP program to a partnering funding source. Partnering funding programs: Aged and Disabled Waiver (A&D), Traumatic Brain Injury Waiver (TBI), Community Integration and Habilitation Waiver (CIH), and Psychiatric Residential Treatment Facility (PRTF) Transitional Waiver MFP services mirror the partnering funding program 1915(i) HCBS State Plan Amendments (SPAs) What are 1915(i) SPAs? Give states the option to offer a wide range of home and community-based services (HCBS) to members through state Medicaid plans. Using this option, states can offer services and supports to a target group of individuals, including individuals with serious mental illness, Serious emotional disturbance, and substance use disorders, to help them remain in the community. Members enrolled in a 1915(i) do not need to meet an institutional level of care to be eligible to use the services. 1915(i) Home and Community Based SPAs Division of Mental Health and Addiction Child Mental Health Wrap-Around (CMHW) Adult Mental Health Habilitation (AMHH) Behavior and Primary Healthcare Coordination (BPHC) Child Mental Health Wraparound (CMHW) -Serves youth with SED, ages 6-17 who meet level of need (LON) criteria. (i.e. CANS score 3 or higher, actively enrolled in any IHCP). -Carved out of managed care (billed as FFS). -No cost neutrality required. -Members can utilize all Medicaid state plan services -Members can utilize 1915(c) Waiver if they qualify. -Member can also utilize Medicaid Rehabilitation Option (MRO) services. Available Services: CMHW Behavioral health and support services Community resources and supports Crisis planning and intervention Family Support and Training for the Unpaid Caregiver Habilitation Parent coaching and education Respite Care Wraparound Facilitation Adult Mental Health Habilitation (AMHH) -Adults age 35 and older, who have a primary mental health diagnosis and would benefit from a habilitative approach to care. -Services can be delivered to the family with or without the member present as well. -Member enrolled in AMHH can utilize all Indiana State Plan if eligible EXCEPT MRO, as this is a rehabilitative service. -Members on certain Managed Care programs can utilize this as a carve out (billed FFS). Available Services- AMHH Adult Day Services Respite Care Therapy and Behavioral Supports Peer Support Services Supported Community Engagement Services Care Coordination Medication Training and Support Home and Community-Based Habilitation and Support Behavior and Primary Healthcare Coordination (BPHC) Different than the other 1915(i) programs as it was designed in conjunction with the 1634 conversion to: Preserve eligibility for Medicaid members who were disabled MRO members with spend down and would not otherwise be Medicaid eligible. Coordinate healthcare as the primary service. Other Resources Policy Information Medicaid Policy Manual: http://www.in.gov/fssa/ompp/4904.htm IHCP Provider Manual http://provider.indianamedicaid.com/general-provider-services/manuals.aspx IndianaMedicaid.com IFCEM.com (application) OMPP STAFF OMPP ELIGIBILITY: 317-232-4966 LAURA KENDALL, ELIGIBILITY MANAGER, FFS & HCC Laura.kendall@fssa.in.gov GINGER GLEAVES, ELIGIBILITY MANAGER, HIP & HHW Ginger.gleaves@fssa.in.gov NONIS SPINNER, ELIGIBILITY DIRECTOR Nonis.spinner@fssa.in.gov