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Medicaid 101 Presented by Diane Buff, IPMG Medicaid Manager January 17, 2014

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Objectives:

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• To have a basic understanding of Medicaid as it relates to individuals on the FSW and CIH Waiver. • To understand how to apply for Medicaid • To be able to identify and monitor annual redetermination • To know where resources are and how to utilize them

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What is Medicaid?

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• Enacted in 1965 through amendments to the Social Security Act, Medicaid is a health and long-term care coverage program that is jointly financed by states and the federal government. • Each state establishes and administers its own Medicaid program and determines the type, amount, duration, and scope of services covered within broad federal guidelines. • Federal law also requires states to cover certain mandatory eligibility groups, including qualified parents, children, and pregnant women with low income, as well as older adults and people with disabilities with low income.

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What is a Medicaid Aid Category?

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• A designation under which a person may be eligible for public assistance and medical assistance. • Medicaid has many aid categories. Examples of these categories are blind, disabled, and aged.

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Medicaid Aid Categories

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The following Medicaid Aid categories are compatible with the Waiver: MA-A MA-B MA-D

Medicaid for the aged Medicaid for the blind Medicaid for individuals who are disabled

MA-DW MA-DI

Medicaid for individuals who are disabled & working

Plus…..

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More Medicaid Aid Categories: MA-C MA-F MA-U MA-Y MA-Z MA-2 MA-9 MA-4

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Medicaid for children (and families) Continued coverage for MA C families when the parent obtains employment SSI recipients in low income families

Children under age 19, code varies by age and income limits

Wards of the DCS who are in foster case and receiving federal assistance under Title IV-E Foster Care MA-8 Under 19 with Adoption Assistance through Department of Child Services MA-14 Former foster children ages 18-20

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What is HHW?

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• Hoosier Healthwise (HHW) is Indiana’s public health insurance program. It is available to children up to age 19, parents and caretakers, and pregnant women. • Eligibility up to 250% of Federal Poverty Level. • Managed through Managed Healthcare Entities including Anthem, MDwise, Managed Health Services (MHS) • Managed Care is NOT compatible with waiver

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What is Medicaid Disability (MAD)?

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Eligibility Criteria • Must meet disability requirements • Resources/assets must be under $1500 Single or $2250 Couple, except for house and 1 vehicle • Resources include savings, retirement (401K) plans, life insurance with cash value, land, cash on hand, etc. • Does not count parent's income/resources for individuals over age of 18, regardless of school status • Comprehensive plan with no cap for Durable Medical equipment (DME) • Children CAN be enrolled in Medicaid Disability (MA-D). There is no minimum age. • Special Waiver Rules apply to this aid category.

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What is MRT Review?

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• State Medical Review Team (MRT) evaluates the application and supporting documents of the individual that is applying and determine whether they meet the definition of disabled. • Only the initial application is reviewed by MRT. Annual re-certifications and reapplications due to lapse in coverage are not reviewed by MRT. • MRT may request progress reports for periodic reviews if disability is not seen as long term. • MA-D and MA-B both utilize MRT

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Special Waiver Rules

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• Senate Bill 30-Provision which allows parental income and resources to be disregarded when determining Medicaid eligibility for children under the age of 18 in a Medicaid certified facility or being considered for the Medicaid Waiver program in lieu of institutionalization • Special Income Level (SIL)-Specific financial eligibility determination test • Special Waiver Rules apply to MA-A, MA-B, MA-D.

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What is a Spend down?

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• Spend down may be applied if someone is over the income limit for Medicaid. • “Deductible” that must be met monthly before Medicaid benefits become effective. Amount depends on the person’s income. • Participation in the waiver increases the income limit before spend down is applied for MA-A, MA-B, & MA-D. This is referred to as the Special Income Level. • Typically, if an individual is on the waiver, the spend down is waived. • If an individual is assigned a spend down, the NOA should be shared with the DFR case worker to assure Special Income Level is applied.

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What is a Premium?

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• An individual with a disability who works may be assigned MA-DW referred to as M. E. D. Works. • A monthly premium based on income needs to be paid in order to retain Medicaid benefits. • Participation in the waiver does not change the income limit before a premium is assigned. • Once an individual earns a certain income level, the MA-DW is the appropriate aid category.

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Resource Limits

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• Resources include savings, retirement (401K) plans, life insurance with cash value, land, cash on hand, etc. For an individual, the resource limits are: • MA-D: $1,500 • MA-DW $2,000 For MA-DW, Independence and Self Sufficiency Account can be requested to save additional money in order to purchase goods and services that will increase or maintain the recipients employability or independence.

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Trusts

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Special Needs Trust will allow the individual to have more than the allowable assets to retain government benefits. • Two types of Special Needs Trusts: Grantor or Third Party Trust • Can be set up using a variety of resources including: --Bank --Lawyer --The ARC Master Trust (www.thearctrust.org) Burial Trust is purchased through the funeral home of choice. Additional funds can be used to purchase or make payments on a recipient’s funeral, burial plot, headstone, and other related expenses.

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What is Medicare?

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• Family members often confuse Medicaid with Medicare • Medicare is a Federal health insurance program for people 65 or older, or for people under 65 with certain disabilities. • Under 65 if receiving Social Security Disability Income (SSDI) for at least 24 months. • Monthly premium for Medicare is paid through deduction of SSDI benefit check or through DFR if eligible.

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What is QMB?

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• Qualified Medicare Beneficiary • Also referred to as Medicare Savings Program • It is a limited coverage Medicaid category for low income Medicare beneficiaries • Medicaid pays the Medicare premiums, coinsurance, and deductibles. • May have QMB only or QMB in addition to traditional Medicaid. • QMB Only is NOT compatible with the waiver. • QMB Also is compatible with the waiver.

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Addressing QMB Only

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• If QMB Only, the individual will have an MA- aid category and believe that they have Medicaid. However, the aid category assigned is not compatible with the waiver and the individual will not be able to receive waiver services. • If an individual has QMB Only, the authorized rep needs to contact DFR at 1-800-403-0864 to determine why full Medicaid coverage was lost (MA-D is most typical aid category for waiver participants) and what is needed in order to establish full coverage. • Full coverage will typically mean QMB Also which is MA-D (Medicaid for the Disabled), MA-A (Medicaid for the Aged), or MA-B, (Medicaid for the Blind) in addition to the QMB to pay the Medicare premiums. • When an individual is assigned QMB Only, it typically means that full Medicaid coverage was lost during the annual recertification due to not submitting required documentation or being over resources. A new application is typically required to correct this.

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Applying for Medicaid

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• Online—Preferred by DFR • Local DFR office • Print DFR application from website and mail/fax/hand deliver • Request assistance from DFR over the phone at 1-800-403-0864

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Applying for Medicaid Online

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• Online at https://www.ifcem.com

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Application Process

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• Application for Medicaid is needed to first apply for Medicaid, to change an aid category, or to reapply when file was closed at annual recertification due to lack of follow through or for being over resources. • Application for Medicaid is submitted on line, at the local office, or via the mail/fax. • Applicant will typically receive notice of interview within 2 weeks of the application. • Phone or in person interview is conducted with DFR • Applicant will receive form from DFR outlining documentation that needs to be submitted. Typically needs to be returned to DFR in 10 days.

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Application Process (cont.)

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• DFR will provide a specific time frame (up to 45 days) for the requested information to be received. • If requested information is not received within the required timeframe, the file will be closed. • Once eligibility is determined, the applicant will receive written notice. • For new applications for MA-B or MA-D, medical records need to be obtained and reviewed by the Medical Review Team. New applications take approximately 90 days to process.

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Intakes without Medicaid

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• Medicaid application needs to be submitted after the initial CCB is approved. • Medicaid coverage is typically approved back to the approval month of the initial CCB. • Retro coverage for the full quarter prior to Medicaid application date is based on parent income for time period when waiver was not in effect. • If MA-D is being pursued, parent s will sign releases for the medical doctors and DFR will obtain medical records to establish eligibility. However, parents would want to submit other documentation to establish the level of disability such as IEP’s, school psychological, and therapy reports. • Seen as two step process: Financial eligibility and documentation of disability. • There needs to be a pending SSI application if not currently eligible.

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Prior Quarter Coverage

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• Once eligibility is determined, the start date will typically be retroactive through the previous three months. • Prior coverage may be greater than three months if there was an appeal, delay of processing, etc. • In order to receive Medicaid coverage for the prior quarter, the applicant needs to meet eligibility criteria and submit supporting documentation for that time frame. • If the applicant incurred any medical expenses during this timeframe, he would want to request that medical professionals resubmit claims to Medicaid.

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Tips for Retaining Medicaid

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Call 1-800-403-0864, visit local DFR office, or access DFR portal online to report changes. Report all changes, such as: • new address • new phone number • change in income • new job • resources (inheritance, lottery, etc.) • authorized rep

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Re-certification

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• Eligibility for Medicaid is re-determined annually. • The month typically stays the same from year to year, as long as there is no lapse in services. • DFR typically sends out the paperwork for recertification approximately 6 weeks prior. • Team members should follow up with individuals, guardians and RHSO provider (if applicable) to insure individual continues to adhere to guidelines to qualify for Medicaid. • Remind them to look for mailing from DFR, submit requested information timely, and ensure resources are below $1500. • If recertification paperwork is not received when anticipated, call DFR to inquire.

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Annual Re-certifications Medicaid only

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• If an individual receives only Medicaid, the recertification is completed by the DFR Change Center in Indy. • A form is sent to the authorized representative which needs to be completed and returned in 10 days along with supporting documentation. • If the authorized representative information is not current or accurate, the annual recertification paperwork will not be received. ***This will likely lead to lapse in Medicaid***

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Annual Re-certifications Medicaid and Food Stamps

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• If an individual receives both Medicaid and Food Stamps, the recertification is handled by the DFR local office. • In addition to the paperwork that needs to be completed and returned, a phone interview is conducted by DFR.

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What if Medicaid lapses?

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• Team members may be notified by individual, parent, guardian, provider, billing denial, ICES Notices, or Advocare Report that Medicaid has lapsed. • Team member should contact the person who supports the individual with Medicaid recertification (authorized rep) to determine why Medicaid has lapsed. • If the authorized rep does not know why Medicaid lapsed, encourage them to contact DFR using 1-800-403-0864 (option 2, option 5) to determine the steps needed to reinstate Medicaid. • If the individual or authorized rep needs support, a team member can obtain authorization to allow inquiry to DFR.

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Authorization for Disclosure

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Authorization for Disclosure of Personal and Health Information can be used for short term inquiries about Medicaid status: o Typically valid for up to 60 days. o Allows an individual or agency to be identified as being able to make inquiries o Ability to interact with DFR is limited to actions noted on the disclosure. o Considered a “1 time use” form. o Disclosure form can be obtained at https://forms.in.gov/Download.aspx?id=9491

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Authorized Representative

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A team member can obtain an authorized rep form which will allow her to obtain information about required documentation and status from DFR in order to be able to assist. o As an authorized rep, team member would receive copies of notices sent to the individual o A specific person is the authorized rep, not an agency o Allows for continued involvement o Up to 4 authorized reps can be requested per individual o Authorized rep form can be obtained at https://forms.in.gov/Download.aspx?id=9518

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Lapse in Medicaid

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• If the Medicaid file has been closed due to lack of follow through in the recertification process, a new Medicaid application is typically required. • If the closure notice is recent, it may be possible for DFR to reopen the file without a new application. • State policy is that the waiver file is terminated after 90 days without active Medicaid (correct aid category). Once Medicaid is restored, individual/guardian would need to contact local BDDS office to request reentry.

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Bar-coded Coversheets

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• This is a cover page that should be used when sharing information with the DFR offices. • Each Medicaid applicant/participant has a unique bar code which helps make sure that documentation received is routed to the correct file. • Cover sheet is obtained when a new Medicaid application is submitted, is included in mailings from DFR when information is requested, or through the DFR Portal.

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Web interChange

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• Used to check eligibility for Medicaid and to file claims • Limited access within each provider agency Able to determine: 1. If Medicaid is active 2. Specific eligibility dates for Medicaid 3. General information regarding type of Medicaid 4. If individual has a spend down 5. Medicaid Case Number

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DFR Portal

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The DFR benefits portal allows the applicant to: • • • • • •

Apply for benefits Check status of a submitted application Review current benefits Print proof of eligibility Report a change in the case Obtain bar coded cover sheet

Team Members can utilize the DFR Portal.

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How to Access DFR Portal?

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Website Access: https://www.ifcem.com

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How to Check Status

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In order to check the status of an individual’s Medicaid online, the following information is required: • Case number • Last name • Date of birth (MM/DD/YYYY) • Last four digits of SSN If the person is a minor or member of household with others who receive Medicaid or public assistance, the case number may be registered with the Case Head’s name, DOB, and SSN.

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DFR Portal: Check Status

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DFR Portal: Log In

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DFR Portal: Case Status

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DFR Portal: Interview

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DFR Portal: Case Information

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DFR Portal: Medicaid Status

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Supported Living

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• Roommates in Supported Living will share the same case number. • One of the individuals will be designated the Case Head by DFR. • Access DFR Portal only through one of their Name/DOB/SSN.

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Medicaid Resources

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http://www.in.gov/fssa/2407.htm# Provides access to: • DFR Portal • DFR Region Map and locations of all county offices • Provider locator by specialty and/or location. • Forms

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DFR Map

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DFR Region Email

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Region emails should be used for: • Non-routine submission of information • Reporting spend down if an individual has been assigned one in error • Action should have been taken by DFR on behalf of an individual and has not been completed If the team member is not the authorized rep, DFR will reply letting her know that issue is being addressed. However, DFR will only provide follow up information to the authorized rep.

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Medicaid Resources

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Medicaid Program Policy Manual: http://www.in.gov/fssa/dfr/3301.htm • Eligibility Criteria for each aid category • Chapter regarding Medicaid Waiver • Defines income and resources

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Medicaid Resources

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www.indianamedicaid.com • Resource for providers and members • Family friendly descriptions of programs and benefits • Resource center • Links to apply, find providers, and seek assistance • Indiana Health Care Plans provider manual

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Handy Phone Numbers

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1-800-403-0864: Establish eligibility for Medicaid and SNAP • Option 2: Health Insurance/Medicaid • Then select Option 2 again for Case Status Player OR • Option 5 to talk with a case worker 1-800-457-4584: Member Services - Used to ask specific questions about Medicaid health coverage 1-855-577-6317: Catamaran - Used to ask specific questions about pharmacy services/coverage 1-800-433-0746: Help Line - Provides assistance with locating Medicaid accepting doctors and other providers.

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Questions

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Diane Buff Medicaid Manager, IPMG 219-472-1593 [email protected]

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