SSI ☼ Medicaid ☼ DAC ☼ Spend down ☼ Deductible ☼ Why it matters anyhow???!?

Deb Hemgesberg, LMSW Project Manager in service to persons with developmental disabilities NEMCMH

Deb’s background, and WHY SHOULD we want to listen to her anyhow? • I was the CMH geek about SSA for 11 years as a case manager in Livingston County as a younger woman. • 2000, I became a certified benefits planner through SSA’s BPAO initiative, I was also one of Michigan’s state specific trainers. • Have been training Medicaid for a few years…I have contacts across the state and throughout the region, who are willing to help me learn and share. • I am rarely satisfied with the easy answer, unless it is backed in writing. • I have a memory for this “stuff”. • I KNOW there are no black and white answers, and MOST people have difficulty understanding this stuff, regardless of their intellect or education. • Knowledge is power • When in doubt, I do my own research

Todays plan: • What is the issue now? • The five most widely used MA programs for Medicaid for persons with a disability in MI (who do NOT have children) • How to access the Medicaid policies. • How to read/understand the MA policies. • How to legally shelter assets to make a person MA eligible. • Access to state employees email and phone • Trusts and their benefits. Unless you are a geek (like Deb) this is DRY material…

What is with CMH general funds and why and how does it affect us? • When the legislator authorized Healthy Michigan: expanded Medicaid - they reduced general spending for CMH boards across the state. • They did increase MA spending for CMH’s and that is helpful, however you cannot use MA and GF funds (analogy: Green and blue money) interchangeably so in essence even with an increase in MA funds, those nonMedicaid people (Medicare and concurrent recipients) now have no funds to meet their spend down as CMH has traditionally done in the past, and CMH systems across the state are having to terminate services for vulnerable people. Certainly an unintended consequence. WE must advocate for these vulnerable people now why we can Before someone is inadvertently hurt. • BTW… we have fixed all but three or four in NE…

The five (ok 7) most widely used MA programs • • • • • • •

BEM 105 MA overview BEM 150 MA for SSI recipients BEM 155 503 individuals (previous SSI) BEM 158 Disabled Adult Children (previous SSI) BEM 163 AD Care (aged and disabled care) BEM 165 Medicare Savings programs BEM 166 Group 2 aged, blind and disabled (spenddown). • BEM 545 Group 2 income elgibility (spenddown)

How to access DHS policies

• http://www.mfia.state.mi.us/olmweb/ex/html/

• BEM is place for the majority of what you will need. • Tables (RFT) will have info needed to calculate a spend down (should you desire to do this)

BEM 105 MA Only • The goal of the Medicaid program is to ensure that essential health care services are made available to those who otherwise could not afford them. Medicaid is also known as Medical Assistance (MA). SSI-RELATED AND FIP-RELATED The Medicaid program is comprised of several sub-programs or categories. • To receive MA under an SSI-related category, the person must be aged (65 or older), blind, disabled, entitled to Medicare or formerly blind or disabled. • Medicaid eligibility for children under 19, parents or caretakers of children, pregnant or recently pregnant women, former foster children, MOMS, Plan First!, and Adult Medical Program is based on Modified Adjusted Gross Income (MAGI) methodology

BEM 105 • GROUP 1 AND GROUP 2 • In general, the terms Group 1 (poverty) and Group 2 (spend down) relate to financial eligibility factors. For Group 1, net income (countable income minus allowable income deductions) must be at or below a certain income limit for eligibility to exist. The income limit, which varies by category, is for nonmedical needs such as food and shelter. Medical expenses are not used when determining eligibility for MAGI-related and SSI-related Group 1 categories. • For Group 2, eligibility is possible even when net income exceeds the income limit. This is because incurred medical expenses are used when determining eligibility for Group 2 categories.

EXHIBIT I SSI-RELATED MA CATEGORIES

BEM 150 MA for SSI recips MA Only • Supplemental Security Income (SSI) is a cash benefit for needy individuals who are aged (at least 65), blind or disabled. The Social Security Administration (SSA) determines SSI eligibility. • In Michigan, DHS supplements federal SSI payments based on the client’s living arrangement. Thus, in this item SSI recipient means a Michigan resident who receives the basic federal payment, the state supplement, or both. • To be automatically eligible for Medicaid (MA) an SSI recipient must both: Be a Michigan resident. Cooperate with third-party resource liability requirements. • DHS administers MA for SSI recipients, including a continued MA eligibility determination when SSI benefits end.

BEM 150 MA for SSI recips • Ongoing MA eligibility begins the first day of the month of SSI entitlement. Some clients also qualify for retroactive (retro) MA cover-age for up to three calendar months prior to SSI entitlement; see BAM 115. The following individuals are considered SSI recipients for MA purposes even though they do not receive an SSI cash grant: • Individuals appealing termination of SSI because SSA has determined they are no longer disabled or blind. DHS local offices are responsible for determining initial and continuing eligibility; see MA While Appealing Disability Termination in this item. • 1619 Recipients - Certain blind or disabled SSI recipients who work and have too much income for an SSI cash grant may be eligible for continued MA coverage. SSA determines eligibility. These recipients are the same as other SSI recipients in Bridges.

BEM 155 -503 individuals MA Only • This is an SSI-related Group 1 MA category. • MA is available to former SSI recipients who receive RSDI benefits and would now be eligible for SSI if RSDI cost-of-living increases paid since SSI eligibility ended were excluded. The reason for SSI ineligibility does not matter. • All eligibility factors must be met in the calendar month being tested. If the month being tested is an L/H month and eligibility exists, go to BEM 546 to determine the post-eligibility patient-pay amount. • 503 individuals eligible for Medicare are covered by the Buy-In Pro-gram (see BAM 810) and are considered eligible for QMB (BEM 165). • Nationally, this MA category is referred to as Medicaid under the Pickle Amendment. NONFINANCIAL ELIGIBILITY FACTORS The person must: – Currently receive RSDI benefits, and – Have stopped receiving SSI benefits after April 1977, and – Have been entitled to RSDI benefits in the last month he was eligible for and received SSI.

BEM 155 -503 individuals • •

Note: RSDI benefits paid retroactively can be considered. An SSI recipient who receives retroactive RSDI benefits does not become retroactively ineligible for SSI even when the retroactive RSDI monthly benefit was more than his SSI benefit. The person must be: – – – – – – – – – – – – –

•

Age 65 or older (BEM 240), or Blind (BEM 260), or Disabled (BEM 260). The MA eligibility factors in the following items must be met. BEM 220, Residence. BEM 221, Identity. BEM 223, Social Security Numbers. BEM 225, Citizenship/Alien Status. BEM 255, Child Support. BEM 256, Spousal/Parental Support. BEM 257, Third Party Resource Liability. BEM 265, Institutional Status. BEM 270, Pursuit of Benefits.

Note: An ex parte review (see glossary) is required before Medicaid closures when there is an actual or anticipated change, unless the change would result in closure due to ineligibility for all Medicaid. When possible, an ex parte review should begin at least 90 days before the anticipated change is expected to result in case closure. The review includes consideration of all MA categories. See BAM 115 and 220.

MA Only • This is an SSI-related Group 1 MA category. • MA is available to a person receiving disabled adult children's (DAC) (also called Childhood Disability Beneficiaries' or CDBs') RSDI benefits under section 202(d) of the Social Security Act if he or she: – 1. Is age 18 or older; and – 2. Received SSI; and – 3. Ceased to be eligible for SSI on or after July 1, 1987, because he became entitled to DAC RSDI benefits under section 202(d) of the Act or an increase in such RSDI benefits; and – 4. Is currently receiving DAC RSDI benefits under section 202(d) of the Act; and

• Note: To receive DAC RSDI a person must have a disability or blindness that began before age 22. – 5. Would be eligible for SSI without such RSDI benefits.

BEM 158 DAC • The Social Security Administration notifies central office when SSI terminates for a person meeting the criteria in 1-4 above. Notification is via a code on State Data Exchange (SDX) tapes. Central office sends a memo (see EXHIBIT I) to the appropriate local office. See SSI TERMINATIONS in BEM 150. • All eligibility factors must be met in the calendar month being tested. If the month being tested is an L/H month and eligibility exists, go to BEM 546 to determine the posteligibility patient-pay amount. • DAC MA recipients eligible for Medicare are covered by the Buy-In Program (see BAM 810) and are considered eligible for QMB (BEM 165).

Please apply for SSI at age 18!!!

biggest

• The reason we can’t get regular Medicaid for people with developmental disabilities, who are currently on Medicaid spend down, is that their parents did NOT apply for SSI at age 18, and they began getting RSDI without ever getting SSI. • If you as a parent do not help your son or daughter apply for SSI, you need to understand you are in essence, plunging them into poverty when you aren’t going to be in a place to be able to help them. (this is an unintended consequence far more people that I am comfortable with have faced)

BEM 163 AD-Care MA Only • This is an SSI-related Group 1 MA category. • Consider eligibility under this category only if eligibility does not exist under BEM 154 through 158. Use this category before using Extended-Care (BEM 164) or any Group 2 MA category. • This category is available to persons who are aged or disabled (AD). Net income cannot exceed 100% of the poverty level. • All eligibility factors in this item must be met in the calendar month being tested. If the month being tested is an L/H month and eligibility exists, go to BEM 546 to determine the post-eligibility patient-pay amount.

BEM 163 AD-Care • NONFINANCIAL ELIGIBILITY FACTORS 1. The person must not be eligible for MA under BEM 154 through 158. 2. The person must be aged (BEM 240, Age) or disabled (BEM 260, MA Disability/Blindness). Note: Blindness is not a basis of eligibility. However, a blind person who is also aged or disabled meets this eligibility factor.

3. The MA eligibility factors in the following items must be met. BEM 220, Residence. BEM 221, Identity. BEM 223, Social Security Numbers BEM 225, Citizenship/Alien Status BEM 255, Child Support. BEM 256, Spousal/Parental Support. BEM 257, Third Party Resource Liability. BEM 265, Institutional Status. BEM 270, Pursuit of Benefits.

BEM 165 Medicare savings programs MA Only • Medicare Savings Programs are SSI-related MA categories. They are neither Group 1 nor Group 2. • This item describes the three categories that make up the Medicare Savings Programs. The three categories are: – 1. Qualified Medicare Beneficiaries This is also called full-coverage QMB and just QMB. Program group type is QMB. – 2. Specified Low-Income Medicare Beneficiaries This is also called limited-coverage QMB and SLMB. Program group type is SLMB. – 3. Q1 Additional Low-Income Medicare Beneficiaries This is also referred to as ALMB and as just Q1. Program group type is ALMB.

BEM 165 Medicare savings programs • There are both similarities and differences between eligibility policies for the three categories. Benefits among the three categories also differ. • Income is the major determiner of category. • QMB Net income cannot exceed 100% of poverty. (2014: $993.00) • SLMB Net income is over 100% of poverty, but not over 120% of poverty. (2014: $994.00-1,187.00) • ALMB (Q1) Net income is over 120% of poverty, but not over 135% of poverty. (2014: $1,188.00 – 1,333.00) • A person who is eligible for one of these categories cannot choose to receive a different Medicare Savings Program category. For example, a person eligible for QMB cannot choose SLMB instead. • All eligibility factors must be met in the calendar month being tested.

BEM 166 Group 2 (aged, blind and disabled) Group 2 means deductible MA Only

• This is an SSI-related Group 2 MA category. • Consider eligibility under this category only when eligibility does not exist under BEM 155 through 164, 170 or 171. • Consider Medicare Savings Program eligibility (BEM 165) in addition to Group 2 MA. • MA is available to a person who is aged (65 or older), blind or disabled. All eligibility factors must be met in the calendar month being tested. If the month being tested is an L/H month and eligibility exists, go to BEM 546 to determine the post-eligibility patient-pay amount.

BEM 166 Group 2 (aged, blind and disabled) • NONFINANCIAL ELIGIBILITY FACTORS • 1. The person must not be eligible for MA under BEM 155 through 164, 170 or 171, but may be eligible for a Medicare Savings Program under BEM 165. • 2. The person must be aged, blind or disabled (BEM 240, Age, or BEM 260, MA Disability/Blindness). The MA eligibility factors in the following items must be met: BEM 220, Residence. BEM 221, Identity. BEM 223, Social Security Numbers. BEM 225, Citizenship/Alien Status. BEM 255, Child Support. BEM 256, Spousal/Parental Support. BEM 257, Third Party Resource Liability. BEM 265, Institutional Status. BEM 270, Pursuit of Benefits.

BEM 166 grp 2 aged, blind and disabled (deductible) MA Only

• This is an SSI-related Group 2 MA category. • Consider eligibility under this category only when eligibility does not exist under BEM 155 through 164, 170 or 171. • Consider Medicare Savings Program eligibility (BEM 165) in addition to Group 2 MA. • MA is available to a person who is aged (65 or older), blind or dis-abled. All eligibility factors must be met in the calendar month being tested. If the month being tested is an L/H month and eligibility exists, go to BEM 546 to determine the post-eligibility patient-pay amount

BEM 174 FTW-MA MA Only • Do not consider Freedom to Work (FTW) eligibility if the month being tested is before January 2004. • This is an SSI-related Group 1 MA category. • FTW is available to a client with disabilities age 16 through 64 who has earned income. (people loose MA at age 65 in this category)

• Eligibility begins the first day of the calendar month in which all eligibility criteria are met. All eligibility factors must be met in the calendar month being tested. • Note: SSI recipients whose SSI eligibility has ended due to financial factors are among those who should be considered for this program. (let bank account go over 2K if ready for FTW-MA, and don’t need cash SSI)

BEM 174 FTW-MA NON-FINANCIAL ELIGIBILITY FACTORS 1. The client must be MA eligible before eligibility for FTW can be considered. 2. The client does not access MA through a deductible. 3. The client must be disabled according to the disability standards of the Social Security Administration, except employment, earnings, and substantial gainful activity (SGA) cannot be considered in the disability determination. Note: FTW clients requiring a disability determination from MRT must be clearly indicated on the medical packet by checking the other Program box and writing “Freedom to Work” or “FTW” in the blank on the DHS-49A Medical Social Eligibility Certification form. 4. The client must be employed. Note: A client may have temporary breaks in employment up to 24 months if the break is the result of an involuntary layoff or is determined to be medically necessary and retain FTW eligibility. 5. The MA eligibility factors in the following items must be met: BEM 220, Residence. BEM 221, Identity. BEM 223, Social Security Numbers. BEM 225, Citizenship/Alien Status. BEM 257, Third Party Resource Liability. BEM 265, Institutional Status. BEM 270, Pursuit of Benefits.

FTW-MA today aka SB 961… • The Amendment to the Freedom to Work legislation was introduced on May 28, 2014 by Sen. Tonya Scuitmaker. It is known as SB 961 • IF SB 961 SHOULD pass, it will likely make it so that many people who are currently without MA due to limitations with the previous legislation, will now be able to again access MA and work. • Putting people to work has a positive affect on so many areas of their/our lives. • MSA and the department have to workout some issues related to the affordable care act and premium structure. With the new legislation we are suggesting “up to 7.5%” of gross income (but potentially looking at a starting figure of about 4%). • This new version of FTW-MA will serve people who have work histories and collect SSDI, but otherwise have only qualified for MA under spend down or Deductibles. They can have up to 250% of FPL. THIS IS WIN:WIN for people… DHS, CMH, DCH and mostly for the people whom we all love and serve daily. • Deb made copies of the bill for you, please advocate for this with your representatives.

BEM 261 SDA State Disability Assistance (SDA) • To receive SDA, a person must be disabled, caring for a disabled person, or age 65 or older. • Note: There is no disability requirement for Adult Medical Program (AMP). • Note: MRS involvement IEP and Spec. Ed…(can be accessed while awaiting other pub benefits for people)

Other useful things to be aware of • • • • • •

BEM 174 FTW-MA BEM 261 Disability - SDA BEM 400 Assets 66 pages in this policy alone! BEM 401 Trusts (18 pages in this one) BEM 546 (for understanding deductible) BEM 554 (Food assistance issues)

trusts • There are two kinds: • Amenities/”Special Needs” Trust: Where Mom/Dad/grandparent/sib set up the trust to shelter funds to make them available without negatively impacting public (needs based) benefits. • OBRA93/Medicaid Payback Trust: where the person receiving benefits shelters their own funds.

A few questions that routinely come up: Rules found: POMS: SI 01120.200 (https://secure.ssa.gov/poms.nsf/lnx/0501120200)

b. Additions to principal. • Additions to trust principal made directly to the trust are not income to the grantor, trustee or beneficiary. (Exceptions to this rule are listed in SI 01120.200G.1.c. and SI 01120.200G.1.d.) • Additions to principal may be income or conversion of a resource, depending on the source of the funds. If funds from a third party are deposited into the trust, the funds are income to the individual. If funds are transferred from an account owned by the individual to the trust, the funds are not income, but conversion of a resource from one account to another. !!BE VERY CAREFUL not to co-mingle the individuals excess money (move this money into the parental trust) with the Ancillary or parental trust for danger the entire trust becomes subject to the Medicaid payback provisions!!

What can a trust pay for? • NOT food or shelter. 1. acupuncture/acupressure 2. advocacy 3. appliances (TV, VCR, stereo, microwave, stove, refrigerator, washer/dryer) 4. bottled water 5. bus pass/public transportation fees 6. clothing 7. clubs and club dues (record clubs, book clubs, health clubs, service clubs) 8. computer (hardware, software, programs, Internet service) 9. courses or classes (academic or recreational) 10.cell phone bill 11.curtains, blinds, drapes 12.dry cleaning and laundry services 13.elective surgery 14.fitness equipment 15.furniture, home furnishings 16.gasoline for automobile 17.haircuts/salon services 18.house cleaning/maid services 19.insurance (automobile and/or possessions)

What can a trust pay for? 1. 2. 3. 4.

linens and towels massage musical instruments (including lessons) nonfood grocery items (laundry soap, bleach, fabric softener, deodorant, dish soap, hand and body soap, personal hygiene products, paper towels, napkins, Kleenex, toilet paper, any household cleaning products) 5. over-the-counter medications (including vitamins or herbs, first aid supplies) 6. personal assistance 7. pet, pet supplies 8. physician specialists 9. private counseling 10.repair services (appliance, automobile, bicycle, household) 11.retail store charge accounts (gift stores, craft stores, hardware stores, pet stores) 12.sporting goods/equipment 13.taxi cab scrip, or transportation costs 14.telephone, internet, cable or satellite television 15.tickets to concerts or events (for beneficiary and accompanying companion) 16.transportation (automobile, motorcycle, bicycle, moped) 17.vacation (including paying for a companion to accompany the beneficiary) •

This list was adapted from a list compiled by Marsha Rose Katz and with the assistance of the Washtenaw Association for Community Advocacy.

Access to state employees • http://www.state.mi.us/dit/directory.aspx

Questions?

Apology

• I am sorry this is (so boring and) dry. It is very important information and your actions will assure your loved one a better life.

Deb Hemgesberg, LMSW [email protected]