indiana health coverage programs. reminders all 2015 marketplace plans are finalized. curious...
TRANSCRIPT
Indiana Health Coverage Programs
Reminders
All 2015 Marketplace plans are finalized. Curious consumers (and assisters) can visit HealthCare.gov for the window shopping tool to view plans in their coverage area.
Outreach Challenge is due Saturday, November 15! Submit for a chance to win a pizza party!
On November 20 at 9:30 AM ET, IPHCA is hosting a call with Matt Cesnik from FSSA again.
• Enacted in 1965 by Title XIX of the Social Security Act • Funded by state and federal government • In Indiana, Medicaid is called Indiana Health Coverage Programs• Provides free or low-cost health insurance coverage to low-
income:– Children– Pregnant women– Parents and caretakers – Blind – Disabled – Aged
• Income limits are based on the Federal Poverty Level (FPL)
What is Medicaid?
• As of January 1, 2014, the states must cover:– Former foster children
• Under age 26 • Receiving Indiana Medicaid when aged out of the system• Not subject to income limits until age 26
– Children age 6-18 • Up to 133% FPL
– Pregnant Women
New Eligibility Groups
What are Federal Poverty Guidelines (FPL)?
• Also known as Federal Poverty Level (FPL)– Issued each year by the Department of Health and Human Services
(HHS)
• Measure of pre-tax income used to determine what is considered poverty in the United States
• Anyone living at 100% or below the FPL is considered living in poverty
ELIGIBILITY SPECIFICS
Children up to age 19 Pregnant women Low income parents/caretakers of
children under age of 18
Offers different benefit packages State determines eligibility and
coverage Member selects MCE and PMP
Hoosier Healthwise
Enrollees excluded from mandatory enrollment in Hoosier Healthwise include:•Individuals in nursing homes and other long-term care institutions•Undocumented individuals who are eligible only for emergency services (Package E)•Individuals receiving hospice or home and community-based waiver services•Individuals enrolled in Medicaid on the basis of age, blindness or disability•Wards of the court and foster children
Hoosier Healthwise
HHW PACKAGE DESCRIPTION
A—Standard Full-service plan for children, pregnant women and families
No premiums
C– Children’s Health Insurance Program (CHIP)
Full service plan for children only (under age 19)
Small monthly premium payment & co-pay for some services based on income
P—Presumptive Eligibility Ambulatory prenatal coverage for pregnant women who are determined “presumptively eligible” while their Indiana Application for Health Coverage is being processed
Services Available under Hoosier Healthwise
• Medical care:• Hospital care• Physician office visits• Check-ups• Well-child visits• Clinic services• Prescription drugs• Over the counter drugs• Lab & X-Rays• Mental health care
• Substance abuse services• Home health care• Nursing facility services• Dental• Vision• Therapies• Hospice• Transportation• Family planning• Foot care• Chiropractors
Medicaid provides coverage for the following
Hoosier Healthwise
Family Size
Parents & Caretaker Relatives
Children Pregnant Women
1 n/a $2,432 n/a2 $247 $3,278 $2,7273 $310 $4,123 $3,4314 $373 $4,969 $4,1345 $435 $5,815 $4,838
Monthly Income Limits
Children’s Health Insurance Program (CHIP)
• Child cannot be covered by other comprehensive health insurance
• Individuals in CHIP are responsible for monthly premiums and must pay the first premium prior to coverage becoming effectuated (There is a 60 day grace period)
• A child whose coverage was dropped voluntarily may not receive CHIP coverage for 90 days following the month of termination with some exceptions
Family FPL Monthly Premium for 1 Child
Monthly Premium for 2 or More Children
158% up to 175% $22 $33175% up to 200% $33 $50200% up to 225% $42 $53225% up to 250% $53 $70
ELIGIBILITY SPECIFICS Hoosier adults between the ages
of 19-64 Household income at or less
than the FPL Not otherwise eligible for
Medicaid
Provides full health benefits including free preventative services ($500), hospital services, mental health care, physician services, prescriptions and diagnostic exams
Does not provide vision, dental or maternity services No co-pays except for non-emergency use of a
hospital ER Provides a Personal Wellness and Responsibility
(POWER) Account valued at $1,100 per adult to pay for medical costs
• Enrollee contributes 2-5% of gross income• Employers and non-profits can contribute
Healthy Indiana Plan (HIP)
Healthy Indiana Plan (HIP) Enrollment
• Individuals who fail to make their monthly POWER Account contribution after a 60-day grace period are disenrolled for 12 months.
• If individuals fail to complete their annual redetermination, they will be disenrolled
Family Size Monthly Income Threshold1 $9732 $1,3113 $1,6494 $1,9885 $2,3266 $2,6657 $3,0038 $3,441
Healthy Indiana Plan (HIP) Key Dates
• In September 2013, the State received authorization from CMS to continue the HIP program for one year (through December 31, 2014).
• Due to problems with the roll out of the federal marketplace, HIP eligibility was extended those over 100% FPL (including the 5% disregard) through April 2014 to allow for transition to the Marketplace.
• On May 15, 2014, Indiana Governor Mike Pence announced a plan to expand HIP from 100% to 138%of the FPL.
• MCEs provide the following services and functions to Hoosier Healthwise & HIP enrollees:– Case management and disease management – Member services helpline– Screening enrollees for special health care needs– 24-hour Nurse Call Line– Managing grievances and appeals– Provide member handbooks
• Hoosier Healthwise & HIP enrollees select one of the three MCEs, or they are auto-assigned 14 days after enrollment
Managed Care Entities (MCEs)
Managed Care Entities (MCEs)
Some factors for beneficiaries to consider when selecting an MCE include the following:oProvider network
• Is the individual’s doctor available in the MCE network?• Are the locations of network providers easily accessible
for the enrollee? • Are the locations convenient to the individual’s work,
home or school?oSpecial programs & enhanced services
• Is there a service or program offered by the MCE that is particularly important or attractive to the enrollee?
Primary Medical Providers
• Once a beneficiary is enrolled in an MCE, he or she also selects a Primary Medical Provider (PMP).
• Enrollees must see their PMP for all medical care;
• Provider types eligible to serve as a PMP include Indiana Health Coverage Program enrolled providers with the following specialties:– Family practice– General practice– Internal medicine– Obstetrics (OB)/Gynecology (GYN )– General pediatrics
Traditional Medicaid (Fee-for-Service)
The following individuals who meet income and resource requirements are eligible:
•Blind, Disabled, and Aged persons
•Persons in nursing homes & other long-term care institutions
•Undocumented aliens who do not meet a specified qualified status;
•Persons receiving home and community-based waiver or hospice services
•Dual eligibles
•Persons eligible on the basis of having breast or cervical cancer
•Refugees who do not qualify for another aid category
•Former Independent Foster Children up to age 18, IV-E Foster Care Children, IV-E Adoption Assistance Children, and Former foster children under the age of 26 who were enrolled in Indiana Medicaid as of their 18th birthday
Traditional Medicaid (Fee-for-Service)
• In Traditional Medicaid, beneficiaries are not enrolled in a Managed Care Entity (MCE) or Care Management Organization (CMO) and can see any Indiana Health Coverage Program enrolled provider.
• All provider claims are paid fee-for-service by the State’s Fiscal Agent, Hewlett-Packard.
BENEFIT PACKAGE DESCRIPTION
Standard Plan Full Medicaid coverage
Medicare Savings Program QMB: Medicare Part A & B premiums, deductibles, & coinsurance SLMB/QI: Medicare Part B premiums QDWI: Medicare Part A premiums
Package E Emergency Services only– for certain immigrants who do not qualify for full Medicaid coverage
Family Planning Family planning services only
Traditional Medicaid (Fee-for-Service)
ELIGIBILITY SPECIFICS
Ages 16-64 Fall below 350% FPL Disabled according to Indiana’s
definition of disability Not exceed asset limit (Single: $2,000
or Couple: $3,000) Be working (there is no minimum work
effort for program)
Full Medicaid benefits Members pay small monthly premium
based on income Individual only program Members can put up to $20,000 in
Savings for Independence and Self-Sufficiency Account
Members can have employer insurance
M.E.D. Works
M.E.D. Works
Monthly Income Premium
Single $1,459 - $1,702 $48$1,703 – $1,945 $69$1,946 - $2,432 $107$2,433 - $2,918 $134$2,919 - $3,404 $161
$3,405 $187
Married $1,967 - $2,294 $65$2,295 - $2,622 $93$2,623 - $3,278 $145$3,279 - $3,933 $182$3,934 - $4,588 $218
$4,589 $254
WAIVER ELIGIBILITY SPECIFICS
Aged and Disabled Income: Up to 300% Supplemental Security Income (SSI) benefit
• Parental income & resources disregarded for children under 18
Meets “Level of Care” Would otherwise be place in
institution such as nursing home without waiver or other home-based services
Complex medical condition which required direct assistance
Traumatic Brain Injury
Diagnosis of Traumatic Brain Injury
Community Integration & Habilitation
Diagnosis of intellectual disability which originates before age 22
Individual requires 24 hours supervisionFamily Supports
Home and Community Based Waivers
Behavioral and Primary Healthcare Coordination Program (BPHC)
– Assists individuals with serious mental illness (SMI) who otherwise won’t qualify for Medicaid or other third party reimbursement
– Individuals meet the following eligibility criteria:• Age 19+• MRO-eligible primary mental health diagnosis• Demonstrated need related to management of behavioral and
physical health • ANSA Level of Need 3+• Income below 300% FPL
Behavioral and Primary Healthcare Coordination Program (BPHC)
• Individuals may apply for the BPHC program through a Community Mental Health Center (CMHC) approved by the FSSA Division of Mental Health and Addiction (DMHA) as a BPHC provider.
• A list of approved CMHCs can be found at http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.aspx.
• Covers low-income Medicare beneficiaries
• Helps pay for out-of-pocket Medicare costs.
• Individuals must be eligible for Medicare Part AProgram Income
ThresholdResource Limit Benefits
Qualified Medicare
Beneficiary (QMB)
100% FPL Single: $7,080Couple: $10,620
Medicare Part A & B Premiums
Co-pays, deductibles, coinsurance
(Specified Low Income) SLMB
120% FPL Single: $7,080Couple: $10,620
Part B Premiums
Qualified Individual (QI)
135% FPL Single: $7,080Couple: $10,620
Part B Premiums
Qualified Disabled Worker
(QDW)
200% FPL Single: $7,080Couple: $10,620
Part A Premiums
Medicare Savings Program
ELIGIBILITY SPECIFICS
Does not qualify for any other category of Medicaid
Meets citizenship or immigration status requirements
Not pregnant Have not had hysterectomy or sterilization Have income at or below 141% FPL
Includes, but not limited to:Annual family planning visitsPap smears Tubal ligation Vasectomies Hysteroscopic sterilization with an implant device Laboratory tests, if medically indicated as part of the decision-making process regarding contraceptive methods FDA approved anti-infective agents for initial treatment of STD/STI
Family Planning Program
Family Planning Program
Services not covered:•Abortions •Artificial insemination •IVF, fertility counseling or fertility drugs•Inpatient hospital stays •Treatment for any chronic condition
Individuals must request to be considered for this program on their Indiana Application for Health Coverage
if not eligible for full Medicaid benefits
ELIGIBILITY SPECIFICS
ISDH diagnosis OR Age 19-64 Need treatment for breast or cervical cancer Not eligible for Medicaid under any other
program No health insurance to cover treatment
Uninsured or underinsured Indiana residents below 200% FPL (age 40+) may qualify for free breast and cervical cancer screenings and tests
Breast and Cervical Cancer Program (BCCP)
Presumptive Eligibility (PE)
• Allows individuals meeting eligibility requirements access to services covered and paid for by Medicaid as they wait for their application determination for full Medicaid
• Entails a simplified application process:– Applicant must know gross family income & citizenship status– Verification documents not required—applicant attests to information
Presumptive Eligibility (PE)
• The PE period extends from the date an individual is determined presumptively eligible until:– When an Indiana Application for
Health Coverage is filed: • Day on which a decision is made on
that application
– When an Indiana Application for Health Coverage is not filed:
• Last day of the month following the month in which the PE determination was made
ELIGIBILITY SPECIFICS
Not currently receiving Medicaid Pregnant Indiana resident US citizen (or qualified immigrant) Family income less than 208% FPL One PE period per pregnancy
Includes doctor visits, tests, lab work, dental care, prescription drugs and other care for pregnancy
Does not pay for hospital stays, hospice, long term care, abortion, postpartum services, labor and deliver, or services unrelated to pregnancy
Presumptive Eligibility for Pregnant Women
Qualified Providers
• Qualified providers (QPs) make PE determinations in accordance with Indiana eligibility policy and procedures.
• QPs must meet the following criteria:– Be enrolled as an Indiana Health Coverage Program (IHCP) provider
– Attend a provider training
– Provide outpatient hospital, rural health clinic or clinic services
Hospital Presumptive Eligibility
• All states are required to permit hospitals that meet state requirements to make PE determinations.
• In Indiana, the eligibility groups or populations for which hospitals will be permitted to determine eligibility presumptively are:– Low-income infants and children– Low-income parents or caretakers– Former foster care children up to the age of 26– Low-income pregnant women– Individuals seeking family planning services only
• Each Medicaid assistance category has specific eligibility requirements such as: – Age– Income – Pregnancy status– Indiana Residency – Citizenship/Immigration– Provide Social Security Number
(SSN)– Provide information on other insurance
coverage – File for other benefits
General Medicaid Eligibility and Requirements
• Applicant must be resident of the state • A homeless individual or residents of shelters
in Indiana meet this requirement• There is no minimum time period for state
residency to be Medicaid eligible• Individuals are permitted to be temporarily absent from
the state without losing eligibility
Requirement: Residency
• Individual must be US citizen, a US non-citizen national or an immigrant who is in a qualified immigration status
• Electronic data sources through the Federal Hub verify status
• Those exempt from citizenship verification process:o Individuals receiving SSI or SSDIo Individuals enrolled in Medicare o Individuals in foster care & who are assisted under Title IV-Bo Individuals who are beneficiaries of foster care maintenance or
adoption assistance payments under Title IV-Eo Newborns born to a Medicaid enrolled mother
Requirement: Citizenship/Immigration Status
• Each Medicaid applicant must supply social security number (SSN) with the following exceptions: Individual ineligible to receive SSN Individual does not have SSN and may only be
issued one for a valid non-work reasons Individual refuses to obtain one due to well-established
religious objections Individual is only eligible for emergency services due to
immigration status Individual is a deemed newborn Individual is receiving Refugee Cash Assistance and
is eligible for Medicaid Individual has already applied for SSN
Requirement: Provide Social Security Number
• Individuals must apply for all other benefits for which they may be eligible as a condition of eligibility unless good cause can be show for not doing so; these include:– Pensions from local, state or federal government– Retirement benefits – Disability – Social Security benefits – Veterans’ benefits – Unemployment compensation benefits– Military benefits – Railroad retirement benefits – Workers’ Compensation benefits– Health and accident insurance payments
Requirement: File for Other Benefits
• Medicaid enrollees can have access to other insurance (third liability); however… – Individuals cannot have other
insurance and enroll in CHIP or HIP– Applicants must provide information
on other insurance they have or change in insurance status
– Medicaid is the payer of last resort– other insurance is the primary payer
Requirement: Report and Use Other Insurance
• Methodology for income counting and determining household size and composition
• Adjusted Gross Income + Tax Excluded Foreign Earned Income + Tax Exempt Title II Security Income = MAGI
• Not counted toward income:• Assets such as homes, stocks or retirement account• Scholarships, awards or fellowships not used toward
living expenses • Income disregards (except tax deductions) and non-
taxable income • Child support received, Worker’s compensation and
Veteran’s benefits
Modified Adjusted Gross Income (MAGI)
MAGI impacts:
New applicants: Adults Parents and Caretaker relatives ChildrenPregnant Women
MAGI does NOT impact:Aged BlindDisabled Those needing long-term care Former foster children under age 26 Deemed newborns
Modified Adjusted Gross Income (MAGI)
2014 Household Composition Rules Household = tax filer and all tax dependents
Married couples living together are included in the same household
Stepparents, stepchildren & stepsiblings now included in the household Income of children & siblings who are required to file a tax return is counted Adult children claimed as a tax dependent are now included in the household of the tax filer For a pregnant woman under MAGI rules, her unborn child(ren) is counted in determining her household size
Modified Adjusted Gross Income (MAGI)
• Application methods:– Online (Recommended)– Telephone – Fax – Mail, or – In Person at Division of Family Resources (DFR) office
• Medicaid eligibility determinations are made within 45 days or 90 days for determination based on disability
• Applicants can check status of online application
Indiana Application for Health Coverage
• Individual or organization which acts on a Medicaid applicant or beneficiary’s behalf in assisting with the application, redetermination process and ongoing communications with the state
• Commonly a trusted family member, but can also be a third party entity
• Designation must be in writing and signed by the applicant or beneficiary and the authorized representative– State Form 55366 can be used
Authorized Representatives
• States only permitted to collect paper documentation from Medicaid applicants when electronic data sources are not available or reasonably compatible
• Data sources used to verify:– Social Security Administration– Department of Homeland Security – TALX Work Number – State Wage Information Collection Agency – State Unemployment Compensation – Vital Statistics
Verifying Factors of Eligibility
• DFR provides written notice, via mail, to applications and beneficiaries regarding any decision affecting eligibility
Eligibility Notices
• Types of notices include, but not limited to:o Approvals o Denials o Terminations o Suspensions of eligibility o Changes in benefit package or aid category
What to expect with eligibility notices: •State sends notice within 24 hours + mailing time •Member ID card, referred to as the Hoosier Health Card, sent within 5 business days + mailing time
– HIP enrollees receive member ID card from their MCE– CHIP & M.E.D. Works receive premium invoices – HIP eligible individuals receive POWER Account contribution notices
•Individuals can be determined Medicaid eligible for up to 3 months of retroactive eligibility from the date of application
– Does not apply to HIP or CHIP
Eligibility Notices
• Conducted every 12 months for MAGI categories – The State renews if there is sufficient information, effective
December 2014 – If there is not sufficient information, a pre-populated renewal
form will be sent beginning in 2015 • Eligibility is terminated if the form is not submitted in a timely
manner• If eligibility is terminated but the documents are submitted within
90 days of the original due date, the documents will be reviewed without the need to submit a new application
Eligibility Redeterminations
Reporting Changes
• Enrollees are required to report changes to the state (FSSA)
• Examples of changes include:– Change in address– Income – Family composition – Babies born to Medicaid enrollees receive coverage for the first
year of life without the need for a separate application• The will be covered under Hoosier Healthwise and enrolled in the
mother’s MCE
Program Application ProcessAged & Disabled Waiver
Apply at Area Agencies on Aging (AAA) or call 1-800-986-3505
Breast & Cervical Cancer Program (BCCP)
Apply for Medicaid coverage, option 3; Family Helpline: 1-855-435-7178
Care Select Contact Enrollment Broker: MAXIMUS:1-866-963-7383Community Integration &
Habilitation or Family Supports Waiver
Apply at Bureau of Developmental Disabilities Services (BDDS) office or call 1-800-545-7763
Family Planning Eligibility Program
Division of Family Resources (DFR) Toll-Free at 1-800-403-0864 OR online
Healthy Indiana Plan (HIP) Print or pick-up application at a DFR office
Hoosier Healthwise (HHW)Apply though FSSA Benefits Portal, by phone (1-800-304-0864), or in person at DFR office
Traditional Medicaid Apply at DFR office, online/phone, Community Enrollment Centers
IHCP Application Methods
Helpful Resources
• Hoosier Healthwise Helpline– 1-800-889-9949
• Healthy Indiana Plan (HIP) Helpline– 1-877-GET-HIP-9
• FSSA Benefits Portal – Apply for cash assistance, SNAP and health coverage
• Indiana Medicaid Website – Eligibility Screening Tools – Guide to programs
Reminders
All 2015 Marketplace plans are finalized. Curious consumers (and assisters) can visit HealthCare.gov for the window shopping tool to view plans in their coverage area.
Outreach Challenge is due Saturday, November 15! Submit for a chance to win a pizza party!
On November 20 at 9:30 AM ET, IPHCA is hosting a call with Matt Cesnik from FSSA again.