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Indiana Health Coverage Programs. Learning Objectives I.Outline the basics of Medicaid and Indiana Health Coverage Programs (IHCP) II.Identify and define.

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Presentation on theme: "Indiana Health Coverage Programs. Learning Objectives I.Outline the basics of Medicaid and Indiana Health Coverage Programs (IHCP) II.Identify and define."— Presentation transcript:

1 Indiana Health Coverage Programs

2 Learning Objectives I.Outline the basics of Medicaid and Indiana Health Coverage Programs (IHCP) II.Identify and define eligibility, goals and specifics of IHCP programs III.Discuss the standard elements of Medicaid and IHCP Eligibility IV.Examine eligibility notices, appeals and redeterminations for Medicaid and IHCP

3 Enacted in 1965 by Title XIX of the Social Security Act The federal government matches state spending on Medicaid In Indiana, Medicaid is called Indiana Health Coverage Programs which is administered by the Office of Policy Planning (OMPP) and Family and Social Services Administration (FSSA) 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) Offers variety of programs with varying criteria What is Medicaid?

4 Indiana’s Medicaid The Office of Medicaid Policy and Planning (OMPP) is responsible for: –Administering Indiana Health Coverage Programs (IHCP) at the State level, including the following functions: Medical policy development Program and contract compliance Contracting with MCEs Addressing cost containment issues Establishing IHCP policies Program reimbursement Program integrity, including claims analysis and recovery

5 Indiana’s Medicaid The Department of Family Resources (DFR) is the division of FSSA responsible for processing applications and making eligibility decisions. The County Offices of the DFR administer IHCP at the local level Online applications for Medicaid are located on the DFR’s Benefit Portal DFR’s Benefit Portal

6 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: Verification of pregnancy no longer required for Medicaid application Counted as 2 people Coverage continues 60 days postpartum New Eligibility Groups

7 Hoosier Healthwise (HHW) Healthy Indiana Plan (HIP) Care Select Traditional Medicaid Medicaid for Employees with Disabilities (M.E.D. Works) Home and Community-Based Service Waivers (HCBS Waivers) Medicare Savings Program Family Planning Services Spend-Down—Eliminated June 1, 2014 Breast and Cervical Cancer Programs What are the Indiana Health Coverage Programs?

8 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 –It is also used to determine eligibility for IHCP and coverage through the federal Marketplace Anyone living at 100% or below the FPL is considered living in poverty –In 2014, an individual with a pre-tax income of $11,670 or less is living in poverty, and so is a family of 4 with pre-tax income at or below $23,850.

9 What are Federal Poverty Guidelines (FPL)? House- hold Size 100% 133% 150%200% 250% 300%400% 1 $11,670$15,521$17,505$23,340 $29,175 $35,010$46, ,730 20,92123,595 31,460 39,325 47,19062, ,790 26,32129,685 39,580 49,475 59,37079, ,850 31,72135,775 47,700 59,625 71,55095, ,910 37,12041,865 55,820 69,775 83,730111, ,970 42,52047,955 63,940 79,925 95,910127, ,030 47,92054,045 72,060 90, ,090144, ,090 53,32060,13580, , ,270160, FPL for the 48 Contiguous States and the District of Columbia

10 GOALSELIGIBILITYSPECIFICS  Provide health care coverage for low-income parents/caretakers, pregnant women and children at little or no cost  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

11 Hoosier Healthwise HHW PACKAGEDESCRIPTION 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

12 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:

13 Hoosier Healthwise Family Size Parents & Caretaker Relatives Children Pregnant Women 1n/a$2,432n/a 2$247$3,278$2,727 3$310$4,123$3,431 4$373$4,969$4,134 5$435$5,815$4,838 Monthly Income Limits

14 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$33 175% up to 200%$33$50 200% up to 225%$42$53 225% up to 250%$53$70

15 GOALSELIGIBILITYSPECIFICS  Reduce the number of uninsured, low-income Hoosiers  Reduce barriers and improve statewide access to health care services  Promote value-based decision making and personal health responsibility  Promote primary prevention  Prevent chronic disease progression with secondary prevention  Provide appropriate and quality- based health care services  Assure State fiscal responsibility and efficient management of the program  Hoosier adults between the ages of  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)

16 HIP provides a basic commercial benefits package. Covered services include: Physician services Prescriptions Diagnostic exams Home health services Outpatient, inpatient hospital and hospice services Preventive services Family planning Case & disease management Mental health coverage Vision, dental and maternity services are not currently covered by HIP

17 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, then they will be disenrolled from the program. Family SizeMonthly Income Threshold 1$973 2$1,311 3$1,649 4$1,988 5$2,326 6$2,665 7$3,003 8$3,441

18 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 to 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. –As of July 2014, Indiana has submitted the HIP 2.0 waiver application to CMS for approvalHIP 2.0 waiver application

19 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 (Anthem, MDWise, MHS), or they are auto-assigned 14 days after enrollment Managed Care Entities (MCEs)

20 Some factors for beneficiaries to consider when selecting an MCE include the following: o Provider 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? o Special programs & enhanced services Is there a service or program offered by the MCE that is particularly important or attractive to the enrollee?

21 HIP enrollees can change MCE:  In the first 60 days or until they make the first POWER Account contribution  Annually at eligibility redetermination  Anytime there is a “just cause” as outlined for Hoosier Healthwise enrollees Hoosier Healthwise enrollees can change MCE:  Anytime during the first 90 days with a health plan  Annually during an open enrollment period  Anytime when there is a “just cause”  Lack of access to medically necessary services covered under the MCE’s contract with State  The MCE does not, for moral or religious objections, cover the service the enrollee seeks  Lack of access to experienced providers  Poor quality of care  Enrollee needs related services performed that are not all available under the MCE network Managed Care Entities (MCEs)


23 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; If specialty services are required the PMP will provide a referral. 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

24 GOALSELIGIBLITYSPECIFICS  Promotion of preventative care  Promotion of treatment regimens for chronic illnesses to better conform evidence-based practices  Promotion of less fragmented and more holistic care  Aged, blind, disabled, a ward of the court or foster child, or a child receiving adoptive services or adoption assistance  MUST have one of the following: Asthma, Diabetes, Congestive, Heart Failure Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hypertension, Severe Mental Illness, Serious Emotional Disturbance (SED) Depression, Chronic Kidney Disease w/o dialysis, co-morbidity of diabetes and hypertension or other combinations, or other approved serious or chronic conditions Enrollees select or are assigned to: Care Management Organization (CMO) (oversees & coordinates care) Primary Medical Provider (PMP) (provides care & referrals) Care Select

25 Individuals do not specifically apply for Care Select. – Medicaid enrollees in an eligible aid category with one of the qualifying conditions, as evidenced by claims history or their medical provider contacting the Enrollment Broker at , have the option to participate Care Select enrollees choose or are assigned to both a Care Management Organization (CMO) and PMP (Primary Medical Provider). –Member services contact information for the State’s two CMOs is as follows : Care Management Organization Phone NumberWebsite Advantage MDwise members/indiana-care-select

26 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; lawful permanent residents who have lived in the USA less than five years; or those whose alien status remains unverified receiving Emergency Services only Persons receiving home and community-based waiver or hospice services Dual eligibles (individuals receiving Medicaid & Medicare) 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 18 th birthday

27 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.

28 BENEFIT PACKAGEDESCRIPTION Standard Plan  Full Medicaid coverage Medicare Savings ProgramQMB: Medicare Part A & B premiums, deductibles, & coinsurance SLMB/QI: Medicare Part B premiums QDWI: Medicare Part A premiums Package EEmergency Services only– for certain immigrants who do not qualify for full Medicaid coverage Family PlanningFamily planning services only Traditional Medicaid (Fee-for-Service)

29 GOALSELIGIBILITYSPECIFICS  Provide full Medicaid for working people with disabilities  Ages  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

30 Monthly IncomePremium 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 Enrollees are responsible for monthly premiums based on income of the applicant and spouse

31 590 Program Provides coverage for residents of state-owned facilities Does not cover incarcerated individuals residing in Department of Corrections (DOC) facilities Eligible for Package A benefits with the exception of transportation

32 WAIVERELIGIBILITYSPECIFICS 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 supervision Family Supports Home and Community Based Waivers (HCBS)

33 To apply for the Aged and Disabled waiver or the Traumatic Brain Injury Waiver, individuals can go the local Area Agencies on Aging (AAA) or call for more information. To apply for the Community Integration & Habilitation or Family Supports waiver, individuals can go the local Bureau of Developmental Disabilities Services (BDDS) office or call for more information. There are currently waiting lists for the Family Supports waiver and the Traumatic Brain Injury waiver.

34 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 (e.g. schizophrenia, bipolar disorder, major depressive disorder) Demonstrated need related to management of behavioral and physical health and need for assistance in coordinating physical and behavioral healthcare ANSA Level of Need 3+ Income below 300% FPL –Single: $2,918/month –Married: $3,933/month

35 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 oviderSearch.aspx. oviderSearch.aspx

36 Covers low-income Medicare beneficiaries Helps pay for out-of-pocket Medicare costs. Individuals must be eligible for Medicare Part A ProgramIncome Threshold Resource LimitBenefits Qualified Medicare Beneficiary (QMB) 100% FPLSingle: $7,080 Couple: $10,620  Medicare Part A & B Premiums  Co-pays, deductibles, coinsurance (Specified Low Income) SLMB 120% FPLSingle: $7,080 Couple: $10,620  Part B Premiums Qualified Individual (QI) 135% FPLSingle: $7,080 Couple: $10,620  Part B Premiums Qualified Disabled Worker (QDW) 200% FPLSingle: $7,080 Couple: $10,620  Part A Premiums Medicare Savings Program

37 GOALSELIGIBILITYSPECIFICS  Prevent or delay pregnancy  Provide family planning services and supplies  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 visits  Pap 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

38 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

39 GOALSELIGIBILITYSPECIFICS  Provide Medicaid coverage to women diagnosed with breast and cervical cancer diagnosed through the Indiana State Department of Health (ISDH)  ISDH diagnosis OR  Age  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) AgeEligible Services 40-49Free office visit & Pap test 50-64Free office visit, Pap test, and mammogram 65 and olderFree office visit, Pap test, and mammogram only if not enrolled in Medicare

40 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

41 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

42 GOALSELIGIBILITYSPECIFICS  Temporary coverage of prenatal care services while Medicaid applications are pending  Ensure timely access to critical prenatal care  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

43 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 –Be able to access HP Web interchange, internet, printer & fax machine –Allow PE applicants to use an office phone to facilitate the PE and Hoosier Healthwise enrollment process May include hospitals, pediatricians, family/general practitioner, internist, medical clinic, rural health clinic among others

44 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

45 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

46 Applicant must be resident of the state State of residency is: –Where individual lives –Including without a fixed address OR –Has entered the state with a job commitment OR seeking employment 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

47 Individual must be US citizen, a US non-citizen national or an immigrant who is in a qualified immigration status o Lawful permanent residents are eligible for full Medicaid after 5 years Electronic data sources through the Federal Hub verify status o If not, paper documentation is required, and a “reasonable opportunity” period is granted to otherwise Medicaid eligible individuals– this period lasts 90 days from the date on the eligibility notice Those exempt from citizenship verification process: o Individuals receiving SSI or SSDI o Individuals enrolled in Medicare o Individuals in foster care & who are assisted under Title IV-B o Individuals who are beneficiaries of foster care maintenance or adoption assistance payments under Title IV-E o Newborns born to a Medicaid enrolled mother Requirement: Citizenship/Immigration Status

48 Medicaid Eligible Immigration Status under Immigration & Naturalization Act (INA) STATUSELIGIBILITY Lawful Permanent Resident  Full Medicaid eligible if residing in US prior to 8/22/96  If entered US on or after 8/22/96 eligible for Package E for 5 years; full Medicaid after 5 years Refugees under Section 207 & Iraqi & Afghani Special Immigrants under Section 101(a)(27)  Full Medicaid Conditional entrants under Section 203(a)(7) prior to April 1, 1980  Full Medicaid Parolees under Section 212(d)(5)  Full Medicaid eligible if granted this status for at least 1 year & entered US prior to 8/22/96  If entered US on or after 8/22/96 eligible for Package E Asylees under Section 208Full Medicaid Persons whose deportation is withheld under Section 243(h) Full Medicaid Amerasians admitted pursuant to Section 584 of P.L & amended by P.L Full Medicaid Cuban & Haitian entrantsFull Medicaid Other immigrants, visitor and non-immigrantsEligible for emergency Medicaid only

49 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

50 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

51 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

52 Methodology for income counting and determining household size and composition Used to determine eligibility for Indiana Health Coverage Programs (IHCP) and tax credits on the Marketplace 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)

53 Adjusted Gross Income Tax Excluded Foreign Earned Income Tax Exempt Interest MAGI Tax Exempt Title II Security Income

54 MAGI impacts: New applicants:  Adults  Parents and Caretaker relatives  Children  Pregnant Women MAGI does NOT impact:  Aged  Blind  Disabled  Those needing long-term care  Former foster children under age 26  Deemed newborns Modified Adjusted Gross Income (MAGI)

55 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)

56 MAGI Conversion The goal is to establish a MAGI-based income standard that is not less than the effective income eligibility according to the ACA Income disregards are not allowed with the exception of a general 5% FPL deduction in certain cases Steps: 1.Calculate the average size of the disregards for individuals whose net income falls within 25% of the FPL below the net income standard 2.Add this average disregard amount to the net income eligibility standard 3.Step 1 + Step 2 = MAGI eligibility standard for the eligibility group

57 The Indiana Application for Assistance includes: –SNAP, cash assistance and Health Coverage 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 using: –Case number –Case name –Date of birth –Last four digits of SSN Indiana Application for Health Coverage

58 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 can be usedState Form Authorized Representatives

59 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

60 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

61 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

62 Individuals wishing to challenge disability eligibility decisions appeal to the Social Security Administration (SSA) or Indiana Medicaid depending on the reason for the denial. –Regarding an SSA disability on file: appeal to SSA –Indiana Medical Review Team (MRT) decision: Indiana Medicaid Eligibility Appeals

63 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 An individual enrolled in Medicaid on or before December 31, 2013 cannot be denied Medicaid eligibility solely because of the implementation of MAGI rules before March 31, 2014 Eligibility Redeterminations

64 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 They will be covered under Hoosier Healthwise and enrolled in the mother’s Managed Care Entity (MCE)

65 ProgramApplication Process Aged & Disabled Waiver Apply at Area Agencies on Aging (AAA) or call Breast & Cervical Cancer Program (BCCP) Apply for Medicaid coverage, option 3; Family Helpline: Care SelectContact Enrollment Broker: MAXIMUS: Community Integration & Habilitation or Family Supports Waiver Apply at Bureau of Developmental Disabilities Services (BDDS) office or call Family Planning Eligibility Program Division of Family Resources (DFR) Toll-Free at 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 ( ), or in person at DFR office Traditional Medicaid Apply at DFR office, online/phone, Community Enrollment Centers IHCP Application Methods

66 Helpful Resources Hoosier Healthwise Helpline – 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

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