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1 A nonprofit service and advocacy organization © 2012 National Council on Aging Benefits Series July 2012 Medicaid 101.

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Presentation on theme: "1 A nonprofit service and advocacy organization © 2012 National Council on Aging Benefits Series July 2012 Medicaid 101."— Presentation transcript:

1 1 A nonprofit service and advocacy organization © 2012 National Council on Aging Benefits Series July 2012 Medicaid 101

2 2 A nonprofit service and advocacy organization © 2012 National Council on Aging What we’ll cover  What is Medicaid?  Stats and Facts  How is Medicaid paid for?  How does Medicaid work? Who is eligible? Other Medicaid-related programs How to Apply I’m eligible. What do I receive?  Long-Term Services and Supports  Medicaid and Other Benefits  Medicaid in Health Care Reform

3 3 A nonprofit service and advocacy organization © 2012 National Council on Aging What is Medicaid?  A need-based public health care coverage program for people with limited income and resources Medicaid only covers certain categories of people; not all people with limited income and resources are eligible.  Established in 1965 under President Johnson  An entitlement program  A federal-state program States run Medicaid within broad parameters set by federal law. The program is jointly financed by the states and the federal government.

4 4 A nonprofit service and advocacy organization © 2012 National Council on Aging What is Medicaid? (cont.)  Some states call Medicaid by different names. For example: In California, it is “Medi-Cal.” In Massachusetts, it is “MassHealth.” In Wisconsin, it is “ForwardHealth.” In Tennessee, it is “TennCare.”  “Dual eligibles” Enrolled in Medicare and full Medicaid  “Partial duals” Enrolled in Medicare and the Medicaid-funded Medicare Savings Programs (MSPs)

5 5 A nonprofit service and advocacy organization © 2012 National Council on Aging Stats and Facts  An estimated 16 million seniors and younger adults living with disabilities relied on Medicaid in  In seven states and the District of Columbia, more than one out of five seniors relied on Medicaid in 2010: Maine (27.8%), Mississippi (25.5%), California (23.6%), Vermont (22.9%), New York (21.8%), the District of Columbia (21.4%), Louisiana (20.8%), and Wisconsin (20.7%)  In 2010, Medicaid allowed nearly 3 million seniors and people with disabilities to remain living in their own homes.

6 6 A nonprofit service and advocacy organization © 2012 National Council on Aging Stats and Facts (cont.)  Dual eligibles represent only 15% of the Medicaid population but account for 39% of total Medicaid spending. In 2007, about six in ten dual eligibles were over the age of 65, and more than a third were disabled adults younger than 65.  According to BenefitsCheckUp® data since 2010, 18% of people screened online were likely eligible and missing out on Medicaid benefits.  Medicaid spending reached $398 billion in 2011.

7 7 A nonprofit service and advocacy organization © 2012 National Council on Aging How is Medicaid paid for?  The states and the federal government jointly finance Medicaid.  The amount that the federal government pays depends on the state’s FMAP, or Federal Medical Assistance Percentage. FMAP accounts for differences in income across the states. The FMAP a state receives can change from year-to-year. In 2012, the FMAP percentages ranged from 50% in 14 areas to 71.48% in Mississippi. The average is 59.62%. o See the graph on the next slide for the 2012 FMAP percentages.

8 8 A nonprofit service and advocacy organization © 2012 National Council on Aging How is Medicaid paid for? (cont.)

9 9 A nonprofit service and advocacy organization © 2012 National Council on Aging How does Medicaid work? Who is eligible?  People must be financially eligible (meet the income and resource guidelines) and also be in one of the covered categories to be eligible for Medicaid.  The current categories of eligibility*: Pregnant women Minor children (age 18 and younger) and their parents People over age 65, and adults with disabilities under age 65

10 10 A nonprofit service and advocacy organization © 2012 National Council on Aging Who is eligible? (cont.)  You must be a U.S. citizen or fall within certain categories of lawful immigrants to receive Medicaid. Most lawfully residing immigrants are banned from receiving Medicaid (except for emergencies) during their first 5 years in the U.S. The rules have recently allowed states the option to cover lawfully residing immigrants during the first 5 years.  States must document citizenship and identity. Most states use a data-match with Social Security to meet this requirement.

11 11 A nonprofit service and advocacy organization © 2012 National Council on Aging Who is eligible? (cont.)  States can opt to cover additional groups, beyond the minimum federal requirements.  The current federal core requirements (to change in 2014*): For children aged 6–18, below 100% FPL (Federal Poverty Level) For children up to age 6 and pregnant women, below 133% FPL For seniors and individuals with disabilities, must be receiving SSI (below 75% FPL in 2011) For parents, below the state’s 1996 welfare level o See the graph on the next slide for 2012 income levels (median: below 63% FPL).

12 12 A nonprofit service and advocacy organization © 2012 National Council on Aging Who is eligible? (cont.)

13 13 A nonprofit service and advocacy organization © 2012 National Council on Aging  Again, because of the great differences among state Medicaid programs, the actual income limits for the other categories can also vary significantly. How income is counted is also determined state-by-state.  States also have the ability to impose an asset test.  Most states have an asset test for Medicaid eligibility for elderly and disabled applicants.  Please find the information specific to your state! Who is eligible? (cont.)

14 14 A nonprofit service and advocacy organization © 2012 National Council on Aging Other Medicaid-Related Programs  Many states provide other types of Medicaid programs that expand service coverage, or allow for more people to qualify  State Medicaid Waiver programs: States essentially “waive” Medicaid rules For example, Home and Community Based Waiver Program (HCBW, also known as 1915(c)) expands Medicaid coverage rules so long- term care services are covered not only in institutional settings (e.g., nursing home) but also in home and community settings  Medicaid “spend down” or Medicaid “surplus income” Your clients may use medical bills to “spend down” excess income to qualify for Medicaid

15 15 A nonprofit service and advocacy organization © 2012 National Council on Aging How to Apply  Because Medicaid programs vary broadly from state to state, there is no uniform application process.  Generally, you can file an application with your local Department of Social Services. Some states have online Medicaid applications. You can also start the application by calling a Social Services office. In some states, you can apply for Medicaid and other need-based programs (SNAP benefits) with one application.

16 16 A nonprofit service and advocacy organization © 2012 National Council on Aging I’m eligible. What do I receive? Medicaid has mandatory services that must be covered: Physicians’ services Hospital services (inpatient and outpatient) Laboratory and x-ray services Federally-qualified health center and rural health clinic services Family planning services and supplies Nurse midwife services Nursing facility services for individuals 21 and older Home health care for persons eligible for nursing facility services Transportation services

17 17 A nonprofit service and advocacy organization © 2012 National Council on Aging Often, there are also optional services made available under state Medicaid programs. Some common services include: Prescription drugs Dental services, dentures, prosthetic devices, eyeglasses and durable medical equipment Rehabilitation and other therapies Case management Intermediate care facility for individuals with mental retardation (ICF/MR) Home ‐ and community ‐ based services Personal care services Hospice services I’m eligible. What do I receive? (cont.)

18 18 A nonprofit service and advocacy organization © 2012 National Council on Aging Long-Term Services and Supports  Usually, the term “long-term services and supports” (LTSS) refers to assistance that does not require skilled care and is not sufficiently recuperative or “medicalized” to meet the requirements of Medicare.  Long-term services and supports can be provided at home, or in assisted living or nursing homes to people with chronic conditions or disabilities % of today’s adults will eventually need long-term care. By 2020, about 12 million seniors will need long-term care.

19 19 A nonprofit service and advocacy organization © 2012 National Council on Aging  Long-term services and supports are often expensive.  In 2012, the median annual rate of a private nursing home room is $81,030. (Since 2007, this figure has grown by over 4% annually.)  Many people become eligible for Medicaid by incurring the high costs of LTSS.  Very few people have insurance that covers LTSS. Medicare does not cover most LTSS costs. Job-based health insurance rarely offers LTSS insurance. Coverage purchased in the private market is limited and expensive. Medicaid and LTSS (cont.)

20 20 A nonprofit service and advocacy organization © 2012 National Council on Aging Medicaid and LTSS (cont.)

21 21 A nonprofit service and advocacy organization © 2012 National Council on Aging Medicaid and Other Benefits  Medicare Savings Programs (MSP) This is a limited Medicaid program that helps pay Medicare premiums and/or cost sharing. For more information, please see our MSP 101 Training.  Extra Help/Low-Income Subsidy (LIS) People eligible for Medicaid are automatically eligible (known as “deemed eligible”) for the Extra Help/LIS under Part D. If a beneficiary does not choose a plan, they will automatically be enrolled into a zero-premium plan. For more information, please see our LIS 101 Training.

22 22 A nonprofit service and advocacy organization © 2012 National Council on Aging Medicaid and Other Benefits (cont.) Supplemental Security Income (SSI) In 32 states and the District of Columbia, people automatically get Medicaid if they are approved for SSI. 8 states have the same standard for Medicaid as SSI but require a separate application. The following states have their own Medicaid eligibility rules, so an application must be filed and eligibility determined separately: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, Virginia. For more information, please see our SSI 101 Training.

23 23 A nonprofit service and advocacy organization © 2012 National Council on Aging  The Affordable Care Act’s Medicaid Expansion While the ACA’s Health Insurance Exchanges are the centerpieces for expanding coverage, the law’s Medicaid expansion was expected to insure over 16 million people by What is the future of Medicaid expansion now that that the Supreme Court has ruled? Medicaid in Health Care Reform

24 24 A nonprofit service and advocacy organization © 2012 National Council on Aging The ACA and Medicaid  The law’s intended effects on Medicaid: Save $366 billion by extending Medicaid’s coordinated care, improving long-term care, and modernizing its administrative system Federally fund 100% of Medicaid expansion coverage for 3 years starting in 2014, followed by 90% in 2017 and later years Allow states to increase the number of insured people by an average of 25% with an increased state cost of less than 3%

25 25 A nonprofit service and advocacy organization © 2012 National Council on Aging Before the Supreme Court Ruling  Establish a national floor for Medicaid coverage at 133% FPL  For people under 65, income alone determines eligibility. No more categorical restrictions for this group Eliminates the exclusion of childless adults  Originally, if states rejected the Medicaid expansion, they would lose out on ALL existing federal funds for Medicaid. Cutting out these federal dollars would mean a loss of over 10% of state budgets. According to Chief Justice Roberts, this left “no real option” for states but to participate in the Medicaid expansion, so....

26 26 A nonprofit service and advocacy organization © 2012 National Council on Aging  It is now easier for states to decide not to participate in the Medicaid expansion.  States that reject the new Medicaid requirements will have to forgo only the new federal funds which are meant for the expansion – not all Medicaid funds. After the Supreme Court Ruling

27 27 A nonprofit service and advocacy organization © 2012 National Council on Aging What will the states do?  This map indicates state participation plans (as of 7/9/12).  Only time will tell which states actually refuse the new funds to expand Medicaid eligibility.

28 28 A nonprofit service and advocacy organization © 2012 National Council on Aging How can you help?  Be familiar with the Medicaid program(s) in your state Eligibility rules, waiver programs, spend-down program, application requirements, etc.  Get connected with the Medicaid eligibility office and caseworkers in your community – partnerships are essential!  Use the person-centered approach when counseling Help your clients understand the benefits of Medicaid, how to apply, and how to keep their benefit - and how they may also be eligible for other public benefit programs

29 29 A nonprofit service and advocacy organization © 2012 National Council on Aging Resources  The Federal Government Website on Medicaid  A Guide to the Medicaid Appeals Process  Medicaid Benefits by State and Service

30 30 A nonprofit service and advocacy organization © 2012 National Council on Aging Resources (cont.)  Medicaid and LTSS Materials  Report: 2007 Medicaid Data Trended Forward to /cutting-medicaid-findings.html  Federal Core Requirements and State Options in Medicaid

31 31 A nonprofit service and advocacy organization © 2012 National Council on Aging Resources (cont.)  Medicaid in Health Reform  2012 FMAP Information  State-by-State Medicaid Expansion Maps state-stands-on-the-medicaid-expansion/

32 32 A nonprofit service and advocacy organization © 2012 National Council on Aging Thank you!  Thank you for participating in the Benefits Series of the National Center for Benefits Outreach and Enrollment.  We invite you to learn more about us by visiting our website:  Use Benefits Checkup, NCOA’s online benefits screening and enrollment tool:  Feel free to us at:


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