Introduction to Medicaid Roger Auerbach Rutgers Center for State Health Policy Regional Housing Conference September 10, 2003

Medicaid Medicaid is a state-federal health program for low-income and medically needy populations

Medicaid State Plan States must file a Medicaid State Plan and have it approved by the Federal government States have substantial flexibility to design its programs within broad Federal requirements related to: eligibility, services, program administration, provider compensation

Mandatory and Optional Services Medicaid State Plan services are either mandatory or optional Mandatory services cover most primary and acute care services (doctors and hospitals), skilled nursing facility services for people 21 and over, home health Optional services include personal care, rehabilitation services, targeted case management, transportation

Home and Community-based Waiver Services States must receive Federal approval to provide these services Services are designed as an alternative to institutional care Services can be targeted to a specific group and do not need to be provided statewide

Home and Community-based Waiver Services Services can include: Personal Care and Assistance Case Management/Care Coordination Habilitation Supported Employment Adult Day Health Skilled Nursing Home Adaptations, Assistive Devices Personal Emergency Response Systems Transportation Other

Home and Community-based Waiver Services Medicaid does not pay for room and board for non-institutionalized participants

Medicaid Eligibility One must be a member of a group which share common characteristics and meet specific requirements such as: Aged, blind or disabled with incomes below 100% of the Federal Poverty Level People receiving Supplemental Security Income (SSI) Medically Needy

Medicaid State Plan Eligibility Must meet both categorical (group) and financial requirements Categorical eligibility requires that a person be a member of an eligible group: Aged, blind or disabled Child or caretaker of a child Pregnant woman

State Plan Financial Eligibility Financial eligibility means that a person must meet certain income and resource standards, the maximum amount one can have and still be eligible

State Plan Financial Eligibility Generally, States must use the Federal SSI program’s rules and processes to determine eligibility for persons who are aged, blind or disabled In most states, if you are eligible for SSI, you are automatically eligible for Medicaid UNLESS The state is a 209 (b) state or an SSI criteria state (discussed below)

State Plan Financial Eligibility Income Standards A person cannot have income over $552 a month, unless the state has an eligibility category for workers with disabilities where the income standard can be up to 250% of the Federal Poverty Limit or higher Resource Standards A person can have $2000 in assets; $4000 for Qualified Medicare Beneficiaries

Methods for Counting Income and Resources Under SSI rules, $20 of income can be excluded; $65 of earned income plus 50% of the remainder of earned income can be excluded; income tax refunds excluded A person’s home and automobile are exempt from countable resources

State Flexibility in Counting Income and Resources Section 1902(r)(2) allows states to use less restrictive income and resource methodologies than SSI for aged, blind or disabled groups States can expand eligibility by disregarding certain types or amounts of income or resources

209 (b) and SSI Criteria States Eligibility 209 (b) and SSI criteria states do not have automatic Medicaid eligibility tied to Federal SSI eligibility 209 (b) states can adopt more restrictive income and resource standards, disregards, definition of disability 209 (b) states include Illinois, Indiana, Minnesota, Missouri; SSI criteria states include Kansas and Nebraska, which use SSI criteria, but determine Medicaid eligibility themselves

Medically Needy Option States can cover people with too much income to otherwise qualify; resource standard remains the same People must meet categorical eligibility States must first cover pregnant women and children before extending it to aged, blind or disabled States must use a single income and resource standard for all medically needy groups

Medically Needy Option Persons who qualify must “spend-down” to the state’s regular income standard before becoming eligible for Medicaid benefits; that is, incur expenses on a periodic basis that brings their income below the standard States can offer the option of paying the “spend-down” amount directly to the State in exchange for immediate coverage

Home and Community-based Waiver Eligibility To be eligible for waiver services, people must be eligible for Medicaid State Plan services Services can be targeted to a specific group and/or specific geographic area States can disregard parents’ or spouse’s income and resources States can design program for people up to 300% of SSI standard ($1656./month)

Questions? Roger Auerbach, Senior Consultant Rutgers Center for State Health Policy