Illinois Medicaid. updated August 2016 AgeOptions All rights reserved.

Transcription

1 Illinois Medicaid updated August 2016 AgeOptions All rights reserved. 1

2 What We Will Cover Today What is Medicaid? Medicaid Eligibility Categories of Medicaid Coverage Medicaid Waiver Programs Medicare & Medicaid 2

3 What We Will Cover Today (continued) Medicaid Spenddown Applying for Medicaid Maintaining Medicaid Coverage Medicaid Coordinated Care 3

4 What is Medicaid? 4

5 What is Medicaid? Health insurance program Must have low income Federal government State government Payer of LAST RESORT 5

6 What is Medicaid? IL Department of Healthcare & Family Services (HFS) IL Department of Human Services (DHS) MEDICAID CARD 6

7 Medicaid Eligibility 7

8 Medicaid Eligibility Low income - based on federal poverty levels (FPL) Prior to the Affordable Care Act (ACA), Medicaid required that you fit into a vulnerable category group in addition to being low income Affordable Care Act Medicaid now has coverage for individuals who have low incomes but do not fit into one of the prior categories New ACA Adult Medicaid category added to the old Medicaid categories - it does not replace them. 8

9 Medicaid Eligibility In order to qualify for most Medicaid programs, a person must be a U.S. citizen or qualified non-citizen. Exceptions: AllKids, Moms and Babies Qualified Non-Citizens must be either a Lawful Permanent Resident (LPR) in U.S. legally for 5 years or more or a member of a special immigrant group such as: Refugee or Asylee U.S. military or veteran and their dependents Admitted under VAWA (Violence Against Woman Act) Cuban or Haitian And More 9

10 Categories of Medicaid Coverage 10

11 All Kids Children up to age 19 Covers unauthorized non-citizen children Income threshold = 300% FPL Premium required if income over 150% FPL Will have a higher share of costs (copays, etc.) if higher income ALL-KIDS ( ) 11

12 Moms & Babies Covers pregnant women - outpatient and inpatient hospital services while pregnant and insurance for 60 days after baby is born Covers child born while on Moms & Babies up to age 1 (then transferred to All Kids) Covers unauthorized non-citizens Income threshold = 200% FPL 12

13 Family Care Covers parents and caretakers (must be living with child up to age 18) Must be U.S. citizen or qualified non-citizen (legal permanent resident for at least 5 years or member or another qualified immigrant group) Income threshold = 138% FPL Small co-pays and premiums at certain levels of income 13

14 AABD/SPD Medicaid Covers people who are age 65 or older, blind, or disabled Must be U.S. citizen or qualified non-citizen (legal permanent resident for at least 5 years or member or another qualified immigrant group) Must Meet income AND asset standards* Income threshold = 100% FPL Assets: < $2,000 individual, < $3,000 couple *AABD spenddown program explained later 14

15 Health Benefits for Workers with Disabilities People with disabilities (age 19-64) who are working Allowed to keep higher income/assets than others Income up to 350% FPL Assets up to $25,000 monthly premium $0 - $119 (depends on person s income) HBWD Medicaid* *HBWD eliminated in Governor s proposed FY16 budget 15

16 1619 Medicaid Special Medicaid category for people who have received Supplemental Security Income (SSI) for at least one month, meet Social Security s disability requirement, and need Medicaid to be able to keep working Individuals on 1619 Medicaid are allowed to keep AABD Medicaid, even if they have higher income/assets than the regular AABD or SSI limits More information about 1619 Medicaid available here: 16

17 Affordable Care Act (ACA) Adult Medicaid New Adult Medicaid Program created by the ACA for individuals who meet the following requirements: age Does not qualify for existing Medicaid programs income less than 138% of the Federal Poverty Level (FPL) Citizen or qualified non-citizen NOTES: NO asset/resource test; no disability test 17

18 Medicaid for Former Foster Children New Medicaid program created by the ACA for individuals who lost medical coverage as a result of aging out of the foster care program at age 18 or older No income/asset limit for this group To be eligible, must be: Age Not qualified for Medicaid benefits under Family Health Plans or AABD Medicaid A recipient of foster care assistance through the Department of Child and Family Services (DCFS) until they aged out at age 18 or older Illinois resident with a Social Security number or proof of application for a Social Security number U.S. citizen or qualified noncitizen 17

19 Medicaid Waiver Programs 19

20 Medicaid Home and Community-Based Service (HCBS) Waiver Programs A waiver is a program that provides services that allow individuals to remain in their own home or live in a community setting. Illinois has nine HCBS waivers. Each waiver is designed for individuals with similar needs and offers a different set of services. Quote from Illinois Healthcare and Family Services website: 20

21 Medicaid Home and Community-Based Service (HCBS) Waiver Programs 9 Illinois HCBS Waiver Programs: Children and Young Adults with Developmental Disabilities Support Waiver Children and Young Adults with Developmental Disabilities Residential Waiver Children that are Technologically Dependent/Medically Fragile Persons with Disabilities Persons with Brain Injuries Adults with Developmental Disabilities Persons who are Elderly Persons with HIV or AIDS Supportive Living Facilities Fact sheets on each waiver program (who is affected, services included, etc.) available here: BS/Pages/default.aspx#HCBSwaivers 21

22 Medicare & Medicaid ( Dual Eligibles ) 22

23 What is Medicare? Federal health insurance program To qualify, must be: Citizen or Qualified Non-Citizen 65 or older OR Under 65 with a qualifying disability Lou Gehrig s disease (ALS) End Stage Renal Disease (ESRD) OR Receiving Social Security Disability Insurance (SSDI) for at least 24 months NOTE: Disabled Adult Children (DAC s) may also qualify for Medicare based on their parents work record 23

24 People with both Medicare and Medicaid Healthcare Coverage If you have Medicaid and: Original Medicare -You may go to any doctor that accepts Medicare and Medicaid and you will pay only Medicaid co-pays for covered services. A Medicare Advantage Plan HMO - If you go to doctors and hospitals that are in that plan s network and accept Medicaid - You will pay low co-pays or coinsurance for covered services. 24

25 People with both Medicare & Medicaid Drug Coverage Most drugs covered by Medicare Part D plan Automatically qualify for Medicare Extra Help program (federal program that helps with Part D plan drug costs) do not need to apply Join a Part D plan or one will be assigned 25

26 Transitioning into Medicare ACA Adult Medicaid to AABD Medicaid Will receive redetermination form in the mail be sure to complete! Switching from ACA Adult managed care program to another (MMAI) Potential loss of Medicaid coverage if income is between 100% and 138% FPL or assets are too high for AABD AABD has spenddown program (will discuss this next) Enroll in Medicare Savings Program if eligible If in AABD Medicaid already, will have to switch from ICP managed care to MMAI 26

27 Medicaid Spenddown 27

28 Medicaid Spenddown Only available to adults on AABD/SPD Medicaid, children, and pregnant women Works like an insurance deductible if an individual s income/assets are too high to qualify for Medicaid outright, Medicaid will pay for medical care when the person can show that he owes or has paid medical bills in the amount of the difference EXAMPLE: individual with monthly income $100 higher than Medicaid income limit monthly spenddown = $100 28

29 Medicaid Spenddown Must meet spenddown amount at least one time every three months to stay enrolled in the program Note: An individual must also meet his/her spenddown amount each of the three months if s/he wants Medicaid medical benefits for those months. An individual who does not meet spenddown at least once in three months must reapply for Medicaid 29

30 Medical Expenses that can be Unpaid medical bills used to meet Spenddown Receipts for medical services and supplies Health insurance premiums including Part B premiums Transportation to and from medical services Any co-pays and deductibles on medical care Cost of services received through Medicaid waiver programs 30

31 Pay-In Spenddown Pay the spenddown amount to meet the spenddown requirement Must enroll to participate in Pay-In Spenddown To enroll, must submit enrollment form. Call HFS Health Benefits hotline ( ) and ask for Pay-in Spenddown Unit. 31

32 Medicaid Spenddown and Medicare Extra Help If someone with Medicare also has Medicaid (even for 1 month through spenddown program), s/he will be automatically enrolled in full Extra Help (which helps cover drug costs) Meets spenddown at least one month between January and June = qualifies for Extra Help for the remainder of the calendar year Meets spenddown at least one month between July and December = qualifies for Extra Help for the remainder of the calendar year AND all of the next calendar year 32

33 Medicaid Spenddown Resources Illinois Department of Healthcare and Family Services brochure on Medicaid spenddown: Pages/HFS591SP.aspx How spenddown works Medical expenses that can be used to meet spenddown Using unpaid medical bills Using receipts for medical expenses Pay-in spenddown Etc. 33

34 Applying for Medicaid 34

35 Medicaid Applications and Income All Medicaid categories except for AABD and HBWD now use Modified Adjusted Gross Income (MAGI) calculations to determine someone s eligibility for Medicaid Based on the tax filing unit (if an individual is a tax dependent, need to include parents income, even if the individual is on SSI) AABD and HBWD still use the same methodology as pre-aca 35

36 Applying for Medicaid Application for Benefits Eligibility (ABE): (800) Can apply for multiple benefits through ABE: Existing Medicaid programs (AABD, HBWD, AllKids, Family Care, Moms and Babies) New Adult Medicaid AABD and TANF cash benefits Food Stamps (SNAP) Medicare Savings Programs 36

37 Applying for Medicaid (if not applying through ABE) Download the application: Follow the directions on the form. Type in as much information as you can. If you cannot answer all of the questions, that is ok. You must include your name and address. You may print out the application and write on it if you prefer. You must sign the form. Once you've completed the application, carry, mail or fax it to your local DHS Family Community Resource Center. Use the DHS Office Locator to locate your local office: 37

38 Applying for Medicaid (if not applying through ABE) While ABE is the fastest and easiest way to apply for Medicaid for most populations, paper applications may work better for certain people. Two examples are: People are 18+ newly approved for SSI and applying for Medicaid for the first time Children and adults who participate in Medicaid waivers (i.e. the three waivers that waive parental income for children) and are applying for Medicaid for the first time. 38

39 Proof of age ABE Verification Proof of income and resources Proof of U.S. Citizenship or legal residence Medical proof of disability or blindness (if applicable) Proof of state residency 39

40 ABE Tips If an individual age 18+ has a court-appointed guardian and is not able to fill out application on their own, must submit guardianship paperwork with application If an individual is age 18+ and does not have a court-appointed guardian but is not able to fill out application on their own, must have a designated Power of Attorney (POA) and submit POA forms with application 40

41 ABE Resources HFS Frequently Asked Questions ABE and Medicaid: ments/aca_faqapplicationformedicalassistan ce.pdf HFS Guide to completing an application in ABE: ments/completingabeapplication.pdf 41

42 Maintaining Medicaid Coverage 42

43 Maintaining Medicaid Coverage Report changes Respond to redetermination notices If coverage cancelled but still eligible, can be reinstated within 90 days 43

44 Maintaining Medicaid Coverage Report changes in address, income, or household size right away Call ABE call center (800) or local DHS FCRC to report changes HFS/DHS send important communications via mail if address is not up to date, could miss important notices (e.g., redetermination notices) 44

45 Maintaining Medicaid Coverage Everyone with Medicaid will receive an annual redetermination Medicaid ONLY: Illinois Medicaid Redetermination Project (IMRP) - (855) Medicaid + SNAP Local DHS Family and Community Resource Center (FCRC) Medicaid + Cash Benefits Local DHS Family and Community Resource Center (FCRC) 45

46 Maintaining Medicaid Coverage Watch mail for redetermination letters; mail back right away (usually only have about 10 days to respond) Can request more time if needed call IMRP or DHS office If person does not respond, Medicaid will be cancelled If letter is lost, can request a new one Call IMRP call center or DHS FCRC, depending on who sent the letter If cancelled, can be reinstated within 90 days Contact IMRP call center or DHS FCRC, depending on who sent the letter 46

47 Find a Medicaid Provider or Get Information about Covered Services Find a provider: Illinois Health Connect Hotline: (877) Dental Providers/Services: DentaQuest: (888) Covered Services: HFS Health Benefits Hotline: (800) If someone is in a Medicaid managed care plan, contact the plan to find network providers. 47

48 Medicaid Managed Care 48

49 Illinois Medicaid Managed Care Programs Integrated Care Program (ICP) ACA Adult/Family Health Plans (ACA/FHP) Medicare Medicaid Alignment Initiative (MMAI) 49

50 Illinois Medicaid Managed Care Programs Programs only in certain geographic areas of Illinois (other areas still use fee-for-service Medicaid) Map of Medicaid managed care programs: CCExpansionMap.pdf Chart of Illinois Medicaid Managed Care Programs: / %20- %20Care%20Coordination%20Chart.pdf 50

51 Integrated Care Program (ICP) Individuals on AABD Medicaid or HBWD Medicaid who are: Age 19 or older On FULL Medicaid (no spenddown) NOT on Medicare NOT on other private insurance (that covers hospital & doctor visits) NOT in the Illinois Breast and Cervical Cancer program Living in one of the program s impacted counties Mandatory Program will be automatically enrolled into a plan if they do not choose one *American Indians/Alaskan Natives will not be automatically enrolled into ICP but can voluntarily enroll if they wish 51

52 Family Health Plans/Affordable Care Act Adult Plans (FHP/ACA) Individuals who are enrolled in ALLKIDS, FamilyCare, or ACA Adult Medicaid and live in one of the impacted counties Some specific populations may be excluded (e.g., certain children with special needs) Mandatory Program will be automatically enrolled into a plan if they do not choose one 52

53 Medicare Medicaid Alignment Initiative (MMAI) Individuals with full Medicare and full AABD Medicaid benefits who: Have both Medicare Parts A and B Do NOT have a spenddown Are age 21 or over Are NOT enrolled in private insurance that provides health coverage (e.g., retiree or employer coverage) Are NOT enrolled in a Medicaid waiver program for individuals with Developmental Disabilities Are living in one of the program s impacted counties NOT a mandatory program. People eligible for MMAI can enroll, change plans, or opt out of the program at any time. (HOWEVER, as of 7/1/16, some people who opt out of MMAI may be required to join an MLTSS plan.) 53

54 Medicaid and Long Term Services and Supports (LTSS) LTSS = care that helps individuals perform activities of daily living (eating, cooking, bathing, getting dressed, cleaning, etc.) Two ways to receive LTSS: Reside in a long term care (LTC) facility Receive services through a Home and Community-Based (HCBS) Medicaid Waiver Program services that allow individuals to remain in their own home or a community setting 54

55 Options for Dual Eligibles with LTSS MMAI Medical services and Long Term Services and Supports (LTSS) covered by Managed Care Organization (MCO) Can change plan or opt out at any time, HOWEVER If someone in the Greater Chicago area opts out of MMAI and receives LTSS, they MUST enroll in MLTSS LTSS, transportation, and some other services covered by MCO Medical services provided through fee-for-service Medicare/Medicaid Locked in for 1 year (after initial 60 day choice period and 90 day switch period) Can enroll in MMAI at any time 55

56 Medicare Medicaid Alignment Initiative (MMAI) Managed Care Organization (MCO) Hospital Home Health Ambulance Doctors Lab Tests Prescription Drugs Mental/ Behavioral Health Services Long Term Services & Supports (LTSS) Transportation Durable Medical Equipment Skilled Nursing Facility

57 Traditional (Fee-for-Service) Medicare and Medicaid for Dual Eligibles Medicare (or Medicare Advantage) & Medicaid Medicaid ONLY hospital doctors Home health ambulance Durable Medical Equipment Lab tests Prescription drugs Skilled Nursing Facility Mental/ behavioral health services Long Term Services & Supports (LTSS) Transportation

58 Managed Long Term Services and Supports (MLTSS) for people who opt out of MMAI Fee-for-Service Medicare (or Medicare Advantage) & Fee-for-Service Medicaid Managed Care Organization (MCO) hospital doctors Home health ambulance Lab tests Prescription drugs Mental/ Behavioral Health Services Long Term Services & Supports (LTSS) Durable Medical Equipment Skilled Nursing Facility Transportation

59 What do all Medicaid Health Plans Have in Common? Everyone eligible for a Medicaid managed care or coordinated care program will receive a letter explaining their options and will have 60 days to choose a plan. All Illinois Medicaid managed care programs provide at least a 90 day transition period to continue seeing out of network providers when enrolled into a new plan. (MMAI provides a 180 day transition period. 59

60 What do all Medicaid Health Plans Have in Common? All enrollment done through: Illinois Client Enrollment Services (877) TTY: (866) Objective, third party entity no relationship to any of the managed care plans All calls are free 60

61 What do all Medicaid Health Plans Have in Common? They all provide full Medicaid benefits. People in Medicaid managed care are still in the Medicaid program and have all of the rights and protections of the Medicaid program. All Medicaid managed care plans must cover all of the services that fee-for-service (FFS) Medicaid covers, and they may not charge more than FFS Medicaid copayments. All plans provide access to care coordinators. Everyone enrolled in a managed care program must designate a primary care physician. 61

62 Enrollment Timeline Initial Letter (60 days before auto assignment) Plan Enrollment and PCP Choice (voluntary or auto assigned) May switch plans once in first 90 days Locked into plan for 12 months Individuals will reach their next enrollment period after being locked into their plan for 12 months will receive another letter and go through the same process each time Each person s enrollment period will be different (depends on individual plan effective date) * Remember: MMAI is NOT mandatory MMAI members can enroll, disenroll, or switch at any time! 62

63 For Cause Switch Individuals in a Medicaid managed care plan who are beyond their initial 90 day change period to switch to another plan MAY be able to change plans if there is cause HFS does a case-by-case review For individuals in ICP, ACA Adult or Family Health plans People in MMAI plans can switch plans or opt out of the program at any time during the year For Cause examples include: PCP is not in the health plan network client is assigned to or leaves the network Client develops a condition that only a sub-specialist contracted with another plan could serve Can request a For Cause Switch by contacting Client Enrollment Services Request then forwarded to HFS for review 63

64 Considerations - Choosing a Medicaid Managed Care Plan Provider Networks primary care doctors, specialists, LTSS providers Drug Formulary are drugs covered? Are there restrictions or prior authorization requirements? Extra Benefits Does the plan offer extra benefits that FFS Medicaid does not? Will the person utilize those benefits? 64

65 Illinois Health Connect Individuals who are NOT eligible for managed or coordinated care will receive information about Illinois Health Connect. Illinois Health Connect helps people with Medicaid in Illinois find and choose a medical home and primary care provider. Information about Illinois Health Connect is available here: home.aspx 65

66 Medicaid Redeterminations and Coordinated Care Warning Letter, Redetermination Letter 10 days to respond, Call for more time Response No Response Redetermination Decision Made Eligible for Different Medicaid Category Eligible Ineligible Get Coverage Reinstated (if requested within 90 days) Must Choose a New Managed Care Plan Keep Coverage and Managed Care Plan Lose Coverage and Managed Care Plan

67 Medicaid Managed Care Resources Make Medicare Work Coalition (MMW) Resources for Professionals on Medicaid Managed Care - Frequently Asked Questions documents, recorded webinars, toolkit on navigating the plans, etc: MedicaidandManagedCare.html#ManagedCareToolkit MMW Resources for Consumers on Medicaid Managed Care PowerPoint, fact sheet, MMAI videos in American Sign Language: 67

68 Thank you! For more information and resources, visit our MMW webpage about Medicaid and Managed Care at: es-and-programs_mmw- MedicaidandManagedCare.html 68