Medicaid Eligibility Kim Grasty Medicaid Eligibility Policy Specialist Iowa Department of Human Services kgrasty@dhs.state.ia.us The material in this presentation is current as of April 2018.

Medicaid Coverage Applicants and members must meet all non-financial eligibly requirements. MAGI- Eligibility is based on Modified Adjusted Gross Income and there are no resource tests for these groups. Non-MAGI (SSI-Related)- Eligibility is based on both countable income and also countable resource limits for each group. (These are the groups this training will focus on.)

Non-Financial Requirements Here are some of the basic requirements, but this is not an all-inclusive list: Must apply for and accept all benefits they may be eligible for. Must be a citizen of the U.S., a U.S. National, or a qualified alien. Cooperation with other agencies, such as Third Party Liability (TPL). Must be an Iowa Resident Must not be a resident of a Public Nonmedical Institution For SSI-Related groups, must be aged, blind, or disabled.

Income Under SSI-Related, “Income” is anything a person receives either in cash or in-kind that can be used to meet the person’s basic needs of food, clothing, or shelter. This includes income deemed from a parent, spouse, or partner.

Resources Any money or item that can be cashed in, sold, or converted to cash to help pay for medical care. Unless specifically exempt, all resources are considered countable. Resources are determined as of the first moment of the first day of the month. (close of business on the last day of previous month) Transfer of Assets for people seeking LTC: the look back period is 60 months from the date of application. If the client has transferred assets for less than fair market value, within the lookback period, there will be a penalty period to face before eligibility can be granted. ***Note: for children on waiver, we do not look at resources.

Resources for People Needing LTC Attribution of Resources When one spouse applies for a facility care, HCBS waiver, or PACE, resources are “attributed” to the “community spouse” (CS) to protect resources for the CS maintenance at home. The amount attributed to the CS depends on the couple’s total combined resources at the time of entry into a facility or for waiver and PACE, the date that LOC has been met. Below is the chart for 2018

Non-MAGI Coverage Groups The most common groups are: SSI People in Medical Institutions Home and Community Based Services (HCBS) Waivers Program for the All-inclusive Care of the Elderly (PACE) Medicare Savings Programs (MSP) Medicaid for Employed People with Disabilities (MEPD)

SSI Groups Members who receive a SSI payment from Social Security (SS) Members who would otherwise receive an SSI payment from SS, but do not due to many different reasons. Income Limit for 2018 is $750 (this changes each year that there is a SS COLA) Resource Limit is $2000

Medical Institutions, HBCS Waivers, and PACE (300% Group) These members either live in a medical institution, or would need to if not for the services that they receive at home. Must meet a Level Of Care (LOC) appropriate for the type of care they get. Income limit is 300% of the SSI amount. 2018- $2,250 Resource limit is $2,000

Medicare Savings Programs (MSP) Qualified Medicare Beneficiary (QMB) Pays Medicare Part A and B premiums, coinsurance, and deductibles. Countable income at or below 100% of the Federal Poverty Level (FPL) for the family size Specified Low-Income Medicare Beneficiary (SLMB) Pays Medicare B premiums. Countable income above 100% FPL, but less than 120% FPL. Expanded Low-Income Medicare Beneficiary (E-SLMB) Is not eligible for any other Medicaid group Countable income at or below 120% FPL but less than 135% FPL.

MSP Current Limits

MEPD Medicaid available to people who are disabled and have earnings from employment. Must be under age 65. Must be determined disabled. Must have earned income from employment or self-employment. Countable resources must be be less than $12,000 for individual or $13,000 for a couple. Net family income must be less than 250% FPL Any premium assessed for a month must be paid before eligibility is granted for that month.

Income limits effective 3/1/18 MEPD Income MEPD eligibility is based on family income. “Family is defined as: Income limits effective 3/1/18

Premiums are reviewed every August. This is the current chart: MEPD Premiums Premiums are reviewed every August. This is the current chart:

MEPD Premiums Continued Premiums are set for a 12-month period and cannot be increased during that certification period, but can be decreased in there is a decrease in income. Members receive a billing statement around the 20th of the month prior to the month the premium is to cover. If a member fails to pay their premium by the 14th of the month it is to cover, their case will be closed.

MEPD Premiums Continued If member pays the overdue premium by the end of the month following the month it was to cover, their case can be reopened. If a member pays the overdue premium within three months after the due date, then they can still get coverage for the month it is to cover, but may not be reopened.

MEPD Example Joe is on MEPD and has a $34 premium. Joe gets his bill on 3/19 for April coverage, due date is 4/14. #1- Joe pays premium on 4/2, he will then be granted Medicaid for April that night and it will pass to ELVS. #2- Joe does not pay premium by 4/14 so his case gets cancelled. Joe then pays his premium on 5/2. His case is reopened, April eligibility is granted, and he is sent a billing statement for May. #3-Joe does not pay premium by 4/14 so his case is cancelled. Joe then pays premium on 6/18. Joe is granted April eligibility but his case is not reopened and he needs to reapply if he wants to be on MEPD again.

Home and Community Based Service (HCBS) Waivers Waivers provide a variety of services in consumers’ homes that are not available through regular Medicaid and are not available to other Medicaid recipients. The total costs of these services and regular Medicaid cannot exceed the total cost of care and services that would be provided for the person living in a medical institution.

HCBS Waivers Cont. There are currently seven HCBS waivers, targeting the following groups: AIDS/HIV Brain Injury (BI) Children’s Mental Health (CMH) Elderly (EW) Health and Disability (HD) Intellectual Disability (ID) Physical Disability (PD) Note: Members can only be active on one waiver at a time.

HCBS Waiver Information Iowa DHS has a homepage for HCBS waivers. http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hcbs/waivers Here you can find: Information packets for each individual waiver. Information on Consumer Choices Options (CCO) Consumer Directed Attendant Care (CDAC) Services Program Comparison Charts Waiver Slot waiting list Many other HCBS documents and useful information

HCBS Waiver Slots There are limits to the number of members who can receive HCBS. When all waiver slots are assigned, the applicant’s name is placed on a waiting list. Once a slot is assigned, the slot is available for the applicant as long as reasonable efforts are being made to arrange services. Once a member is approved for and access waiver services, the slot is for use only by that member as long as they continue to meet eligibility criteria.

HCBS Slot Waiting List If no payment slot is available, the applicant’s name is place on a waiting list. The wait list for many waivers is often 24 months or longer so it is best to submit the application as soon as possible. As slots become available, applicants are selected from the waiting list and awarded a waiver slot, based on their application date. IM is notified that a slot has opened for the applicant IM sends a notice to the applicant of the open slot and lets them know if they would like to pursue the waiver they need to send back the enclosed application. Applicant has 30 days to return the application. If they do not return the application, it is considered that they do not wish to continue with waiver eligibility and the slot will be given to the next individual on the waiting list.

Accessing the Slot Waiting List from the waiver homepage: http://dhs

HCBS Waiver Slot Waiting List You will get a 3 page document with all of the different waivers and the current status as of the current month. Example: In this scenario the HD waiver has a waiting list of 2,244 people and the next person who will get a slot will have an original application date of 10/10/16

Applying for a HCBS Waiver cont. While the IM is gathering the information needed to make an income and resource eligibility determination, Telligen (group contracted by the state) will contact the member to set up a time to do an assessment so that the medical information can be turned into Medical Services at IME to determine if the applicant meets the needed LOC for eligibility. Once the IM has determined the applicant meets financial eligibility requirements and Medical Services has approved LOC, the applicant will be approved for Medicaid and show as eligible to receive waiver services. The eligibility is then passed to the MCO to create an individualized waiver service plan for the member. Once the service plan is in place, the member will begin to receive waiver services.

Waiver Case Example 5/3/17- IM receives a waiver application for Clarke Kent. 5/8/17- IM pends case and slot is available. 5/9/17- IM sends an RFI for needed verification of income and resources with a due date of 5/19/17. 5/18/17- Applicant gets sent back to the IM. 5/26/17- IM reviews information and checks for LOC. They see that the LOC has not yet been approved by Medical Services as they have requested for IME physician to review so will need to wait to process.

Waiver Case Example Cont. 6/7/17- IM and gets notification that LOC has been set as of 5/15/17. The IM will complete an attribution if there is a spouse at home. 6/8/17- IM determines financial eligibility has been met and is able to approve the case. Medical is approved as of 5/1/17 (first of month LOC is met) and a Notice of Decision (NOD) is sent to the member 6/9/17- eligibility is updated in the system overnight and the MCO assignment process begins.

Waiver Case Example Cont. 6/18/17- Member chooses which MCO they wish to enroll with. 6/20/17- chosen MCO gets enrollment information and can begin working with client to set up a service plan. 7/20/17- MCO has completed service plan set up and the member can begin to receive waiver services.

Medical Assistance Income Trust For people seeking Long Term Care (LTC) Members with gross income over the $2,250 income limit can still qualify for Medicaid payment by setting up and using a medical assistance income trust (MAIT or Miller’s Trust) Total income needs to be less than 125% of the statewide average charge for NF care. 7/1/17- $7,287 Trusts can be set up by working with the member’s lawyer, or contacting Iowa Legal Aid

Transfers to a Facility Since eligibility criteria are the same for waiver and facility, a member who is active on a waiver can go into a facility and have their coverage group changed to facility care without needing a new application. Effective 9/6/17- Waiver recipients may receive care in a hospital, nursing facility or intermediate care facility for persons with intellectual disabilities for up to 120 days and transition back to waiver without the need to reapply. This is a change from the former 30 day stay rule. Provider entry into PathTracker will generate the Case Activity Report to notify the IM at the Centralized Facility Eligibility Unit (CFEU) of the facility admission or discharge.

Applications Applications can be filed online at: https://dhsservices.iowa.gov/apspssp/ssp.portal or you can print https://dhs.iowa.gov/sites/default/files/470-5170.pdf and mail. Once an application is filed, it is assigned to an Income Maintenance (IM) worker to begin processing and determining eligibility. If it is determined that more information/verification is needed, the IM sends the applicant a Request For Information (RFI). The applicant will have 10 days to return the requested information. If the applicant needs more time to gather the needed information, they will need to call the IM and request an extension. If the requested information is not provided by the due date, the IM will deny the application.

Grace Period At Application If benefits are denied for failure to provide requested information or verification, and the information or verification is provided within 14 calendar days of the effective date of the denial, the department will continue with the eligibility determination as though the information have been timely received. After a Cancellation Eligibility for Medicaid may be reinstated without a new application when all information necessary to establish eligibility, including verification of any changes, is provided within 14 calendar days of the effective date of the cancellation.

90-Day Reconsideration Period If a member fails to return their review form, or the needed verification supporting the information on their review form, they will be cancelled. If that member subsequently submits the review form (NOT a new application), with needed verification, within 90 days from the effective date of termination the department will reconsider the members eligibility without requiring a new application. The department will look back and determine eligibility for each of the months since cancellation.

90-Day Reconsideration Cont. Exceptions: Qualified Medicare Beneficiaries: eligibility begins the first of the month following the month of decision HCBS Waivers and PACE: programs follow application processing guidelines and will not cover any months previous to when the review is actually received Example: Sam is on facility Medicaid and is cancelled for not returning his review form as of 12/31/17). Sam turns his review form and verifications in on 3/12/18 (less than 90 days from date of cancellation. Sam's worker will determine if he meets eligibility for January, February, and March.

Ongoing Eligibility Members Must Report Changes within 10 days: Income Resources Health insurance premiums Living address (including medical facility stays) Members Have an Annual Review Required for all members receiving medical assistance (unless they are an SSI Recipient) Review form automatically sent out each year Must provide proof of current income and resources.

Common Reasons for Losing Medicaid Eligibility Age- no longer meet age requirement of group. Income/Resources- no longer meet set guidelines. Not Cooperating- such as not cooperating with TPL. Not providing requested information- such as yearly review form. No longer meeting needed LOC- for waiver or facility. Incarceration- you do not lose Medicaid but are put into a suspended status so only inpatient claims can be paid.

Estate Recovery Program The cost of medical assistance is subject to recovery from the estates of certain Medicaid members. Members affected: Are 55 years of age or older, regardless of where they are living. Are under age 55 and: Are residents of a nursing facility, intermediate care facility for the intellectually disabled, or a mental health institute, and Cannot reasonable be expected to be discharged and return home. Questions about the Estate Recovery Program: Call 1-888-513-5186

Questions?