Medicaid and CHP+ for Beginners February Medicaid and Child Health Plan Plus (CHP+) An overview for beginners who need to know the basics

Medicaid and CHP+ for Beginners February What You Need to Know Medicaid and Child Health Plan Plus (CHP+) What are these 2 programs? Who is eligible for each? What are the different categories I might hear people refer to?

Medicaid and CHP+ for Beginners February Public Health Insurance Medicaid and CHP+ Government Funded –Partial federal/state Safety-net for most vulnerable groups –Largest source of funding for health-related services Not to be confused with Medicare

Medicaid and CHP+ for Beginners February A Little History Lesson MedicaidCHP+ Title XIX (19) of the Social Security Act Title XXI (21) of Social Security Act Began in 1965Began in 1997 States contribute funds Federal Government provides a % of matching funds to States Federal Government provides a % of matching funds to States, which is capped Entitlement programOptional program. Initially only authorized for 10 years; was reauthorized through 2013

Medicaid and CHP+ for Beginners February Who do they serve? MedicaidCHP % of Federal Poverty Level (depending on the age of clients) % of Federal Poverty Level (depending on the age of clients) Children Pregnant Women Plus Parents w/dependent children Blind, Disabled, or Elderly Children Pregnant Women

Medicaid and CHP+ for Beginners February About Medicaid Families and Children Disabled Children and Adults Different Populations = Different Needs Various Programs within Medicaid –For children, parents, and pregnant women –For disabled, elderly, or those in need of long-term care Elderly

Medicaid and CHP+ for Beginners February Colorado Medicaid Includes benefits such as: –Physician visits –Prescription drugs –Labs and X-rays –Emergency Services –Inpatient Hospital Services –Outpatient Hospital Services …and many more

Medicaid and CHP+ for Beginners February How is eligibility for Medicaid determined? Family Size and Makeup Citizenship Income –Earned Income (through working) –Unearned Income (such as Supplemental Security Income) –% of Federal Poverty level Different levels for different groups Other considerations –Resources –Disability –Level of Care

Medicaid and CHP+ for Beginners February Family Medicaid Insures children, adults with dependent children, and pregnant women

Medicaid and CHP+ for Beginners February Family Medicaid Income Levels Parents whose income is at or below 60% of the Federal Poverty Level Children age 6-19 whose family income is at or below 100% of the Federal Poverty Level Children under the age of 6 and pregnant women whose family income is at or below 133% of the Federal Poverty Level

Medicaid and CHP+ for Beginners February Medicaid Income Levels % of Federal Poverty Level

Medicaid and CHP+ for Beginners February Medicaid Income Levels Family Medicaid Monthly Income Levels April 1, 2009 – March 31, 2010 FAMILY SIZE Adults with a child on Medicaid or CHP+ Children ages 6-18 Children Birth – 5 and pregnant women 1$542$903$1201 2$729$1215$1615 3$916$1526$2030 4$1103$1838$2444 5$1290$2150$2859 6$1477$2461$3273

Medicaid and CHP+ for Beginners February What is EPSDT? Early Periodic Screening Diagnosis and Treatment (EPSDT) –PREVENTIVE health care program focusing on early identification and treatment of medical, dental, vision, hearing and developmental problems for clients ages 20 and under –Primary Care Physician (PCP) or Managed Care Organizations (MCO) performs Periodic Screening exams Federally mandated, and administered in partnership with each state

Medicaid and CHP+ for Beginners February Benefits of EPSDT Emphasizes preventive care and complete early treatments Provides comprehensive health care benefit package for Medicaid enrolled children, ages birth through 20 years Assures availability and accessibility of required health care services and items HMO or provider staff and EPSDT Outreach Coordinators assist Medicaid clients and their parents or guardians effectively use these resources

Medicaid and CHP+ for Beginners February ESPDT Coordinators FREE Resource for Families Notifies every enrolled family of the scope of EPSDT benefits and outreach coordination support services Guides families to appropriately use their Medicaid benefits with emphasis on education, prevention, diagnosis and timely treatment

Medicaid and CHP+ for Beginners February ESPDT Coordinators Assists providers in reducing the incidence of multiple appointments missed by Medicaid enrolled children and youth Identifies and refers families to other community resources such as: –Housing –Part C –Food banks –Women, Infants and Children food program (WIC) –Waiver sites –Prenatal Plus –Head Start

Medicaid and CHP+ for Beginners February Emergency Medicaid For Non-citizens who would otherwise qualify for Medicaid –Non-qualified aliens (those without appropriate legal documentation) –Legal aliens who have been in country <5 years Life or limb emergency only –Labor and Delivery is considered a medical emergency –Prenatal care is NOT included in Emergency Medicaid

Medicaid and CHP+ for Beginners February State-Only Prenatal Provided for legal aliens who have not been in the country 5 years –Not eligible for regular Medicaid during 5 year bar State-Only Prenatal provides prenatal care for this population –No federal funds provided for prenatal care for this population –State funding fills the coverage gap

Medicaid and CHP+ for Beginners February State-Only Prenatal Would qualify for Medicaid except for their alien status –Woman’s portion of household income is at or below 133% of the Federal Poverty Level Pregnancy has been verified by doctor’s statement or staff observation Eligibility ends 60 days after pregnancy ends

Medicaid and CHP+ for Beginners February Medicaid Benefits for Pregnant Women

Medicaid and CHP+ for Beginners February Needy Newborn A baby born to a mother for whom Medicaid paid for the labor and delivery –Any form of Medicaid, such as: Emergency, Family Medicaid, etc. –Babies born to mothers on State Only Prenatal also qualify Automatically eligible for Medicaid for 1 full year –As long as the baby stays with the mom in the home Anyone can report the birth to the county Department Human/Social Services to add the baby into CBMS

Medicaid and CHP+ for Beginners February Questions about Medicaid?

Medicaid and CHP+ for Beginners February What is Child Health Plan Plus (CHP+)? Even working families and those above the poverty level have a hard time affording health insurance CHP+ offers coverage for children and pregnant women who make a little too much for Medicaid

Medicaid and CHP+ for Beginners February About CHP+ Children Two Programs within CHP+ –CHP+ (for children only) –CHP+ Prenatal Care Program Pregnant Women

Medicaid and CHP+ for Beginners February Colorado CHP+ Include benefits such as: –Physician visits –Prescription drugs –Immunizations (shots) –Hospital services –Prenatal care –Dental Care (for kids only) …and many more

Medicaid and CHP+ for Beginners February How is eligibility for CHP+ determined? Family Size and Makeup Citizenship Income –Earned Income (through working) –Unearned Income (such as child support) –Allowable Income Deductions –% of Federal Poverty level Different levels for different groups Other requirements –Is not eligible for Medicaid –Does not have other health insurance –Does not have access to State Employee benefits

Medicaid and CHP+ for Beginners February Comparison of Income Levels % of Federal Poverty Level

Medicaid and CHP+ for Beginners February CHP+ April 1, 2009 – March 31, 2010 Maximum Income Levels FAMILY SIZE MONTHLY INCOMEWEEKLY INCOME HOURLY WAGE 1$1,851$430$12 2$2,490$579$16 3$3,128$727$20 4$3,767$876$24 5$4,406$1,025$28 6$5,045$1,173$32 Certain expenses such as childcare, medical costs, health insurance premiums, child support and alimony payments may be deducted from a family's gross income. This means that families may make more money and still qualify for CHP+. CHP+ Income Levels

Medicaid and CHP+ for Beginners February Some differences between the CHP+ Programs ChildrenPrenatal Birth – 18 years of age19 and older Guaranteed coverage for 1 year from application unless: income goes DOWN, moves out of state, or obtains other health insurance Guaranteed coverage for at least 60 days after the pregnancy ends unless: income goes DOWN, moves out of state, or obtains other health insurance Dental benefits includedNo dental benefits May pay enrollment fee and small co-pays No enrollment fee or co-pays for prenatal care; may pay small co-pays for other care

Medicaid and CHP+ for Beginners February CHP+ Newborn Guarantee CHP+ Newborn: A baby born to a mother enrolled in the CHP+ Prenatal Care Program at the time of birth –Mother must be 19 or older to be in Prenatal Program –Baby born to a mother in regular CHP+ (for kids) is not guaranteed enrollment Automatically eligible for CHP+ for 12 months –Even if income increases or decreases Anyone can report the birth to add the baby into CBMS –Must notify CHP+ of baby's birth in order to enroll

Medicaid and CHP+ for Beginners February Questions about CHP+?

Medicaid and CHP+ for Beginners February What is PE? Presumptive Eligibility (PE) is immediate medical coverage for certain individuals who appear eligible for either Medicaid or CHP+ Only available for: –Children under 19 –Pregnant women Presumptive Eligibility can only be granted at a site authorized to determine PE

Medicaid and CHP+ for Beginners February What does PE cover? Provides no less than 45 days of temporary coverage while client waits for eligibility determination Immediate access to health care includes: –Medicaid PE for children: all Medicaid-covered services –Medicaid PE for pregnant women: only outpatient services –CHP+ PE (children and pregnant women): all CHP+ services except dental benefits

Medicaid and CHP+ for Beginners February Questions about Presumptive Eligibility?

Medicaid and CHP+ for Beginners February Where to Find More Information Medicaid and EPSDT: Colorado.gov/hcpf Customer service: Denver metro (303) Toll free (800) CHP+: CHPplus.org Customer Service: (800)