1. Affordable Care Act Overview - ACA 100
10/22/2017
SC Healthy Connections
Medicaid Overview
April 2017
Talking Points:
The purpose of today’s training is to provide a general overview of South Carolina’s Medicaid program. This includes a discussion of the impact of the Affordable Care Act and new benefit programs that have been initiated.
© State of South Carolina Health and Human Services

2. South Carolina Department of Health and Human Services
The South Carolina Department of Health and Human Services (SCDHHS) administers the Medicaid program, which provides health insurance coverage for eligible residents in South Carolina.
The Medicaid program is a “need-based” government insurance program, and is jointly funded by the State and Federal governments. The Federal government requires coverage for certain mandatory eligibility groups, and gives states the option to cover additional groups; therefore, eligibility can vary from state to state.
Eligibility for Medicaid is determined through an application process. The Healthy Connections Application (Form 3400 or Form 3401) must be completed to apply for coverage. Individuals who meet the categorical, financial, and non-financial requirements may qualify for benefits.

3. Medicaid Eligibility Criteria
Individual age 65 years or older, blind, or disabled
Child under age 19
Pregnant woman
Family with dependent children
Individual receiving cash assistance, i.e. Supplemental Security Income (SSI) or Optional State Supplementation (OSS)
Individual qualifying for the Breast and Cervical Cancer Program
Individual qualifying for Family Planning services only
Categorical Criteria
U.S. Citizen, or a legal non-citizen who meets certain criteria
South Carolina resident
Social Security Number
Non-Financial Criteria
See the following charts.
Financial Criteria

4. MAGI ELIGIBILITY CATEGORIES
MAGI CATEGORY
2017 RATE
Federal Poverty Limit (FPL)
Pregnant Women and Infants (PW)
[Optional Coverage for Pregnant Women and Infants (OCWI)]
194% FPL
Family Planning (FP)
[Healthy Connections Checkup (HCC)]
Partners for Healthy Children (PHC)
208% FPL
Parent Caretaker Relative (PCR)
[Low-Income Families (LIF)]
62% FPL
Regular Foster Care (RFC)
Subsidized Adoption
No Limit
Former Foster Care (FFC)
Refugee Assistance Program (RAP)
---
The Federal Poverty Limit (FPL) is determined by the U.S. Department of Health and Human Services (DHHS).

5. Determining MAGI Eligibility
Construct a Medicaid household for each applicant based on tax filer status
Household composition determines whose income is counted
Determine the Medicaid household income for each household member
Determine whether each individual is eligible for Medicaid based on income eligibility
Talking Points:
Citizenship/Immigration, residency, SSN, incarceration - no changes. Continues to follow existing Medicaid rules
Change of Circumstances - Continuous eligibility for pregnant women and children and other programs have a $150 reporting requirement

6. Income Source Differences
Household Composition under MAGI
10/22/2017
Income Source Differences
Income Sources
Former Medicaid Rules
MAGI Medicaid Rules
Self-Employment Income
Counted with deductions for some, but not all, business expenses
Counted with deductions for most expenses, depreciation, and business losses
Salary deferrals (flexible spending, cafeteria and 401(k) plans
Counted
Not Counted
Child Support Received
Alimony Paid
Not deducted from income
Deducted from income
Veterans’ Benefits
Workers compensation
Gifts & Inheritances
Counted as lump sum income in month received
TANF & SSI
© State of South Carolina Health and Human Services

7. Household for Medicaid
Household Composition under MAGI
10/22/2017
Household for Medicaid
Based on expected tax filing status
Three categories of individuals
Tax filers not claimed as a tax dependent
Tax dependent
Non-filers and not claimed as tax dependents
© State of South Carolina Health and Human Services

8. Newer Programs and Services
Former Foster Care
Tuberculosis Only Services
Adult Dental Services

9. NON-MAGI ELIGIBILITY CATEGORIES
NON-MAGI CATEGORY
2017 RATE
Aged, Blind, Disabled (ABD)
100% FPL
Specified Low-Income Beneficiaries (SLMB)
120% FPL
Qualifying Individual (QI)
135% FPL
General Hospital (GH)
300% FBR
Nursing Home (NH)
Katie Beckett (TEFRA)
Home and Community-Based Services (HCBS)
Qualified Disabled Working Individuals (QDWI)
200% FPL
Working Disabled (WD)
250% FPL
Optional State Supplementation (OSS)
$1420 Monthly Income
Transitional Medicaid (TMA)
185% FPL in final 6 months of coverage
Breast and Cervical Cancer Program (BCCP)
NON-MAGI ELIGIBILITY CATEGORIES
The Federal Poverty Limit (FPL) is determined by the U.S. Department of Health and Human Services (DHHS).
The Federal Benefit Rate (FBR) is determined by the Social Security Administration (SSA).
Financial eligibility is typically based on income and available resources.
For long term care, a 5-year look-back for asset transfers is required.

10. Affordable Care Act Overview - ACA 100
10/22/2017
Application Process
Talking Points:
Applicants can enroll for coverage by phone, paper application, online or through a Medicaid eligibility worker in an eligibility office, navigator or community partner.
Mandates that all states use a standard, streamlined application form developed by HHS for all insurance affordability programs, or an approved alternative that is no more burdensome (3400 Healthy Connections), and accept it via an internet Web site and other electronic means, telephone, mail, and in person.
Beginning in October 2014, the Health Insurance Marketplace provides a new option for South Carolinians to apply for health coverage through their online application web portal. The Marketplace also provides a way for families to enroll in a Qualified Health Plan (QHP).
© State of South Carolina Health and Human Services

11. Affordable Care Act Overview - ACA 100
10/22/2017
Screening Tool
Start Application
Talking Points:
© State of South Carolina Health and Human Services

12. How to Submit a Completed Paper Application or Review Form
Mail to:
SCDHHS – Central Mail
PO Box
Columbia, SC
Fax to:
In person at County office:
For questions or to request an application or review form in Spanish, call the Healthy Connections Member Services Center at:

13. Medicaid Application – DHHS Form 3400

14. DHHS Form 3400A: Additional Information for Select Medicaid Programs

15. DHHS Form 3400B: Additional Information for Nursing Home and In-Home Care

16. DHHS Form 3401: Application for Nursing Home, Residential or In-Home Care

17. DHHS Form 1282: Authorized Representatives and Release of Information

18. Annual Review Process 1x/year or when changes occur
Different review forms for different programs
Reassess eligibility based on changes in eligibility criteria
Can be automated for MAGI categories
Receive Continuation of Benefits Notice
Always by paper for other eligibility groups

19. Long Term Care Programs – General Overview

20. Long Term Care Programs – General Overview
Nursing Home Assistance
Medicaid sponsors the payment of long-term care for individuals who:
Reside in Licensed and certified nursing facilities
Receive Long Term Care services through Home and Community Based Waivers and PACE Programs.
Have long term hospital stays of 30 days or longer
Medicaid may also assist individuals who reside in Community Residential Care Facilities.

21. Long Term Care Programs
Nursing Home Assistance
Skilled Nursing Facilities
Swing Beds
Intermediate Care Facilities for the Intellectually Disabled (ICF/ID)
Nursing Home Assistance

22. Long Term Care Programs
Purpose of the Waivers
To provide and alternative to institutional care
Participants meet nursing home level of care but choose to remain in the community.
Waivers are operated by:
Community Long Term Care
Department of Mental Health & SCDHHS
Department of Disabilities and Special Needs (DDSN)
Home and Community Based Services

23. Long Term Care Programs
The General Hospital Program covers long term hospital stays of 30 days or longer.
General Hospital

24. Long Term Care Programs
Optional State Supplementation
Assistance for residents of Community Residential Care Facilities
Optional State Supplementation (OSS)

25. Long Term Care Programs – Categorical Criteria -- General
Must be Aged 65 or Older, Blind or Disabled as defined by Supplemental Security Income (SSI) guidelines
Notes:
Disability – expected to be totally disabled for a period of one year or longer.
If a person is under age 65 and has Medicare A & B, they have been determined disabled.

26. Long Term Care Programs – Categorical Criteria Nursing Home & Waiver Services
Level Of Care – Must meet an Intermediate or Skilled level of care
30 Consecutive Days – The applicant must be in the hospital, nursing home, and/or participating in Waiver Services for 30 consecutive days or more before Medicaid can be approved. If all criteria are met, eligibility may begin the first date of the month of admission or enrollment.
Exceptions:
Already eligible in a full coverage Medicaid category.
Passed away before the 30 days were met.
Must not be subject to a Penalty for a transfer of assets.

27. Income Gross income from all sources must be considered and verified.
Acceptable forms of verification include:
Copies of award letters
Copies of check stubs
Copies of IRS Form 1099
Self employment – Copies of tax returns or ledgers
Copies of Promissory Notes
System matches
Note: Bank statements reflecting direct deposits should not be used to verify income as it may not reflect the necessary gross amounts.

28. Income Income exclusions may include the value of:
Veterans Benefits for the following if the amounts can be verified
Aid & Attendance
Dependent Indemnity Compensation (DIC)

29. Income – Nursing Home Two Steps
When Medicaid sponsors an Individual’s nursing home stay, they receive two services:
A Medicaid Card
Vendor Payment – Payment toward the room and board cost at the facility.
An Individual’s income Is subject to paying toward the cost of their nursing home care. Their cost of care is known as recurring income.
Budgeting has two steps:
Eligibility Determination
Recurring Income Determination (Post Eligibility)

30. Income Trust
Special Trust also known as a “Miller” trust Authorized by the Omnibus Budget Reconciliation Act of 1993 (OBRA 93)
Intent – To enable individuals who need institutional care to qualify for Medicaid if they meet all eligibility criteria other than the Medicaid Cap (income limit).
The Medicaid Cap is $2205 effective January 1, 2017
Provisions apply to the Nursing Home and Home and Community Waivered Services programs but does not apply to the General Hospital or Optional State Supplementation programs.
The earliest possible date of eligibility is the first day of the month the Income Trust document is signed.

31. Income Trust
An individual may have an attorney assist them with an Income Trust, but it is not required.
The DHHS Form 905 is a template which can be completed.
Requirements:
The applicant is the primary beneficiary.
The Medicaid agency is the secondary beneficiary.
Other beneficiaries may be named but may not receive any money until Medicaid has been repaid.
If funds remain in the Income Trust account at the time of the individual’s death, it is required that the trust reimburse the Medicaid agency for expenses paid on the individual’s behalf.

32. Income Trust – Separately Identifiable Account
The income assigned to the Income Trust must be placed in a separately identifiable account.
May designate a current account or open a new account
Only the applicant and trustee’s names may be on the account
May be a regular checking account
If the Facility is the Trustee, a separate ledger account may be used. It must be separate from the Patient Personal Fund account.
Only the income assigned to the Income Trust on the Schedule A can be deposited
Only allowable deductions such as cost of care may be withdrawn.
Account must be funded prior to Medicaid approval

33. Establishing an Income Trust
The beneficiary must appoint a trustee to manage the Income Trust
An individual can not be their own trustee
The Trustee may be anyone of their choosing, such as a:
Family member
Friend
Facility
Court appointee
Only the applicant or their legal representative (Power of Attorney, Conservator) can sign the Income Trust document

34. Income – Nursing Home Cost of Care
Recurring income is calculating beginning with the applicant’s gross countable income. From there, certain deductions are allowed. These deductions may include:
$30 Personal Allowance
Community Spouse’s allocation
Dependent’s allocation
Home Maintenance Allowance
Beneficiary’s health insurance premiums
Protected Income (Month of admission from / discharge to community)
The amount remaining after deductions is the individual’s Monthly Cost of Care

35. Resources
Resources include assets an individual owns and can use to meet food, clothing, and shelter needs such as:
Non-Home Property
Bank Accounts
CDs, Stocks, Bonds, Investment funds,
Life Insurance
Inheritances
The value of the applicant’s resources cannot exceed $2,000, following exclusions. If they are ABD eligible, resources cannot exceed $7,280
The value of a married couple’s resources cannot exceed $68,480, following exclusions.
If all other criteria are met and the applicant is approved, they have 90 days from the date of approval to transfer resources from the applicant to the community spouse’s name.

36. Resources Resource exclusions may include the value of:
The home, if the equity value is less than $543,000,
Up to two cars,
A life estate interest,
Household goods and personal effects,
Up to $1,500 for a burial fund (but more may be excluded if the applicant purchased a pre-need burial contract) and
The cash value of life insurance policies with face values totaling more than $10,000.

37. Resources The following documentation may be requested:
Copies of the applicant and spouse’s financial account statements --
Checking, savings, CD’s, Stocks, Investment funds
NOTE: At minimum, DHHS must look at the month of application and the three months prior.
Copies of trust agreements
Copies of annuity contracts
Tax verification of vehicles and property owned
Copies of burial contracts, burial fund accounts, or plot certificates
Copies of life insurance policies

38. Additional Requirements: Look-Back
A look-back may be required to determine if the applicant or their spouse has transferred assets in the 60 months preceding the date of application.
We are currently asking for bank information that reflects the month of application and the three months prior to the month of application. Additional months may be requested if a potential transfer is identified or if the applicant’s indicates a transfer has occurred.

39. Additional Requirements: Look-Back
The following documentation may be requested:
Verification of closed accounts
Copies of HUD statement from sale of home
Verification of amounts gifted

40. Transfer of Assets -- Nursing Home
A penalty is applied to institutionalized individuals and their spouses if the individual transferred assets for less than Fair Market Value (FMV) within the 60- month look-back period.
Although an individual can receive services (Medicaid card) during the penalty period, Medicaid will not pay for the vendor payment services until the penalty period is over.
EXCEPTION: Income Trust cases can not receive a Medicaid card during the penalty period.
The penalty period is calculated by dividing the uncompensated value of the transferred assets by the average private pay nursing home rate (currently the rate is $6,672.80)

41. Transfer of Assets -- Nursing Home
No penalty is imposed if:
The assets were transferred to a spouse or a blind or disabled child,
The home was transferred to a spouse, and in some cases, to a child or sibling,
The individual can show the transfer was intended to be for FMV,
The individual can show the assets were transferred for a reason other than to qualify for Medicaid, or
It creates an undue hardship, which would place the individual in a life- threatening situation.

42. Transfer of Assets – Home and Community Based Services
A penalty is applied to individuals, who receive waiver services, and their spouses if the individual transferred assets for less than Fair Market Value (FMV) within the 60-month look- back period.
Waivered services cannot begin if there is a sanctionable transfer.
Medicaid may be approved if the individual meets the eligibility criteria in a non-institutional payment category, such as ABD, PCR, etc.

43. Medicaid and Transfer Penalties
Regular Nursing Home Cases
Income Trust Cases
May receive a Medicaid card during the penalty
Must contact Medicaid office to request a vendor payment when penalty ends
Medicaid card is approved only for the initial month to begin the penalty.
Case is closed during the penalty to enable beneficiary to use income to pay during the penalty.
Must reapply for Medicaid when the penalty expires.

44. Optional State Supplementation
Assistance for residents of Community Residential Care Facilities

45. Optional State Supplementation– Additional Catgegorical Criteria
Reside in a Community Residential Care Facility licensed by DHEC
Be assigned an approved OSS Slot
Note: Eligibility must be determined before a slot can be requested.

46. Optional State Supplementation– Differences in Financial Eligibility
Income Limit: $1420
Resources
Limit: $2000
Resources are counted as of the first day of the month. If countable resources exceed the limit on the first day of the month, the individual is ineligible for that month.
Life Insurance Cash Values are counted if the Face Value exceeds $1500
The Value of Life Estate and Remainder Interest are countable resources.

47. Long Term Care Programs – Payment Categories
Payment Category
Name
Income Limit
Resource Limit
PC 10
Nursing Home – MAO NH
$2205 / month*
$2,000 Individual
$68,480 Couple
PC 33
ABD Nursing Home
$1005
$7390
PC 54
SSI Nursing Home
$735
$2,000
PC 15
Waiver Services
PC 14
General Hospital
$2205 / month
PC 85
OSS
$1420
$2,000**
PC 86
OSS/SSI
*If a nursing home or wavier services’ applicant’s income exceeds $2205, they may establish an Income Trust to qualify for Medicaid.
** Resources must be below the limit on the First Day of the month.

48. How to Assist an Applicant
Encourage them to give complete information on the application
Explain what types of documents may be submitted to assist with the eligibility determination.
Income Verifications
Resources Verification
Copies of Legal documents if there is a Legal Represenative
Power of Attorney
Conservator
Guardian
If assisting with the process, the applicant may sign a DHHS 1282 allowing DHHS to discuss the application and needed verifications with you.

49. For More Information
Donna Day Eligibility Policy and Process Lori Risk