1. Understanding Medicaid
National Head Start Directors Association Training
Nashville, Tennessee
June 11, 2018
Carolyn Roach
Member Relations Program Manager
South Carolina Department of Health and Human Services
My name is Carolyn Roach and I work for the South Carolina Department of Health and Human Services which is the agency that administers the Healthy Connections Medicaid program in South Carolina. Thank you for inviting me to talk about our Medicaid program. Please feel free to ask questions at any time.

2. Our Mission
Purchase the most health care for our citizens at the least possible cost to the taxpayer.

3. SC Dept. of Health and Human Services
DHHS administers the state’s Medicaid program called Healthy Connections, which has provided healthcare coverage for the state’s citizens since 1968.
Medicaid was created in States did not have to enroll in the Medicaid program; in fact South Carolina did not join until July 1968.
Eligibility is determined through an application process.

4. Medicaid Explained Funded by state and federal governments
Needs-based government insurance program
The federal government requires certain mandatory coverage groups and benefits
The federal government gives states the right to provide for optional coverage groups and benefits; therefore eligibility can vary from state-to-state
The Medicaid program is funded by the State and Federal Government. Every State has its own Medicaid program. Every state has different rules and services.
You have a Coverage Group chart handout. Each program is annotated as “M” or “O”. “M” is for Mandatory coverage groups; which means South Carolina must establish eligibility for these Medicaid programs and “O” is for Optional; which means South Carolina made a choice to establish eligibility for these programs.

5. Medicaid Facts
In FY 2017, Medicaid payments totaled approximately $7.1 billion
Approximately 65% of Medicaid members are age 0 to 18.
Approximately 65% of all children in SC are on Medicaid.
Medicaid pays for 60% of all births in SC.
Medicaid pays for 85% of all teen births in SC.

6. Basic Medicaid Coverage Groups
Medicaid coverage programs are divided into two basic groups:
MAGI –(Modified Adjusted Gross Income) basic eligibility criteria are modeled after the Family Independence (FI) program, previously known as Aid to Families with Dependent Children (AFDC). These programs provide coverage for minor children, pregnant women and parent/caretaker relative.
NON-MAGI –basic eligibility criteria are modeled after the Supplemental Security Income (SSI) program. These programs provide coverage for individuals who are aged, blind or disabled.
There are two types of coverage groups:
The 1st group is MAGI- (Modified Adjusted Goss Income) , which is modeled after the Family Independence program, previously known as Aid to Families with Dependent Children (AFDC). These programs provide coverage for minor children, pregnant women and parent/caretaker relative.
The 2nd group is Non-MAGI and it is modeled after the Supplemental Security Income (SSI) program. These programs are based on Social Security policy and provide coverage for individuals who are aged, blind or disabled.

7. Healthy Connections Categories
MAGI
Pregnant Women and Infants
Partners for Healthy Children
Parent/Caretaker Relative
Family Planning
Foster Care
IV-E Foster Care
Former Foster Care up to age 26
Subsidized Adoption
NON-MAGI
Supplemental Security Income (SSI)
Aged (65+), Blind or Disabled
Optional State Supplementation (OSS)
TEFRA-Tax Equity and Fiscal Responsibility Act
Nursing Home
Home and Community Based (Waivered) Services
SLMB-Specified Low Income Medicare Beneficiaries
QI-Qualifying Individual
These are the Healthy Connections Medicaid categories.
Highlight programs for children
Partners for Healthy Children
Parent/Caretaker Relative
TEFRA-Tax Equity and Fiscal Responsibility Act

8. Categorical Criteria for Medicaid Eligibility
Individual receiving cash assistance such as Supplemental Security Income (SSI)
Family with a dependent child/children
Child under age 19
Pregnant woman
Optional State Supplementation (OSS)
Individual age 65 or older, blind or disabled
Individuals diagnosed and found to be in need of treatment for either breast or cervical cancer, or pre-cancerous lesions (CIN 2/3 or atypical hyperplasia)
Individual qualifying for family planning services only
Here is a list of the current categorical criteria. In order for an individual to be Medicaid eligible, eligibility workers must determine if an individual fits into one of these categories. Usually they determine that by the information provided on the application or information that is given to them by the applicant over the phone.
Highlight programs for children
Individual receiving cash assistance such as Supplemental Security Income (SSI)
Family with a dependent child or children
Child under age 19

9. Financial and Non Financial Criteria
Income is calculated in relation to a percentage of the Federal Poverty Level (FPL).
Normally the Federal Poverty Level is updated annually.
Non-Financial Criteria
South Carolina Resident
Identity
Citizenship and Alienage
Social Security Number
Applying for and accepting other benefits
Not only does an applicant have to meet categorical requirements, they must meet financial and non-financial requirements.
Eligibility workers no longer need to ask for original documents to verify citizenship and identity because verification of citizenship and identity is done through the Federal Data Hub, which is an automatic process.
As a condition of eligibility, each applicant or beneficiary is required to apply for and accept all benefits entitled and assign Healthy Connections the rights to payment for medical care from any third party.

10. MAGI Coverage Programs
Eligible Group
Income Limit
Resource Limit
Partners for Healthy Children-PHC
Low-income families with children up to age 19 if their family income is at or below 213% of federal poverty level
Income limit based on family size.
Based on a family of 4 cannot exceed $4, / month.
No resource limit
Parent
Caretaker Relative-PCR
At least one child in the home is under age 18 (under age 19 if in a secondary school) and lives in a family with low income.
Net income for family of 4 cannot exceed $1, / month.
Transitional
Medicaid-TM
Individuals who lost eligibility for PCR because of the earned income of the parent/ caretaker(s)
Medicaid benefits for up to 12 months beginning with the month of PCR. Earned income less childcare expenses cannot exceed 185% of FPL.
Highlight programs for children
Partners for Healthy Children
Parent Caretaker Relative

11. NON-MAGI Coverage Programs
Eligible Group
Income Limit
Resource
Limit
SSI-Supplemental Security Income
(administered by SSA; in SC, automatically eligible for Medicaid)
Aged (65+), blind or totally and permanently disabled.
$750 / individual
$1,125 / couple
$2,000/ individual
$3,000/ couple
ABD-Aged, Blind or Disabled
100% of FPL
$1,012 / individual
$1,372 / couple
$7,560/ Individual
$11,340/ couple
TEFRA- Tax Equity and Fiscal Responsibility Act (Katie Beckett Children)
Disabled children under age 19 who meet level of care required in ICF-MR facility, nursing facility or hospital.
Parent's income is not counted. Child’s limit is $2,250 / month
$2,000 / child
Note: Parent’s income & resources NOT considered
Highlight programs for children
SSI -Supplemental Security Income
TEFRA

12. Retroactive Coverage
An applicant may be eligible to receive Medicaid benefits for any or all of the 3 calendar months prior to the application month. The application date is the date a signed application is received by the Medicaid Office. If beneficiary is receiving Supplemental Security Income (SSI), the date of the SSI application date is used.
The following requirements must be met:
Applicant must allege having outstanding medical bills and request eligibility be determined for retroactive benefits.
Applicant would have been financially and categorically eligible for Medicaid in any or all of the months in question. Actual income and resources are verified for each of the retro months.
Exception: There is not a resource limit for the MAGI groups (families and children programs).

13. Right to Appeal and Request a Fair Hearing
Any Medicaid applicant or member who believes Healthy Connections took action in error may appeal and request a fair hearing for an impartial review of his/her circumstances.
A beneficiary may continue receiving benefits if the request is received within ten (10) calendar days, and the request is made before eligibility ends. EXCEPTION: Eligibility does not continue in a Supplemental Security Income (SSI) category.
Any Medicaid applicant or beneficiary who believes the South Carolina Department of Health and Human Services (SCDHHS) took action in error may appeal and request a fair hearing.
A beneficiary may continue receiving benefits if the request is received within 10 calendar days and the request is made before eligibility ends. Even though a member may continue receiving benefits while appealing; if a hearing officer determines the decision was correct, the beneficiary will be required to pay back the cost of any benefits received during the appeal process.

14. Managed Care Participation
Managed Care is Optional for Tribal Beneficiaries
Children up to age 19
Families with at least 1 child
Pregnant women and infants
TEFRA
SSI children 18 years and under
South Carolina is a managed care health plan State for most Medicaid programs. Most children will fall under one of these categories. Selecting a managed care health plan is optional for Tribal Medicaid beneficiaries. If a managed care health plan is selected, a request can be made at anytime to dis-enroll from the plan.

15. Transportation
Non-emergency transportation is available for most Medicaid members for doctor appointments, dialysis, x- rays, lab work, drugstore or other medical appointments.
Transportation is not available to a medical service not covered by Medicaid.
The request for a ride must be made at least three (3) days in advance of the appointment.
Call at least 24 hours in advance for ride cancellations.
or or
Transportation requests require a Medicaid ID number so the Medicaid Healthy Connections card needs to be retained even when a beneficiary receives a separate insurance card from his/her managed care health plan.
These telephone numbers can be used to schedule a ride r this website can be used to schedule on-line appointment.

16. SC Healthy Connections Medicaid Card
The SC Medicaid program and its insurance card are referred to as
Healthy Connections.
A Medicaid handbook and insurance card are mailed to beneficiaries when approved.
Beneficiaries enrolled in a Managed Care Organization (MCO) receive an additional card identifying the MCO in which they are enrolled.
This is how the Medicaid card looks. It is made of plastic. A Medicaid beneficiary will always keep the same Medicaid #.
When an application is approved, the Medicaid beneficiary receives a handbook and a letter of approval.

17. How to Apply? Online apply at www.scdhhs.gov
At any South Carolina Department of Health and Human Services (SCDHHS) county office
At The Benefit Bank of South Carolina(a program of SC Thrive). Visit
At out-stationed locations such as county health departments, Department of Social Services offices, community health centers and most hospitals
Paper applications may be printed at or requested from the Member Services Call Center by calling The hours of operation are 8:00 a.m. - 6:00 p.m. Monday - Friday.
A listing of the county Medicaid offices is on the agency website.
Also volunteers with The Benefit Bank of SC are assisting in outreach efforts to help residents apply for Medicaid health insurance coverage. The Benefit Bank assists residents with other services such as taxes, SNAP, Free Application for Federal Student Aid etc. For more information you can visit their website.
Our Agency has made several significant process improvement changes to the way we process eligibility cases. All applications are scanned into an electronic system. This electronic system enables us to process cases state-wide. There are no longer assigned eligibility workers.

18. Have questions or need help? Keep in touch with us!
Member Contact Center…………… Healthy Connections website……………..scdhhs.gov Facebook…………………….facebook.com/scmedicaid Twitter…… twitter.com/scmedicaid Pinterest… pinterest.com/scmedicaid
The Medicaid Member Contact Center is available 8:00 a.m.-6:00 p.m. Monday- Friday