Missouri HealthNet and Medicare Savings Programs

Missouri HealthNet and Medicare Savings Programs
CLAIM Time Webinar Missouri HealthNet and Medicare Savings Programs

Medicaid and the Children's Health Insurance Program
What is Medicaid? Federal and state program Medical assistance for people with limited income and resources Covers about 74 million adults and children Medicaid—67 million individuals enrolled Supplements Medicare for more than 10 million people who are aged and/or disabled Medicaid is a federal and state program that helps with medical costs for certain individuals and families with limited income and resources. Medicaid isn’t a cash support program; it pays medical providers directly for care. Medicaid is the largest source of funding for medical and health-related services for those with limited income and resources. Medicaid provides health coverage to an estimated 74 million people, including children, pregnant women, parents, seniors, and individuals with disabilities. The program became law in 1965 as a cooperative venture jointly funded by the federal and state governments (including the District of Columbia and the Territories) to help states provide medical assistance to eligible persons. For more information, visit Medicaid.gov/medicaid/program-information/medicaid- and-chip-enrollment-data/report-highlights/index.html. July 2018 Medicaid and the Children's Health Insurance Program

Medicaid Administration
Jointly financed federal and state program Federally established national guidelines States get federal matching funds Known as the Federal Medical Assistance Percentage (FMAP) Used to calculate amount of federal share of state costs Varies from state-to-state Based on state per capita income Medicaid is a joint federal and state partnership program with federally established national guidelines. States get federal matching funds for covered services. The federal matching rate, also known as the Federal Medical Assistance Percentage (FMAP), is used to calculate the amount of the federal share of state costs for services The FMAP varies from state-to-state based on state per capita income FMAPs are updated every fiscal year and can be found at aspe.hhs.gov/federal- medical-assistance-percentages-or-federal-financial-participation-state-assistance- expenditures. July 2018 Medicaid and the Children's Health Insurance Program

State Medicaid Administration
Within broad federal guidelines, each state Develops its own programs Develops and operates its own plan Establishes its own eligibility standards Determines the type, amount, duration, and scope of services Sets the payment rate for services Partners with the Centers for Medicare & Medicaid Services (CMS) to administer its program Administers its own program once approved by the federal government States may change eligibility, services, and reimbursement during the year Within broad federal guidelines, each state Develops its own programs. Develops and operates a Medicaid State Plan outlining the nature and scope of services. The state plan is a contract between the Centers for Medicare & Medicaid Services (CMS) and the state, and any amendments must be approved by CMS. Establishes its own eligibility standards in accordance with federal guidelines. A person who’s eligible for Medicaid in one state may not be eligible in another state. Determines the type, amount, duration, and scope of services covered within federal guidelines. Also, the services provided by one state may differ considerably in amount, duration, or scope from services provided in a similar or neighboring state. Sets the payment rate for services with CMS approval. Partners with CMS to administer its program. Administers its own program once approved by the federal government. States may change their Medicaid eligibility, services, and reimbursement during the year, subject to federal approval. July 2018 Medicaid and the Children's Health Insurance Program

The Single State Medicaid Agency
Administers the Medicaid State Plan May delegate some administrative functions Local office names may vary Social Services Public Assistance Human Services Family Support Division A state must designate a “single state agency” to “administer or supervise the administration” of its Medicaid Program. Most state Medicaid Programs are administered by several state and local agencies. This is because the “single state agency” may delegate to other state agencies, to localities certain administrative responsibilities other than the issuance of policies, rules, or regulations. Local offices may have different names. These offices are sometimes called Social Services, Public Assistance, or Human Services. For more information about eligibility requirements and to apply for Medicaid, contact your state’s Medicaid office at Medicaid.gov/about-us/contact-us/contact-state- page.html or contact your local State Health Insurance Assistance Program (SHIP) at shiptacenter.org. July 2018 Medicaid and the Children's Health Insurance Program

Medicaid Eligibility States are required to cover certain population groups, like Low income families Qualified pregnant women and children Individuals receiving Supplemental Security Income (SSI) States have flexibility to cover other population groups, like Individuals receiving home and community based services Children in foster care who aren't otherwise eligible Financial and non-financial requirements must be met to qualify for Medicaid To qualify for Medicaid, you must belong to one of the eligibility groups specified under the federal Medicaid law and chosen to be covered in the state in which you live. To be eligible for federal funds, states have to cover people in certain groups up to federally defined income requirements. However, many states have expanded Medicaid beyond these thresholds and have extended coverage to other optional groups. There are financial and non-financial requirements that must be met to qualify for Medicaid. Non-financial requirements include residency, citizenship and immigration status requirements, and certain program requirements like spousal impoverishment, estate recovery, third party liability and coordination of benefits. Visit Medicaid.gov/medicaid/eligibility/index.html for more information about Medicaid eligibility. Also, visit Medicaid.gov/medicaid-chip-program-information/by- topics/waivers/1115/downloads/list-of-eligibility-groups.pdf to view the list of eligibility groups. July 2018 Medicaid and the Children's Health Insurance Program

Medicaid Eligibility (continued)
In all states: You can qualify for Medicaid based on income, household size, disability, family status, and other factors. Eligibility rules differ between states. In states that have expanded Medicaid coverage to the adult group: You can qualify based on your income and non-financial eligibility factors. If your household income is below 133% of the federal poverty level (FPL), you qualify. Some states have expanded their Medicaid programs to cover non-disabled, non- pregnant adults age 19 through 64, with household incomes below a certain level. Whether you qualify for Medicaid coverage in this adult group depends partly on whether your state has expanded its program. In all states, you can qualify for Medicaid based on income, household size, disability, family status, and other factors. Eligibility rules differ between states. In states that have expanded Medicaid to the adult group, you can qualify based on meeting the income standard as well as the non-financial eligibility factors. If your household income is below 133% of the federal poverty level (FPL), you qualify. (Because of the way this is calculated, it turns out to be 138% of the FPL.) States were given the option to extend eligibility to the adult group beginning At the same time, mandatory eligibility for children was increased to at least 138% of the FPL in every state (most states cover children to higher income levels). The majority of states have chosen to expand coverage to the adult group, and those that have not yet expanded may choose to do so at any time. For more Medicaid expansion information, visit Healthcare.gov/medicaid- chip/medicaid-expansion-and-you/. NOTE: Because of the way this is calculated, it turns out to be 138% of the FPL. A few states use a different income limit. July 2018 Medicaid and the Children's Health Insurance Program

Modified Adjusted Gross Income (MAGI) Methodology
MAGI is a methodology for how income is counted and how household composition and family size are determined MAGI-based rules are used to determine Medicaid and CHIP eligibility for most individuals MAGI is based on information for filing a tax return. MAGI is a methodology for how income is counted and how household composition and family size are determined. MAGI-based rules are used to determine Medicaid and CHIP eligibility for most individuals, including individuals who don’t file a tax return. MAGI rules create consistency and promote coordination between Medicaid and CHIP and coverage available through QHPs. July 2018 Medicaid and the Children's Health Insurance Program

Verification Primary reliance on electronic data sources Supported by Federal Data Services Hub Social Security Internal Revenue Service (IRS) U.S. Department of Homeland Security Decreased reliance on documentation Increased reliance on self-attestation States rely on available electronic data from a number of federal and local sources including Social Security, the Internal Revenue Service (IRS), and the Department of Homeland Security to verify eligibility for applicants and beneficiaries and promote program integrity, while minimizing the amount of paper documentation that consumers need to provide. States may also accept self-attestation to verify certain eligibility criteria. July 2018 Medicaid and the Children's Health Insurance Program

Coverage—Mandatory Medicaid State Plan Benefits
Inpatient hospital services Federally Qualified Health Center services Outpatient hospital services Laboratory and X-ray services Early and Periodic Screening, Diagnostic, and Treatment services (assurance for children under 21) Family planning services Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Nursing facility services (except for Medically Needy) Freestanding Birth Center services (when licensed or otherwise recognized by the state) Home health services (for individuals entitled to nursing facility care) Transportation to medical care Physician services Tobacco cessation counseling for pregnant women Rural Health Clinic services Mandatory Medicaid State Plan benefits include the following services: Inpatient hospital services Outpatient hospital services Early and Periodic Screening, Diagnostic, and Treatment services (assurance for children under 21) Nursing facility services Home health services (for individuals entitled to nursing facility care) Physician services Rural Health Clinic services Federally Qualified Health Center services Laboratory and X-ray services Family planning services Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Freestanding Birth Center services (when licensed or otherwise recognized by the state) Transportation to medical care Tobacco cessation counseling for pregnant women For more mandatory and optional benefits information, visit Medicaid.gov/medicaid/benefits/list-of-benefits/index.html. July 2018 Medicaid and the Children's Health Insurance Program

Treatment of an Emergency Medical Condition
Medicaid provides payment for emergency services for individuals who have an emergency medical condition and are otherwise eligible for Medicaid in the state (must meet Medicaid income and state residency standards), but don't meet the citizenship and immigration status requirements. Medicaid provides payment for emergency services for individuals who have an emergency medical condition and are otherwise eligible for Medicaid in the state (must meet Medicaid income and state residency standards), but don’t meet the citizenship and immigration status requirements. Section 1903(v)(2) and (v)(3) of the Social Security Act. States have flexibility to develop their own definition of which services are covered to treat an emergency medical condition, and the scope of services available. However, this definition excludes services related to organ transplant procedures and routine prenatal and postpartum care. July 2018 Medicaid and the Children's Health Insurance Program

Medicaid Spend-down MO HealthNet Spend-Down is a public assistance program that pays for certain health care costs of qualified persons. This program is for those with income above the MO HealthNet limits. It allows them to “spend down” or “pay down” their income to the Medicaid limit in order to receive benefits. The spend-down amount is determined on a monthly basis. In order for MO HealthNet to pay for medical expenses a person must meet or exceed their spend-down amount for that month. A person is not required to pay or meet that amount every month for general purposes of maintaining MO HealthNet. Enrollment for MO HealthNet Spend-Down is done through FSD. July 2018 Medicaid and the Children's Health Insurance Program

Medicaid Spend-down To determine the spend-down amount, the FSD Eligibility Specialist first determines the total monthly gross income based on the following: Earned income (e.g. wages) Unearned income (e.g. Social Security, pension, bank interest) Then the FSD Eligibility Specialist subtracts the following: $20 personal income exemption Amount paid each month for Medicare and certain types of medical insurance (Medigap policy, EGHP premium) 85% of the current federal poverty level (MO HealthNet ceiling) for which is $905/mo (single) and $1,218/mo (couple) The remainder is the spend-down amount. July 2018 Medicaid and the Children's Health Insurance Program

Meeting a Spend-down How to meet a spend-down: Provide receipts or bills for the month to give to the FSD Eligibility Specialist. They can be prescription drugs, hospitalization, doctor care, and other medical services. Do they have to be bills for the same month medical services are needed? No. Bills that are currently owed to meet Spend Down in a different month than when they were incurred can be eligible expenses incurred in the three months prior to the current month. If the amount of expenses from prior months exceeds the current month’s Spend Down amount, the excess balance can be used towards Spend Down for the following three months. If your spend-down is met at least once January to July, your Extra Help will continue for the rest of the calendar year. If met after July through December, it will continue through the entire following calendar year. July 2018 Medicaid and the Children's Health Insurance Program

Meeting a Spend-down Another option is to pay the spend-down amount directly to the state. If your spend-down is met at least once January to July, your Extra Help will continue for the rest of the calendar year. If met after July through December, it will continue through the entire following calendar year. Spend-down Unit You may also go to and search for “spend down” for further detailed information. July 2018 Medicaid and the Children's Health Insurance Program

How Are Medicare and Medicaid Different?
National program that is the same across the country Statewide programs that are different between states Administered by the federal government Administered by state governments within federal rules (federal/state partnership) Health insurance for people 65 or over, with certain disabilities, or diagnosed with End-Stage Renal Disease (ESRD) Health coverage for people who meet financial and non-financial requirements Nation’s primary payer of inpatient hospital services for the elderly and people with ESRD Nation’s primary public payer of mental health and long-term care services; covers 40% of all births/prenatal and postpartum Medicare and Medicaid are different in these ways: Medicare is a national program that is the same across the country; Medicaid consists of statewide programs that are different between states. Medicare is administered by the federal government; Medicaid is administered by state governments within federal rules (federal/state partnership). Medicare eligibility is based on age, disability, or End-Stage Renal Disease (ESRD); Medicaid eligibility is based on limited income and resources, and other non- financial requirements. Medicare is the nation’s primary payer of inpatient hospital services for the elderly and people with ESRD; Medicaid is the nation’s primary public payer of mental health and long-term care services (nursing home care) and finances 40% of all births (including prenatal care, labor, delivery and 60 days of postpartum and other pregnancy-related care). July 2018 Medicaid and the Children's Health Insurance Program

Medicare-Medicaid Enrollees— “Dual Eligibles”
8.3 million nationally Medicaid may provide full benefits and/or partial assistance with Medicare costs Medicare Savings Programs (MSPs) are partial Medicaid benefits that help pay Medicare premiums and sometimes cost-sharing You can qualify for full Medicaid only, full Medicaid with an MSP, or just a MSP For those with full Medicaid, Medicare pays first and Medicaid pays second for covered services In total, 8.3 million people are "dually eligible" and enrolled in both Medicaid and Medicare, composing more than 17% of all Medicaid enrollees. Dual-eligible beneficiaries include individuals who get full Medicaid benefits and those who only get help with Medicare premiums or cost-sharing. Medicare Savings Programs (MSPs) are operated by state Medicaid agencies and provide coverage for Medicare premiums and cost-sharing for low-income individuals that receive Medicare. Some Medicare enrollees are only eligible for this source of Medicaid assistance. Other people with Medicare may be eligible for full Medicaid coverage in addition to being eligible for MSPs, and others are eligible for full Medicaid coverage, but not MSPs. For people with Medicare that also have full Medicaid coverage, Medicare pays first and Medicaid pays second for care that Medicare and Medicaid both cover. Medicaid may cover additional services that Medicare may not or only partially covers—like long- term care services and supports. NOTE: For more information, review the “Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs” factsheet (ICN February 2017) available at CMS.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.p df, and visit Medicare.gov/your-medicare-costs/help-paying- costs/medicaid/medicaid.html. July 2018 Medicaid and the Children's Health Insurance Program

Medicare Savings Programs (MSPs)
MSPs are categorized into groups: Qualified Medicare Beneficiary* (QMB) Specified Low-Income Medicare Beneficiary* (SLMB) Qualified Individuals* (QI) Qualified Disabled and Working Individuals (QDWI) *Automatically qualify for Extra Help for Part D You can get help from your state Medicaid program to pay your Medicare premiums. In some cases, MSPs may also pay Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments if you meet certain conditions. There are 4 kinds of MSPs: Qualified Medicare Beneficiaries (QMB) get some help from Medicaid to pay their Medicare premiums up to an amount set by their state. NOTE: Federal law bars Medicare and Medicare Advantage (MA) providers from balance billing a QMB beneficiary under any circumstance. Providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. However, as permitted by Federal law, States can limit Medicare cost-sharing payments, under certain circumstances. Regardless, persons enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. Specified Low-Income Medicare Beneficiaries (SLMB), Qualified Individuals (QI), and Qualified Disabled and Working Individuals (QDWI) get some help from Medicaid to pay Medicare premiums only. If you qualify for QMB, SLMB, or QI you automatically get Extra Help paying for Medicare prescription drug coverage. NOTE: Federal law bars Medicare and Medicare Advantage (MA) providers from balance billing a QMB beneficiary under any circumstances. July 2018 Medicaid and the Children's Health Insurance Program

CLAIM Money Tips Sheet Extra Help from Social Security Single $1,581
Program Monthly Income Resources What it pays for How to Apply Extra Help from Social Security Single $1,581 Couple $2,134 $14,390 $28,720 Reduces Part D premiums, deductibles, copays and eliminates the coverage gap based on income and resource level Complete On Line Form at or Submit Paper Application Qualifying Individual- 1 (QI-1) (Subject to Federal Funding) $1,426 $1,923 $7,730 $11,600 Medicare Part B premium You are auto enrolled in Part D Extra Help, which lowers the cost of premiums, deductibles, copays, coinsurance, and eliminates coverage gaps. Local Department of Family Support Office Download form: MO HealthNet Application Specified Low-Income Medicare Beneficiary (SLMB) $1,269 $1,711 Qualified Medicare Beneficiary (QMB) $1,061 $1,430 Medicare Part A premiums, if applicable Medicare Part B premiums Co-insurance and deductibles for Parts A & B Cost-sharing for Medicare Advantage MO HealthNet $905 $1,218 $3,000* $6,000* May apply for QMB July 2018 Medicaid and the Children's Health Insurance Program

LIS – Limited Income Sources
Extra Help through Social Security Administration May qualify for zero premium for Part D Drug Plan Reduced co-payments/co-insurance Qualify for continuous open enrollment to change plans Eligibility and level of help determined by income and resources Application available through Social Security or CLAIM Online at July 2018 Medicaid and the Children's Health Insurance Program

LIS – Extra Help Part D Low-Income Subsidy (LIS) through Social Security * Increases by number of dependents based on FPL LIS Numbers effective January 2019 Single Couple Federal Poverty Levels (Income maximums or below) Name Brand Co-Pay Generic Co-Pay Annual Income * Asset Limit 150% of poverty 1, 2, 6,7 15% 2 $18,975 $14,390 $25,605 $28,720 135% of poverty 1, 2, 4, 5, 6,7 $8.50 2 $3.40 2 17,102 $9,230 $23,069 $14,600 100% of poverty 1, 2, 4, 5, 6,7 $3.80 2 $1.25 2 $12,490 $16,910 Supplemental Security Income (SSI) Individual Couple SSI 3, 4, 5 $9260/year ($771/mo) $13,888/year ($1,157 /mo) Resource Limits $2,000 $3,000 QMB, SLMB, QI-1, MO HealthNet, and LIS numbers also include the $20/mo income disregard. In ALL states, the first $65 of monthly wages (earned income) and one-half of monthly wages (after the $65 is deducted) will never be counted for the Medicare Savings Programs (QMB, SLMB & QI-1) or SSA Extra Help. July 2018 Medicaid and the Children's Health Insurance Program

Medicare Savings Programs
Federal and State funding through MO HealthNet to assist with: Medicare premiums Deductibles and coinsurance (QMB only) Auto enrolled in Part D Extra Help Income and resources determines assistance- QMB SLMB Qualifying Individual Enrollment - Missouri Family Support Division

Missouri RX Missouri’s State Pharmacy Assistance Program (SPAP) Pays 50% of the beneficiary cost sharing at all coverage levels of Part D coverage Does not pay Plan premiums Federally accepted plan Payments count toward Part D plan out of pocket maximums July 2018 Medicaid and the Children's Health Insurance Program

Missouri RX Be enrolled in a Medicare Part D Plan Meet income and asset requirements (Dual eligible, or in a MSP) Be a Missouri resident Provide a copy of: Medicare Card Social Security Card Plan benefit requirements: A Missouri Pharmacy A 30/31 day supply Medication must be formulary on the plan or have a coverage exception. MORX is not accepted at all pharmacies. July 2018 Medicaid and the Children's Health Insurance Program

SNP Plans – Medicare Plan Finder
July 2018 Medicaid and the Children's Health Insurance Program

Questions??? July 2018 Medicaid and the Children's Health Insurance Program

Acronyms BHP Basic Health Program CHIP Children’s Health Insurance Program CMS Centers for Medicare & Medicaid Services ESRD End-Stage Renal Disease FMAP Federal Medical Assistance Percentage FPL Federal Poverty Level HCBS Home and Community- Based Services MAGI Modified Adjusted Gross Income MSP Medicare Savings Program NTP National Training Program QDWI Qualified Disabled and Working Individual QHP Qualified Health Plans QI Qualified Individual QMB Qualified Medicare Beneficiary SLMB Specified Low-Income Medicare Beneficiary SSA Social Security July 2018 Medicaid and the Children's Health Insurance Program

Missouri HealthNet and Medicare Savings Programs

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