AGENDA

1
AGENDA

• Tools with case studies
• Touch the other Topic Packets
• Questions taken at any time

2
Minnesota Children with Special Health Needs
(MCSHN)

• Map of District Consultants p. 6
• Programs and Services p.7

3
TOOLS

• beginning on p. 151

4

• Possible Funding Ideas Cash p. 152
• Free or Low Cost Health/Dental Care Resources
  p.153
• Possible Funding Ideas Health Coverage p.155

5
Case study 1- Barbara

• Mother of 3 children (age 18 months, 8 years, 19
  years)
• 18 mo. old has spina bifida 8 year old has
  asthma
• Mom makes 19,000 per year, including little or
  no child support
• What about assets?
• What about divorce custody?

6
FUNDING FLOW CHART
Documented Citizen?
No
See Noncitizen Flow Chart
Yes

• Doors into MA?
• Basis of Eligibility ex Family Size
  Income
• Eligibility with a Spenddown
• On SSI
• Over MA income, but is Certified Disabled
  MA-TEFRA
• MA-EPD
• On SSI

MA
Yes
Need services above and beyond what is covered by
regular MA? (must meet disability and level of
care criteria)
No
Eligible for MinnesotaCare (MCRE)?
No
Yes
Eligible for GAMC ? NOTE GAMC program ends
3-1-10
HCBS (Home Community Based Services) -
Waivers Note May also be eligible for SSI or
SSDI
No
Eligible for Transitional MinnesotaCare?
See Other Resources Handout
7
Doors into MA Family Size Income Different
income guideline based on who you are in the
family
Pregnant women Up to age 2yr 2
through18yr 19 and 20yr Parents Elderly,
Blind or Disabled
8
Case study 2 Blended Families

• Mom brings 3 of her biological children to the
  family. Mom makes 32,000/yr.
• Stepfather brings his 1 biological child to the
  family. He makes 30,000/yr.
• What if Mom Stepfather become pregnant?
• Would the new infant be covered?

9
Doors into MA
Spenddown
10
Case Study 3 Olivia

• Mom Dad have 1 child (age 6 yr).
• Family income is 28,400.
• Last month Olivia was in the ER for diabetes and
  was hospitalized for 3 days. The bill was over
  5,000.
• Mom has insurance through work, but has a 5,000
  deductible per person per year

11
Door in MA - Spend downFamily Income
SPENDDOWN (all familys unpaid Medical/Dental
bills, /or Insurance Premiums - last 3 months)
MA Income
12
Doors into MA

• Disability
• MA-TEFRA (no parent income)
• MA-EPD (working)

13
Case Study 4 Sydney

• Sydney is 11 and lives with his mother.
• He has autism, is very active, likes to run
  outside and has with little sense of danger. He
  also has a heart condition
• Mom is has a self-employed business, making
  53,000/year gross income.
• Mom has 2 cars, a motorcycle and a time-share
  condo in Florida.
• Mom has private health insurance and high
  deductible and co-pays.

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Estimating total out-of-pocket costs with and
without TEFRA
15
Doors into MA
Preg. women Up to age 2y 2-18yr
19-20yr Parents Blind or disabled
Eligibility with a spendown
On SSI
MA-TEFRA
MA-EPD
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Case study 5 MaryAnn

• MaryAnn is 20, has cerebral palsy and seizures.
  She has been certified disabled. She lives with
  her boyfriend.
• She works part time at a local bookstore and
  makes 24,000. She has some insurance through
  her employer, but has large co-pays and
  deductibles.

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FUNDING FLOW CHART
Documented Citizen?
No
See Noncitizen Flow Chart
Yes

• Doors into MA?
• Basis of Eligibility ex Family Size
  Income
• Eligibility with a Spenddown
• On SSI
• Over MA income, but is Certified Disabled
  MA-TEFRA
• MA-EPD
• On SSI

MA
Yes
Need services above and beyond what is covered by
regular MA? (must meet disability and level of
care criteria)
No
Eligible for MinnesotaCare (MCRE)?
No
Yes
Eligible for GAMC ? NOTE GAMC program ends
3-1-10
HCBS (Home Community Based Services) -
Waivers Note May also be eligible for SSI or
SSDI
No
Eligible for Transitional MinnesotaCare?
See Other Resources Handout
18
Case Study 6 Joseph

• Joseph is 9 and has been diagnosed with FAS, ADHD
  and O.D.D.
• School testing has shown a Full Scale IQ of 68.
  He is not toilet trained and has significant self
  care needs. He sleeps very little at night. He
  has self-injurious behaviors and constant
  supervision.
• He is on MA and has PCA services. The family
  needs respite care and wonders if they can
  continue to care for him even with PCA help.

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Dept. of Human Services (DHS)

• Program Information (cash, food medical
  programs) p.13
• Minnesota Health Care Programs p.17
• Authorization p.21
• Home Care Services p.23

20
DHS

• TEFRA p.31
• TEFRA Required Documentation
• Physical p. 35
• Developmental p.36
• Mental Health p.37
• Parental Fees p.39

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DHS

• MA-EPD p.43
• Home Community Based Services (waivers)
  p.45
• Family Support Grant p.53
• Consumer Support Grant p.54
• Chemical Health p.55
• Answers to Grandparents Questions p.59

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FUNDING FLOW CHART
Documented Citizen?
No
See Noncitizen Flow Chart
Yes

• Doors into MA?
• Basis of Eligibility ex Family Size
  Income
• Eligibility with a Spenddown
• On SSI
• Over MA income, but is Certified Disabled
  MA-TEFRA
• MA-EPD
• On SSI

MA
Yes
Need services above and beyond what is covered by
regular MA? (must meet disability and level of
care criteria)
No
Eligible for MinnesotaCare (MCRE)?
No
Yes
Eligible for GAMC ? NOTE GAMC program ends
3-1-10
HCBS (Home Community Based Services) -
Waivers Note May also be eligible for SSI or
SSDI
No
Eligible for Transitional MinnesotaCare?
See Other Resources Handout
23
Case Study 7 - Jacob

• Robin (age 23) and Mark (age 22) live with their
  son, Jacob (age 3).
• Robin and Mark are not married. Paternity has
  been legally acknowledged.
• Robin and Mark both have been only able to find
  part time work and neither are offered health
  insurance through work.
• Robin makes 10,500 per year. Mark makes 16,000
  per year.

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Non-citizen Information

• Table p.160
• MHCP p.161
• Definitions p.162

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Case Study 8 Miguel and Sondra

• Laris lives with her 2 minor children, (Miguel
  and Sondra) and her friend Tim, who is not the
  childrens father.
• Laris and both of her minor children are
  undocumented citizens. Tim is a US citizen.
• There are health concerns for both Miguel and
  Sondra Miguel has untreated ear infections and
  Sondra has severe dental caries.

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Cultural Resources

• Multicultural Resources p. 83
• Public Benefits for Non-Citizens
• p. 87

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Medical Funding Summary

• MA p.167
• TEFRA-MA see replacement page
• MA-EPD see replacementpage
• MinnesotaCare (MCRE) p.169
• HCBS (Waivers) see replacement page
• GAMC p.171
• Transitional MCRE see new page
• EMA / RMA / NM see replacement page

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Covered Services p.173
29
Covered Equipment and Supplies p.178
Non-Covered Services, Equipment and Supplies p.
179
30
Insurance (Non-public) p.203 ? Coverage
of dependentsMinnesota Comprehensive Health
Association (MCHA) p.204
31
Social Security Administration (SSA) Overview

• B.E.S.T. p.181
• Work Incentive Programs p.182
• RedBook p.183
• Social Security Disability Insurance (SSDI)
  p.183
• Supplemental Security Income (SSI) see
  replacement page

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Case Study 9 - Sally

• Age 14 and living with 2 parents. She has 2
  younger brothers.
• Sally has been diagnosed with major depression
  and has been hospitalized for suicidal attempts.
• Both parents work, and family (gross) earned
  income is 3,600/month Family is below SSI asset
  guidelines

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Childrens Mental Health

• Behavioral Mental Health Concerns p.63
• Childrens Mental Health Services p.67
• Financial Resources p.75
• Respite Care p.77
• Minnesota Mental Health Resources
• p.79

34
SSI (Supplemental Security Income) - Income
Guidelines p.185
35
SSI Medical Evaluation Guidelines
p.187 A summary of childrens (under age
18yr) disability guidelines - Bluebook Part
B.Adult (Part A) not included in this
training. For complete adult and child
disability criteria go on the SSA
Websitewww.socialsecurity.gov/disability/profess
ionals/bluebook
36
Appeals

• Welfare Appeals p.95
• PCA Appeals p.97
• Strategy for Appealing Health Plan Decisions
  p.103
• Sample Appeals Letter p.104
• Appeal Options for Persons Covered by Health
  Plans p.105

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Appeals

• Self-Insured / Self-Funded Health Plan Complaints
  p.107
• Resources for Letters of Medical Necessity and
  Appeals p.109
• SSI Appeals p.111
• SSI Overpayment p.112

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School

• Additional School Resources p.116
• 504 Plans p.117
• Individual Education Plan (IEP) Services- DHS
  p.119
• Third Party Billing p.125

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Transition

• Things You Need to Know About Transition p.131
• Ready to Manage Your Own Health Care p.141
• Suggested Skills for Transition p.143
• SILS Program p.147
• Accommodations Categories Chart p.148
• Transition Resources p.149

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Case Study 10 Anne, Sara Rose

• Anne lives with her unmarried 17 yr. old
  daughter, Sara and Saras 1 yr. old daughter
  Rose.
• Sara has a part-time job on weekends, making
  100/week. Total household income (including
  Sara and Annes) is 40,000.
• No one in the household has other insurance or
  access to ESI.

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Is a US Citizen
Not eligible for MA
Not eligible for MinnesotaCare
Not eligible for GAMC (only for adults over age
21)
See Other Resources Handout p.205
No
42
Case Study 11Bob, Grace, Linda, Rachel Justin

• Bob and Grace live with their 19 yr. old daughter
  Linda, her 3 yr. old daughter Rachel, and
  Rachels father Justin.
• The total family income, including Bob Grace,
  is 70,000.
• Bob and Grace have health insurance through their
  employers. Bobs employer does not offer family
  coverage. Graces employer offers family
  coverage, but the employer does not pay any of
  the monthly premium cost for the family portion.

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Case Study 12 3 generations

• The household consists of 19 yr. old mother
  (Dani) her 3 mo. old daughter (Caroline) her 2
  yr. old daughter (Olivia), her boyfriend (John,
  age 21, the biological father of Caroline
  Olivia) Joyce (Carolines paternal grandmo) Joe
  (step grandfa) Mary (Joyces 15 yr. old
  daughter).
• Caroline has a chromosomal abnormality. She has a
  trach and GTube. Caroline is on MA.
• Dani had to quit her job due to Carolines
  medical needs she couldnt afford COBRA
  insurance. Dani has no insurance coverage.
• John works road construction in the summer. He
  makes 52,000yr. (road construction in summer
  unemployment in winter)
• Joyce and Joe both work at a small book store,
  making 25,000/year each. They are not offered
  health insurance.
• Dani would like to move out live on her own
  with Caroline, Olivia and John.

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Start with MA (Household composition looked at
individually)

• Caroline (age 3 mo.) already on MA (her family
  size is 4 herself, sister (Olivia) biological
  parents (Dani John)
• Olivia (age 2yr) Family size of 4 (herself,
  sister (Caroline) biological parents (Dani
  John). Dani Johns income would be counted.
• Mary (age 15yr) Family size of 2 (herself her
  biological mom (Joyce). John is age 21 so isnt
  counted in Marys family size. Only Joyces
  income is counted (not stepfather, Joe)
• Dani (age 19 yr) Family size of 3 (herself
  her 2 children, Caroline Olivia. John isnt
  counted in Danis family size because they arent
  married. Dani has currently no income.
• John (age 21yr) Family size of 3 (himself,
  Caroline Olivia). Joyces income wouldnt be
  counted because he is age 21.
• Joyce - Family size of 3 (herself, Mary Joe),
  both Joe Marys income would be counted.
• MINNESOTACARE Uses total household size
  income (3rd generation exception) . John is
  over-income (makes more than 50,000/yr.). Joyce
  Joe would count everyone in their total
  household size total household income over
  income.

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Please fill out the purple evaluation form.

• Thank you.