Indiana Health Coverage Programs

1
Indiana Health Coverage Programs
2
Learning Objectives

1. Outline the basics of Medicaid and Indiana Health
   Coverage Programs (IHCP)
2. Identify and define eligibility, goals and
   specifics of IHCP programs
3. Discuss the standard elements of Medicaid and
   IHCP Eligibility
4. Examine eligibility notices, appeals and
   redeterminations for Medicaid and IHCP

3
What is Medicaid?

• Enacted in 1965 by Title XIX of the Social
  Security Act
• The federal government matches state spending on
  Medicaid
• In Indiana, Medicaid is called Indiana Health
  Coverage Programs which is administered by the
  Office of Policy Planning (OMPP) and Family and
  Social Services Administration (FSSA)
• Provides free or low-cost health insurance
  coverage to low-income
• Children
• Pregnant women
• Parents and caretakers
• Blind
• Disabled
• Aged
• Income limits are based on the Federal Poverty
  Level (FPL)
• Offers variety of programs with varying criteria

4
Indianas Medicaid

• The Office of Medicaid Policy and Planning (OMPP)
  is responsible for
• Administering Indiana Health Coverage Programs
  (IHCP) at the State level, including the
  following functions
• Medical policy development
• Program and contract compliance
• Contracting with MCEs
• Addressing cost containment issues
• Establishing IHCP policies
• Program reimbursement
• Program integrity, including claims analysis and
  recovery

5
Indianas Medicaid

• The Department of Family Resources (DFR) is the
  division of FSSA responsible for processing
  applications and making eligibility decisions.
• The County Offices of the DFR administer IHCP at
  the local level
• Online applications for Medicaid are located on
  the DFRs Benefit Portal

6
New Eligibility Groups

• As of January 1, 2014, the states must
  cover
• Former foster children
• Under age 26
• Receiving Indiana Medicaid when aged
  out
  of the system
• Not subject to income limits until age 26
• Children age 6-18
• Up to 133 FPL
• Pregnant Women
• Verification of pregnancy no longer required for
  Medicaid application
• Counted as 2 people
• Coverage continues 60 days postpartum

7
What are the Indiana Health Coverage Programs?

• Hoosier Healthwise (HHW)
• Healthy Indiana Plan (HIP)
• Care Select
• Traditional Medicaid
• Medicaid for Employees with Disabilities (M.E.D.
  Works)
• Home and Community-Based Service Waivers (HCBS
  Waivers)
• Medicare Savings Program
• Family Planning Services
• Spend-DownEliminated June 1, 2014
• Breast and Cervical Cancer Programs

8
What are Federal Poverty Guidelines (FPL)?

• Also known as Federal Poverty Level (FPL)
• Issued each year by the Department of Health and
  Human Services (HHS)
• Measure of pre-tax income used to determine what
  is considered poverty in the United States
• It is also used to determine eligibility for IHCP
  and coverage through the federal Marketplace
• Anyone living at 100 or below the FPL is
  considered living in poverty
• In 2014, an individual with a pre-tax income of
  11,670 or less is living in poverty, and so is a
  family of 4 with pre-tax income at or below
  23,850.

9
What are Federal Poverty Guidelines (FPL)?
2014 FPL for the 48 Contiguous States and the
District of Columbia
 House-hold Size  100   133  150 200 250  300 400
 1 11,670 15,521 17,505 23,340 29,175 35,010 46,680
 2 15,730  20,921 23,595   31,460 39,325 47,190 62,920
 3 19,790  26,321 29,685   39,580 49,475 59,370 79,160
 4 23,850  31,721 35,775   47,700 59,625 71,550 95,400
 5 27,910  37,120 41,865   55,820 69,775 83,730 111,640
 6 31,970  42,520 47,955   63,940 79,925 95,910 127,880
 7 36,030  47,920 54,045   72,060 90,075 108,090 144,120
 8 40,090  53,320 60,135 80,180 100,225 120,270 160,360
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Hoosier Healthwise
GOALS ELIGIBILITY SPECIFICS
Provide health care coverage for low-income parents/caretakers, pregnant women and children at little or no cost Children up to age 19 Pregnant women Low income parents/caretakers of children under age of 18 Offers different benefit packages State determines eligibility and coverage Member selects MCE and PMP

• Enrollees excluded from mandatory enrollment in
  Hoosier Healthwise include
• Individuals in nursing homes and other long-term
  care institutions
• Undocumented individuals who are eligible only
  for emergency services (Package E)
• Individuals receiving hospice or home and
  community-based waiver services
• Individuals enrolled in Medicaid on the basis of
  age, blindness or disability
• Wards of the court and foster children

11
Hoosier Healthwise
HHW PACKAGE DESCRIPTION
AStandard Full-service plan for children, pregnant women and families No premiums
C Childrens Health Insurance Program (CHIP) Full service plan for children only (under age 19) Small monthly premium payment co-pay for some services based on income
PPresumptive Eligibility Ambulatory prenatal coverage for pregnant women who are determined presumptively eligible while their Indiana Application for Health Coverage is being processed
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Services Available under Hoosier
Healthwise
Medicaid provides coverage for the following

• Medical care
• Hospital care
• Physician office visits
• Check-ups
• Well-child visits
• Clinic services
• Prescription drugs
• Over the counter drugs
• Lab X-Rays
• Mental health care

• Substance abuse services
• Home health care
• Nursing facility services
• Dental
• Vision
• Therapies
• Hospice
• Transportation
• Family planning
• Foot care
• Chiropractors

13
Hoosier Healthwise
Monthly Income Limits
Family Size Parents Caretaker Relatives Children Pregnant Women
1 n/a 2,432 n/a
2 247 3,278 2,727
3 310 4,123 3,431
4 373 4,969 4,134
5 435 5,815 4,838
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Childrens Health Insurance Program (CHIP)

• Child cannot be covered by other comprehensive
  health insurance
• Individuals in CHIP are responsible for monthly
  premiums and must pay the first premium prior to
  coverage becoming effectuated (There is a 60-day
  grace period)
• A child whose coverage was dropped voluntarily
  may not receive CHIP coverage for 90 days
  following the month of termination with some
  exceptions

Family FPL Monthly Premium for 1 Child Monthly Premium for 2 or More Children
158 up to 175 22 33
175 up to 200 33 50
200 up to 225 42 53
225 up to 250 53 70
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Healthy Indiana Plan (HIP)
GOALS ELIGIBILITY SPECIFICS
Reduce the number of uninsured, low-income Hoosiers Reduce barriers and improve statewide access to health care services Promote value-based decision making and personal health responsibility Promote primary prevention Prevent chronic disease progression with secondary prevention Provide appropriate and quality-based health care services Assure State fiscal responsibility and efficient management of the program Hoosier adults between the ages of 19-64 Household income at or less than the FPL Not otherwise eligible for Medicaid Provides full health benefits including free preventative services (500), hospital services, mental health care, physician services, prescriptions and diagnostic exams Does not provide vision, dental or maternity services No co-pays except for non-emergency use of a hospital ER Provides a Personal Wellness and Responsibility (POWER) Account valued at 1,100 per adult to pay for medical costs Enrollee contributes 2-5 of gross income Employers and non-profits can contribute
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Healthy Indiana Plan (HIP)

• HIP provides a basic commercial benefits package.
  Covered services include
• Physician services
• Prescriptions
• Diagnostic exams
• Home health services
• Outpatient, inpatient hospital and hospice
  services
• Preventive services
• Family planning
• Case disease management
• Mental health coverage
• Vision, dental and maternity services are not
  currently
  covered by HIP

17
Healthy Indiana Plan (HIP) Enrollment

• Individuals who fail to make their monthly POWER
  Account contribution after a 60-day grace period
  are disenrolled for 12 months.
• If individuals fail to complete their annual
  redetermination, then they
  will be disenrolled from the program.

Family Size Monthly Income Threshold
1 973
2 1,311
3 1,649
4 1,988
5 2,326
6 2,665
7 3,003
8 3,441
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Healthy Indiana Plan (HIP) Key Dates

• In September 2013, the State received
  authorization from CMS to continue the HIP
  program for one year (through December 31, 2014).
  
• Due to problems with the roll-out of the federal
  marketplace, HIP eligibility was extended to
  those over 100 FPL (including the 5 disregard)
  through April 2014 to allow for transition to the
  Marketplace.
• On May 15, 2014, Indiana Governor Mike Pence
  announced a plan to expand HIP from 100 to 138
  of the FPL.
• As of July 2014, Indiana has submitted the HIP
  2.0 waiver application to CMS for approval

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Managed Care Entities (MCEs)

• MCEs provide the following services and functions
  to Hoosier Healthwise HIP enrollees
• Case management and disease management
• Member services helpline
• Screening enrollees for special health care needs
• 24-hour Nurse Call Line
• Managing grievances and appeals
• Provide member handbooks
• Hoosier Healthwise HIP enrollees select one of
  the three MCEs (Anthem, MDWise, MHS), or they are
  auto-assigned 14 days after enrollment

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Managed Care Entities (MCEs)

• Some factors for beneficiaries to consider when
  selecting an MCE include the following
• Provider network
• Is the individuals doctor available in the MCE
  network?
• Are the locations of network providers easily
  accessible for the enrollee?
• Are the locations convenient to the individuals
  work, home or school?
• Special programs enhanced services
• Is there a service or program offered by the MCE
  that is particularly important or attractive to
  the enrollee?

21
Managed Care Entities (MCEs)

• HIP enrollees can change MCE
• In the first 60 days or until they make the first
  POWER Account contribution
• Annually at eligibility redetermination
• Anytime there is a just cause as outlined for
  Hoosier Healthwise enrollees

• Hoosier Healthwise enrollees can change MCE
• Anytime during the first 90 days with a health
  plan
• Annually during an open enrollment period
• Anytime when there is a just cause
• Lack of access to medically necessary services
  covered under the MCEs contract with State
• The MCE does not, for moral or religious
  objections, cover the service the enrollee seeks
• Lack of access to experienced providers
• Poor quality of care
• Enrollee needs related services performed that
  are not all available under the MCE network

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Managed Care Entities (MCEs)
MCE MEMBER SERVICES WEBSITE
1-866-408-6131 WWW.ANTHEM.COM
1-800-356-1204 WWW.MDWISE.ORG
1-800-647-4848 WWW.MHSINDIANA.COM
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Primary Medical Providers

• Once a beneficiary is enrolled in an MCE, he or
  she also selects a Primary Medical Provider
  (PMP).
• Enrollees must see their PMP for all medical
  care
• If specialty services are required the PMP will
  provide a referral.
• Provider types eligible to serve as a PMP include
  Indiana Health Coverage Program enrolled
  providers with the
  following specialties
• Family practice
• General practice
• Internal medicine
• Obstetrics (OB)/Gynecology (GYN )
• General pediatrics

24
Care Select
Care Select will phase-out January 1, 2015 due to
a new coordinated care program
GOALS ELIGIBLITY SPECIFICS
Promotion of preventative care Promotion of treatment regimens for chronic illnesses to better conform evidence-based practices Promotion of less fragmented and more holistic care Aged, blind, disabled, a ward of the court or foster child, or a child receiving adoptive services or adoption assistance MUST have one of the following Asthma, Diabetes, Congestive, Heart Failure Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hypertension, Severe Mental Illness, Serious Emotional Disturbance (SED) Depression, Chronic Kidney Disease w/o dialysis, co-morbidity of diabetes and hypertension or other combinations, or other approved serious or chronic conditions Enrollees select or are assigned to Care Management Organization (CMO) (oversees coordinates care) Primary Medical Provider (PMP) (provides care referrals)
25
Care Select

• Individuals do not specifically apply for Care
  Select.
• Medicaid enrollees in an eligible aid category
  with one of the qualifying conditions, as
  evidenced by claims history or their medical
  provider contacting the Enrollment Broker at
  1-866-963-7383, have the option to participate
• Care Select enrollees choose or are assigned to
  both a Care Management Organization (CMO) and PMP
  (Primary Medical Provider).
• Member services contact information for the
  States two CMOs is as follows

Care Management Organization Phone Number Website
Advantage 1-800-784-3981 www.advantageplan.com
MDwise 1-800-356-1204 http//www.mdwise.org/for-members/indiana-care-select
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Traditional Medicaid (Fee-for-Service)

• The following individuals who meet income and
  resource requirements are eligible
• Blind, Disabled, and Aged persons
• Persons in nursing homes other long-term care
  institutions
• Undocumented aliens who do not meet a specified
  qualified status lawful permanent residents who
  have lived in the USA less than five years or
  those whose alien status remains unverified
  receiving Emergency Services only
• Persons receiving home and community-based waiver
  or hospice services
• Dual eligibles (individuals receiving Medicaid
  Medicare)
• Persons eligible on the basis of having breast or
  cervical cancer
• Refugees who do not qualify for another aid
  category
• Former Independent Foster Children up to age 18,
  IV-E Foster Care Children, IV-E Adoption
  Assistance Children, and Former foster children
  under the age of 26 who were enrolled in Indiana
  Medicaid as of their 18th birthday

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Traditional Medicaid (Fee-for-Service)

• In Traditional Medicaid, beneficiaries are not
  enrolled in a Managed Care Entity (MCE) or Care
  Management Organization (CMO) and can see any
  Indiana Health Coverage Program enrolled
  provider.
• All provider claims are paid fee-for-service by
  the States Fiscal Agent, Hewlett-Packard.

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Traditional Medicaid (Fee-for-Service)
BENEFIT PACKAGE DESCRIPTION
Standard Plan Full Medicaid coverage
Medicare Savings Program QMB Medicare Part A B premiums, deductibles, coinsurance SLMB/QI Medicare Part B premiums QDWI Medicare Part A premiums
Package E Emergency Services only for certain immigrants who do not qualify for full Medicaid coverage
Family Planning Family planning services only
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M.E.D. Works
GOALS ELIGIBILITY SPECIFICS
Provide full Medicaid for working people with disabilities Ages 16-64 Fall below 350 FPL Disabled according to Indianas definition of disability Not exceed asset limit (Single 2,000 or Couple 3,000) Be working (there is no minimum work effort for program) Full Medicaid benefits Members pay small monthly premium based on income Individual only program Members can put up to 20,000 in Savings for Independence and Self-Sufficiency Account Members can have employer insurance
30
M.E.D. Works

• Enrollees are responsible for monthly premiums
  based on income of the applicant and spouse

  Monthly Income Premium
Single 1,459 - 1,702 48
Single 1,703 1,945 69
Single 1,946 - 2,432 107
Single 2,433 - 2,918 134
Single 2,919 - 3,404 161
Single 3,405 187
Married 1,967 - 2,294 65
Married 2,295 - 2,622 93
Married 2,623 - 3,278 145
Married 3,279 - 3,933 182
Married 3,934 - 4,588 218
  4,589 254
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590 Program

• Provides coverage for residents of state-owned
  facilities
• Does not cover incarcerated individuals residing
  in Department of Corrections (DOC) facilities
• Eligible for Package A benefits with the
  exception of transportation

32
Home and Community Based Waivers (HCBS)
WAIVER ELIGIBILITY SPECIFICS
Aged and Disabled Income Up to 300 Supplemental Security Income (SSI) benefit Parental income resources disregarded for children under 18 Meets Level of Care Would otherwise be place in institution such as nursing home without waiver or other home-based services Complex medical condition which required direct assistance
Traumatic Brain Injury Income Up to 300 Supplemental Security Income (SSI) benefit Parental income resources disregarded for children under 18 Meets Level of Care Would otherwise be place in institution such as nursing home without waiver or other home-based services Diagnosis of Traumatic Brain Injury
Community Integration Habilitation Income Up to 300 Supplemental Security Income (SSI) benefit Parental income resources disregarded for children under 18 Meets Level of Care Would otherwise be place in institution such as nursing home without waiver or other home-based services Diagnosis of intellectual disability which originates before age 22 Individual requires 24 hours supervision
Family Supports Income Up to 300 Supplemental Security Income (SSI) benefit Parental income resources disregarded for children under 18 Meets Level of Care Would otherwise be place in institution such as nursing home without waiver or other home-based services Diagnosis of intellectual disability which originates before age 22 Individual requires 24 hours supervision
33
Home and Community Based Waivers (HCBS)

• To apply for the Aged and Disabled waiver or the
  Traumatic Brain Injury Waiver, individuals can go
  the local Area Agencies on Aging (AAA) or call
  1-800-986-3505 for more information.
• To apply for the Community Integration
  Habilitation or Family Supports waiver,
  individuals can go the local Bureau of
  Developmental Disabilities Services (BDDS) office
  or call 1-800-545-7763 for more information.
• There are currently waiting lists for the Family
  Supports waiver and the Traumatic Brain Injury
  waiver.

34
Behavioral and Primary Healthcare Coordination
Program (BPHC)

• Assists individuals with serious mental illness
  (SMI) who otherwise wont qualify for Medicaid or
  other third party reimbursement
• Individuals meet the following eligibility
  criteria
• Age 19
• MRO-eligible primary mental health diagnosis
  (e.g. schizophrenia, bipolar disorder, major
  depressive disorder)
• Demonstrated need related to management of
  behavioral and physical health and need for
  assistance in coordinating physical and
  behavioral healthcare
• ANSA Level of Need 3
• Income below 300 FPL
• Single 2,918/month
• Married 3,933/month

35
Behavioral and Primary Healthcare Coordination
Program (BPHC)

• Individuals may apply for the BPHC program
  through a Community Mental Health Center (CMHC)
  approved by the FSSA Division of Mental Health
  and Addiction (DMHA) as a BPHC provider.
• A list of approved CMHCs can be found at
  http//www.indianamedicaid.com/ihcp/ProviderServic
  es/ProviderSearch.aspx.

36
Medicare Savings Program

• Covers low-income Medicare beneficiaries
• Helps pay for out-of-pocket Medicare costs.
• Individuals must be eligible for Medicare Part A

Program Income Threshold Resource Limit Benefits
Qualified Medicare Beneficiary (QMB) 100 FPL Single 7,080 Couple 10,620 Medicare Part A B Premiums Co-pays, deductibles, coinsurance
(Specified Low Income) SLMB 120 FPL Single 7,080 Couple 10,620 Part B Premiums
Qualified Individual (QI) 135 FPL Single 7,080 Couple 10,620 Part B Premiums
Qualified Disabled Worker (QDW) 200 FPL Single 7,080 Couple 10,620 Part A Premiums
37
Family Planning Program
GOALS ELIGIBILITY SPECIFICS
Prevent or delay pregnancy Provide family planning services and supplies Does not qualify for any other category of Medicaid Meets citizenship or immigration status requirements Not pregnant Have not had hysterectomy or sterilization Have income at or below 141 FPL Includes, but not limited to Annual family planning visits Pap smears Tubal ligation Vasectomies Hysteroscopic sterilization with an implant device Laboratory tests, if medically indicated as part of the decision-making process regarding contraceptive methods FDA approved anti-infective agents for initial treatment of STD/STI
38
Family Planning Program

• Services not covered
• Abortions
• Artificial insemination
• IVF, fertility counseling or fertility drugs
• Inpatient hospital stays
• Treatment for any chronic condition
• Individuals must request to be considered for
  this program on their Indiana Application for
  Health Coverage if not eligible for full Medicaid
  benefits

39
Breast and Cervical Cancer Program (BCCP)
GOALS ELIGIBILITY SPECIFICS
Provide Medicaid coverage to women diagnosed with breast and cervical cancer diagnosed through the Indiana State Department of Health (ISDH) ISDH diagnosis OR Age 19-64 Need treatment for breast or cervical cancer Not eligible for Medicaid under any other program No health insurance to cover treatment Uninsured or underinsured Indiana residents below 200 FPL (age 40) may qualify for free breast and cervical cancer screenings and tests
Age Eligible Services
40-49 Free office visit Pap test
50-64 Free office visit, Pap test, and mammogram
65 and older Free office visit, Pap test, and mammogram only if not enrolled in Medicare
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Presumptive Eligibility (PE)

• Allows individuals meeting eligibility
  requirements access to services covered and paid
  for by Medicaid as they wait for their
  application determination for full Medicaid
• Entails a simplified application process
• Applicant must know gross family income
  citizenship status
• Verification documents not requiredapplicant
  attests to information

41
Presumptive Eligibility (PE)

• The PE period extends from the date an individual
  is determined presumptively eligible until
• When an Indiana Application for Health Coverage
  is filed
• Day on which a decision is made on that
  application
• When an Indiana Application for Health Coverage
  is not filed
• Last day of the month following the month in
  which the PE determination was made

42
Presumptive Eligibility for Pregnant Women
GOALS ELIGIBILITY SPECIFICS
Temporary coverage of prenatal care services while Medicaid applications are pending Ensure timely access to critical prenatal care Not currently receiving Medicaid Pregnant Indiana resident US citizen (or qualified immigrant) Family income less than 208 FPL One PE period per pregnancy Includes doctor visits, tests, lab work, dental care, prescription drugs and other care for pregnancy Does not pay for hospital stays, hospice, long term care, abortion, postpartum services, labor and deliver, or services unrelated to pregnancy
43
Qualified Providers

• Qualified providers (QPs) make PE determinations
  in accordance with Indiana eligibility policy and
  procedures.
• QPs must meet the following criteria
• Be enrolled as an Indiana Health Coverage Program
  (IHCP) provider
• Attend a provider training
• Provide outpatient hospital, rural health clinic
  or clinic services
• Be able to access HP Web interchange, internet,
  printer fax machine
• Allow PE applicants to use an office phone to
  facilitate the PE and Hoosier Healthwise
  enrollment process

• May include hospitals, pediatricians,
  family/general practitioner, internist, medical
  clinic, rural health clinic among others

44
Hospital Presumptive Eligibility

• All states are required to permit hospitals that
  meet state requirements to make PE
  determinations.
• In Indiana, the eligibility groups or populations
  for which hospitals will be permitted to
  determine eligibility presumptively are
• Low-income infants and children
• Low-income parents or caretakers
• Former foster care children up to the age of 26
• Low-income pregnant women
• Individuals seeking family planning services only

45
General Medicaid Eligibility and Requirements

• Each Medicaid assistance category has specific
  eligibility requirements such as
• Age
• Income
• Pregnancy status
• Indiana Residency
• Citizenship/Immigration
• Provide Social Security Number
  (SSN)
• Provide information on other insurance coverage
• File for other benefits

46
Requirement Residency

• Applicant must be resident of the state
• State of residency is
• Where individual lives
• Including without a fixed address OR
• Has entered the state with a job commitment OR
  seeking employment
• A homeless individual or residents of shelters in
  Indiana meet this requirement
• There is no minimum time period for state
  residency to be Medicaid eligible
• Individuals are permitted to be temporarily
  absent from the state without losing eligibility

47
Requirement Citizenship/Immigration Status

• Individual must be US citizen, a US non-citizen
  national or an immigrant who is in a qualified
  immigration status
• Lawful permanent residents are eligible for full
  Medicaid after 5 years
• Electronic data sources through the Federal Hub
  verify status
• If not, paper documentation is required, and a
  reasonable opportunity period is granted to
  otherwise Medicaid eligible individuals this
  period lasts 90 days from the date on the
  eligibility notice
• Those exempt from citizenship verification
  process
• Individuals receiving SSI or SSDI
• Individuals enrolled in Medicare
• Individuals in foster care who are assisted
  under Title IV-B
• Individuals who are beneficiaries of foster care
  maintenance or adoption assistance payments under
  Title IV-E
• Newborns born to a Medicaid enrolled mother

48
Medicaid Eligible Immigration Status under Immigration Naturalization Act (INA) Medicaid Eligible Immigration Status under Immigration Naturalization Act (INA)
STATUS ELIGIBILITY
Lawful Permanent Resident Full Medicaid eligible if residing in US prior to 8/22/96 If entered US on or after 8/22/96 eligible for Package E for 5 years full Medicaid after 5 years
Refugees under Section 207 Iraqi Afghani Special Immigrants under Section 101(a)(27) Full Medicaid
Conditional entrants under Section 203(a)(7) prior to April 1, 1980 Full Medicaid
Parolees under Section 212(d)(5) Full Medicaid eligible if granted this status for at least 1 year entered US prior to 8/22/96 If entered US on or after 8/22/96 eligible for Package E
Asylees under Section 208 Full Medicaid
Persons whose deportation is withheld under Section 243(h) Full Medicaid
Amerasians admitted pursuant to Section 584 of P.L. 100-202 amended by P.L. 100-461 Full Medicaid
Cuban Haitian entrants Full Medicaid
Other immigrants, visitor and non-immigrants Eligible for emergency Medicaid only
49
Requirement Provide Social Security Number

• Each Medicaid applicant must supply social
  security number (SSN) with the following
  exceptions
• Individual ineligible to receive SSN
• Individual does not have SSN and may only be
  issued one for a
  valid non-work reasons
• Individual refuses to obtain one due to
  well-established religious objections
• Individual is only eligible for emergency
  services due to immigration status
• Individual is a deemed newborn
• Individual is receiving Refugee Cash Assistance
  and
  is eligible for Medicaid
• Individual has already applied for SSN

50
Requirement File for Other Benefits

• Individuals must apply for all other benefits for
  which they may be eligible as a condition of
  eligibility unless good cause can be show for not
  doing so these include
• Pensions from local, state or federal government
• Retirement benefits
• Disability
• Social Security benefits
• Veterans benefits
• Unemployment compensation benefits
• Military benefits
• Railroad retirement benefits
• Workers Compensation benefits
• Health and accident insurance payments

51
Requirement Report and Use Other Insurance

• Medicaid enrollees can have access to other
  insurance (third liability) however
• Individuals cannot have other insurance and
  enroll in CHIP or HIP
• Applicants must provide information on other
  insurance they have or change in insurance status
  
• Medicaid is the payer of last resort other
  insurance is the primary payer

52
Modified Adjusted Gross Income (MAGI)

• Methodology for income counting and determining
  household size and composition
• Used to determine eligibility for Indiana Health
  Coverage Programs (IHCP) and tax credits on the
  Marketplace

• Not counted toward income
• Assets such as homes, stocks or retirement
  account
• Scholarships, awards or fellowships not used
  toward living expenses
• Income disregards (except tax deductions) and
  non-taxable income
• Child support received, Workers compensation and
  Veterans benefits

53
Modified Adjusted Gross Income (MAGI)
Adjusted Gross Income
Tax Excluded Foreign Earned Income
Tax Exempt Interest
Tax Exempt Title II Security Income
MAGI
54
Modified Adjusted Gross Income (MAGI)

• MAGI does NOT impact
• Aged
• Blind
• Disabled
• Those needing long-term care
• Former foster children under age 26
• Deemed newborns

• MAGI impacts
• New applicants
• Adults
• Parents and Caretaker relatives
• Children
• Pregnant Women

55
Modified Adjusted Gross Income (MAGI)

• 2014 Household Composition Rules
• Household tax filer and all tax dependents
• Married couples living together are included in
  the same household
• Stepparents, stepchildren stepsiblings now
  included in the household
• Income of children siblings who are required to
  file a tax return is counted
• Adult children claimed as a tax dependent are now
  included in the household of the tax filer
• For a pregnant woman under MAGI rules, her unborn
  child(ren) is counted in determining her
  household size

56
Modified Adjusted Gross Income (MAGI)

• MAGI Conversion
• The goal is to establish a MAGI-based income
  standard that is not less than the effective
  income eligibility according to the ACA
• Income disregards are not allowed with the
  exception of a general 5 FPL deduction in
  certain cases
• Steps
• Calculate the average size of the disregards for
  individuals whose net income falls within 25 of
  the FPL below the net income standard
• Add this average disregard amount to the net
  income eligibility standard
• Step 1 Step 2 MAGI eligibility standard for
  the
  eligibility group

57
Indiana Application for Health Coverage

• The Indiana Application for Assistance includes
• SNAP, cash assistance and Health Coverage
• Application methods
• Online (Recommended)
• Telephone
• Fax
• Mail, or
• In Person at Division of Family Resources (DFR)
  office
• Medicaid eligibility determinations are made
  within 45 days or 90 days for determination based
  on disability
• Applicants can check status of online application
  using
• Case number
• Case name
• Date of birth
• Last four digits of SSN

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Authorized Representatives

• Individual or organization which acts on a
  Medicaid applicant or beneficiarys behalf in
  assisting with the application, redetermination
  process and ongoing communications with the state
  
• Commonly a trusted family member, but can also be
  a third party entity
• Designation must be in writing and signed by the
  applicant or beneficiary and the authorized
  representative
• State Form 55366 can be used

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Verifying Factors of Eligibility

• States only permitted to collect paper
  documentation from Medicaid applicants when
  electronic data sources are not available or
  reasonably compatible
• Data sources used to verify
• Social Security Administration
• Department of Homeland Security
• TALX Work Number
• State Wage Information Collection Agency
• State Unemployment Compensation
• Vital Statistics

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Eligibility Notices

• DFR provides written notice, via mail, to
  applications and beneficiaries regarding any
  decision affecting eligibility

• Types of notices include, but not limited to
• Approvals
• Denials
• Terminations
• Suspensions of eligibility
• Changes in benefit package
  or aid category

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Eligibility Notices

• What to expect with eligibility notices
• State sends notice within 24 hours mailing time
  
• Member ID card, referred to as the Hoosier Health
  Card, sent within 5 business days mailing time
• HIP enrollees receive member ID card from their
  MCE
• CHIP M.E.D. Works receive premium invoices
• HIP eligible individuals receive POWER Account
  contribution notices
• Individuals can be determined Medicaid eligible
  for up to 3 months of retroactive eligibility
  from the date of application
• Does not apply to HIP or CHIP

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Eligibility Appeals

• Individuals wishing to challenge disability
  eligibility decisions appeal to the Social
  Security Administration (SSA) or Indiana Medicaid
  depending on the reason for the denial.
• Regarding an SSA disability on file appeal to
  SSA
• Indiana Medical Review Team (MRT) decision
  Indiana Medicaid

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Eligibility Redeterminations

• Conducted every 12 months for MAGI categories
• The State renews if there is sufficient
  information, effective December 2014
• If there is not sufficient information, a
  pre-populated renewal form will be sent beginning
  in 2015
• Eligibility is terminated if the form is not
  submitted in a timely manner
• If eligibility is terminated but the documents
  are submitted within 90 days of the original due
  date, the documents will be reviewed without the
  need to submit a new application
• An individual enrolled in Medicaid on or before
  December 31, 2013 cannot be denied Medicaid
  eligibility solely because of the implementation
  of MAGI rules before March 31, 2014

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Reporting Changes

• Enrollees are required to report changes to the
  state (FSSA)
• Examples of changes include
• Change in address
• Income
• Family composition
• Babies born to Medicaid enrollees receive
  coverage for the first year of life without the
  need for a separate application
• They will be covered under Hoosier Healthwise and
  enrolled in the mothers Managed Care Entity
  (MCE)

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IHCP Application Methods
Program Application Process
Aged Disabled Waiver Apply at Area Agencies on Aging (AAA) or call 1-800-986-3505
Breast Cervical Cancer Program (BCCP) Apply for Medicaid coverage, option 3 Family Helpline 1-855-435-7178
Care Select Contact Enrollment Broker MAXIMUS1-866-963-7383
Community Integration Habilitation or Family Supports Waiver Apply at Bureau of Developmental Disabilities Services (BDDS) office or call 1-800-545-7763
Family Planning Eligibility Program Division of Family Resources (DFR) Toll-Free at 1-800-403-0864 OR online
Healthy Indiana Plan (HIP) Print or pick-up application at a DFR office
Hoosier Healthwise (HHW) Apply though FSSA Benefits Portal, by phone [phone]), or in person at DFR office
Traditional Medicaid Apply at DFR office, online/phone, Community Enrollment Centers
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Helpful Resources

• Hoosier Healthwise Helpline
• 1-800-889-9949
• Healthy Indiana Plan (HIP) Helpline
• 1-877-GET-HIP-9
• FSSA Benefits Portal
• Apply for cash assistance, SNAP and health
  coverage
• Indiana Medicaid Website
• Eligibility Screening Tools
• Guide to programs