Medicaid Eligibility Allen Bryan, Centers for Medicare and Medicaid (CMS) Bethany Hamm, MaineCare

1. Medicaid Eligibility Allen Bryan, Centers for Medicare and Medicaid (CMS) Bethany Hamm, MaineCare Marybeth McCaffrey, Vermont AHS, Economic Services Division June 2009

2. Section 2: Medicaid Eligibility Process Table of Contents • Category • General Eligibility Factors, Other Than Category • Financial Eligibility Factors • Eligibility Determination Process • Coverage-Medicaid and SCHIP Benefits

3. Category • Disability • Aged • Blind • Children • Parent/Caretaker Relative

4. General Eligibility Factors Other Than Category • After establishing age or disability category, other eligibility factors need to be determined • U.S. Citizenship and identity (n/a to SSI, SSDI, Medicare recipients • Residency • Who is living with applicant? • What resources are owned by applicant and family? • How much income is received by applicant and family? • Retroactive coverage for up to 3 months before month of application provided all eligibility requirements met

5. Financial Eligibility Factors • Key terms • Financial responsibility • Methodologies • Standards

6. Financial Eligibility Factors: Key Terms • Federal Poverty Level (FPL) • Income tests based on FPL • FPL is adjusted annually according to the cost of living • Medically Needy Income Level (MNIL) • Levels are based on law and cannot exceed 133 1/3% of 1931 income standards • Compares a group’s countable income to MNIL to determine financial eligibility for Medicaid • Spenddown • Groups who fail MNIL will have income Spenddown to meet before Medicaid services are covered • Similar to deductible associated with medical insurance • Usually for six month period

7. Financial Eligibility Factors: Financial Responsibility • Whose income and resources to count? • Very challenging to analyze • Household composition? • Which family members are requesting coverage? • General rules • Parents are financially responsible for their minor children • Spouses are financially responsible for each other

8. Financial Eligibility Factors: Methodologies • What income and resources are countable vs. excludable? • Resource methodologies • Burial funds • Term life insurance • Personal property (not real property) • Home • One car • Annuities are special • Income methodologies • Excluded income (e.g. gifts, food stamp benefits, senior companion) • Countable income • Disregarded income ($20) • Deductions from countable income (varies)

9. Financial Eligibility Factors: Standards • Resource standards • $2000 for individual • $3000 for group of two • Income standards

10. Income Standards

11. Eligibility Determination Process • Takes into account category, general eligibility factors and financial eligibility factors (previous 3 sections) • Determines whether person meets eligibility coverage for any coverage group • Based on income, person may need to contribute in order to enroll or access certain coverage • Cost sharing (e.g. may be required for prescription coverage) • Premiums (e.g. may be required before person can be enrolled • Deductibles

12. Coverage-Medicaid & SCHIP Benefits • Medicaid & SCHIP offer mandatory and optional services • States have latitude to offer optional services

13. Contact Information • Allen Bryan Allen.Bryan@cms.hhs.gov • Bethany Hamm Bethany.Hamm@maine.gov • Marybeth McCaffrey Marybeth.McCaffrey@ahs.state.vt.us 13