Indiana Health Coverage Programs

1. Indiana Health Coverage Programs 2 days until Open Enrollment!

2. Reminders All 2015 Marketplace plans are finalized. Curious consumers (and assisters) can visit HealthCare.gov for the window shopping tool to view plans in their coverage area. Outreach Challenge is due Saturday, November 15! Submit for a chance to win a pizza party! On November 20 at 9:30 AM ET, IPHCA is hosting a call with Matt Cesnik from FSSA again.

3. What is Medicaid? • Enacted in 1965 by Title XIX of the Social Security Act • Funded by state and federal government • In Indiana, Medicaid is called Indiana Health Coverage Programs • 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)

4. 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

5. 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 • Anyone living at 100% or below the FPL is considered living in poverty

6. Hoosier Healthwise • 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

7. Hoosier Healthwise

8. 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

9. Hoosier Healthwise Monthly Income Limits

10. Children’s 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

11. Healthy Indiana Plan (HIP)

12. 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, they will be disenrolled

13. 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 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.

14. 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, or they are auto-assigned 14 days after enrollment

15. Managed Care Entities (MCEs) • Some factors for beneficiaries to consider when selecting an MCE include the following: • Provider network • Is the individual’s doctor available in the MCE network? • Are the locations of network providers easily accessible for the enrollee? • Are the locations convenient to the individual’s 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?

16. 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; • 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

17. 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; • Persons receiving home and community-based waiver or hospice services • Dual eligibles • 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

18. 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 State’s Fiscal Agent, Hewlett-Packard.

19. Traditional Medicaid (Fee-for-Service)

20. M.E.D. Works

21. M.E.D. Works

22. Home and Community Based Waivers

23. Behavioral and Primary Healthcare Coordination Program (BPHC) • Assists individuals with serious mental illness (SMI) who otherwise won’t qualify for Medicaid or other third party reimbursement • Individuals meet the following eligibility criteria: • Age 19+ • MRO-eligible primary mental health diagnosis • Demonstrated need related to management of behavioral and physical health • ANSA Level of Need 3+ • Income below 300% FPL

24. 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/ProviderServices/ProviderSearch.aspx.

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

26. Family Planning Program

27. 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

28. Breast and Cervical Cancer Program (BCCP)

29. 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 required—applicant attests to information

30. 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

31. Presumptive Eligibility for Pregnant Women

32. 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

33. 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

34. 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

35. Requirement: Residency • Applicant must be resident of the state • 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

36. Requirement: Citizenship/Immigration Status • Individual must be US citizen, a US non-citizen national or an immigrant who is in a qualified immigration status • Electronic data sources through the Federal Hub verify status • 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

37. 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

38. 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

39. 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

40. Modified Adjusted Gross Income (MAGI) • Methodology for income counting and determining household size and composition • Adjusted Gross Income + Tax Excluded Foreign Earned Income + Tax Exempt Title II Security Income = MAGI • 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, Worker’s compensation and Veteran’s benefits

41. 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

42. 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

43. Indiana Application for Health Coverage • Application methods: • Online (Recommended) • Telephone • Fax • Mail, or • In Person at Division of Family Resources (DFR) office • Medicaid eligibility determinations are made within45 days or 90 days for determination based on disability • Applicants can check status of online application

44. Authorized Representatives • Individual or organization which acts on a Medicaid applicant or beneficiary’s 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

45. 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

46. 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

47. 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

48. 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

49. 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 • The will be covered under Hoosier Healthwise and enrolled in the mother’s MCE

50. IHCP Application Methods