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Medicaid Eligibility

Medicaid Eligibility. Provider Fair 2010. Presented by : Christie Twardoski Family Medicaid Policy Specialist Department of Public Health and Human Services 444-1917 ctwardoski@mt.gov. Application Process. Complete & sign application; return to OPA

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Medicaid Eligibility

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  1. Medicaid Eligibility Provider Fair 2010

  2. Presented by : Christie Twardoski Family Medicaid Policy Specialist Department of Public Health and Human Services 444-1917 ctwardoski@mt.gov

  3. Application Process Complete & sign application; return to OPA No interview required, but strongly recommended Provide information necessary to determine eligibility Eligibility determination in 45 days or less Retro coverage may be provided up to 3 months prior to application. Must be in a “group” to be eligible Applications may be filled out in any county Office of Public Assistance office in Montana Open cases can then be maintained in any county in Montana , at the recipient’s request

  4. Eligible Groups Aged, Blind, Disabled (ABD) Aged (65 or older) Blind Disabled Must be determined blind or disabled using SSA criteria FAMILY -RELATED Minor Children Pregnant Woman Caretaker’s with minor children Women diagnosed with breast and/or cervical cancer or pre-cancer

  5. When can someone Apply for Medicaid ? Everyone must be given the opportunity to apply for Medicaid whenever and how often they choose to do so. Most Medicaid eligibility can be retro actively awarded for up to three months prior to the month in which the application is submitted if there was a medical need in any of those prior 3 months

  6. Exceptions: Retroactive coverage is sometimes not available for nursing home (not usually, but only sometimes) coverage due to pre-admission screening requirements and usually not available for waiver due to both case management and waiver enrollment requirements. If a recipient requests an additional level of coverage (for example, nursing home coverage after receiving QMB in the community), the request of additional coverage is called a “coverage request” and is treated much the same as a new application for the new coverage level

  7. Eligibility Requirements U.S. Citizen or Qualified Alien Identity Social Security Number Montana Resident Income within program limits Resources within limits Cooperate with Third Party Liability (TPL) and Program Compliance Other requirements vary by group

  8. Income Eligibility Varies by group 34% FPL or less to cover adults with children 133% to cover children under age 19 150% FPL to cover pregnant women 200% FPL for women diagnosed with breast and/or cervical cancer/pre-cancer Aged, Blind and Disabled – related to SSI standard (currently $674 - 1/$1011 - 2)

  9. Resource Eligibility Aged, Blind, Disabled: $2000 single $3000 couple Medicare Savings Program: $6600.00 single $9910.00 couple Excluded: Home & land it sits on One vehicle per household for most programs Family-Related: No resource limit for children on Healthy Montana Kids + $3000 all other groups Family Medicaid Pregnant woman’s Medicaid Medically Needy

  10. Medically Needy For adults and children whose income exceeds program standards adults must be Aged, Blind, Disabled, or Pregnant to also known as incurment or ‘spend down’ To receive Medicaid, the countable income cannot be in the excess of $645.00. If the income exceeds $645.00, then the individual (or couple) can receive Medicaid by paying the difference of the standard of $645.00 and the household’s income. Incurment or ‘spend down’ can be met by cash payment, (similar to a health insurance premium) or by paying medical expenses (similar to health insurance deductibles).

  11. Income – Medically Needy Income exceeds a standard of $645.00 per month Recipients may elect to satisfy the incurment or ‘spend down’ with: Paid/unpaid bills – past 3 months Current payments on old bills Insurance/Medicare premiums Cost sharing amounts Cash option (payment to State) ‘similar to a health insurance premium’ Combination medical bills and payment to State

  12. Basic vs. FullMedicaid Coverage Full Coverage Aged, blind, disabled, pregnant, less than 21 years old & Breast and Cervical Cancer Treatment Eligible for all Medicaid payable services (subject to limitations and prior authorization) Basic Coverage Everyone else Not all Medicaid payable services are covered

  13. What isn’t covered for those receiving Basic Medicaid? Dental Eyeglasses and exams Hearing aids and test Durable Medical Equipment Personal care services in the home

  14. HMK + (Medicaid) HMK+ Healthy Montana Kids Plus = Medicaid HMK Healthy Montana Kids = CHIP

  15. HMK+ Who does it cover? Replaces the Child under age 6, and 6-19 programs. New application that can be used for both HMK+ and HMK (CHIP) No resources Full coverage

  16. Types of cards HMK+ HMK Christie Twardoski MEMBER NO. 9999999 DOB 1980/10/01

  17. Nursing Home Coverage Spouses of nursing home residents may retain more assets & an income allowance Can keep home property if intending to return within six months of leaving Nursing home and other medical expenses must exceed monthly income Asset/Resource transfers prior to or after Medicaid application may result in penalties

  18. Residents of Nursing Facilities An aged, blind, or disabled individual living in a nursing facility: Must have income that is less than the monthly Medicaid payment rate for the facility in which she or he lives. If Medicaid eligible, a nursing home resident will contribute most of her income toward the cost of his care in the facility… However……..

  19. Residents of Nursing Facilities cont’d A nursing home resident is allowed to keep up to $50 dollars a month for personal needs as well as the amount needed to pay: health insurance premiums legally obligated child support and alimony expenses.

  20. Residents of Nursing Facilities cont’d And in some cases: Home maintenance allowance (for a period of time) ABD person who is married but living in a nursing home will have his income eligibility determined solely on his individual income. He or she may also be allowed to pass some or all of his income to the spouse remaining in the community, depending on that spouse’s own income.

  21. Resources for Nursing Home clients How are resources treated for Nursing Home recipients? All assets of the spouses, whether owned jointly or separately, are combined and a ‘resource assessment’ is completed It is often recommended, but not required, that the resource assessment be done at the time a spouse enters a nursing home.

  22. Resources for Nursing Home clients cont’d Resource assessments evaluate the asset values as of the first day of the first month in which the spouse entered a nursing home for a period of at least 30 days. The spouse in the community is allowed to keep: A minimum of $21,912 * or; ½ (not to exceed $ 109,560.00*) of the total assets of the couple *all dollar figures listed in this document are based on policy July 2009

  23. Retroactive MedicaidCoverage Up to three months prior to: the month the application is submitted, or the month of request, whichever is later Must have been eligible and had a medical need in each month Exceptions: QMB sometimes waiver coverage sometimes nursing home coverage

  24. Recipient Rights Make application without delay Be assisted with application/ redetermination Be informed of coverage, conditions of eligibility, scope of program, etc. Be informed of consequences for failure to comply with requirements

  25. Recipient Rightscont’d Be determined eligible or ineligible within 45 days of application Receive timely notice of adverse action Be informed of right to a fair hearing Have their information treated confidentially Not be discriminated against

  26. Recipient Responsibilities Complete/sign all required documents Provide required verification/ documentation Comply with all eligibility requirements Report all changes within 10 days of knowledge

  27. Recipient Responsibilitiescont’d Cooperate with Program Compliance reviews Cooperate with Third Party Liability Cooperate with Managed Care (PASSPORT) Cooperate with Child Support Enforcement

  28. Questions ?

  29. The Claim Form Presented by ACS

  30. Complete Instructions and Information • Available at: • CMS 1500: www.nucc.org • UB-04: www.nubc.org • Both: www.cms.hhs.gov Includes field definitions and valid data for all fields

  31. UB-04:The Institutional Claim

  32. UB – 04Institutional Claim Form

  33. Zip + 4 (Required) Form locator 01 Patient Number Form locator 3a Type of Bill Form locator 4 UB-04 (Top) Key Form Locators Header Date of Service (Statement Cover Period) Form locator 6 PASSPORT # / Exemption Form locator 7 Client Name Form locator 8a or 8b

  34. Admit Date Form locator 12 Admit Hour Form locator 13 Admit Type Form locator 14 UB-04 (Top) Admit Source Form locator 15 Discharge Status Form locator 17

  35. Condition Codes Form locators 18-28 A4 = Family Planning B3 = Pregnancy UB-04 (Top Half) Value Codes Form locators 39-41 1 = Medicare Deductible 2 = Medicare Co-insurance 68 = EPO units

  36. UB-04 (Mid-Section) National Drug Code Form locator 43 Revenue Code Form locator 42

  37. Data is required for any physician administered billing Form locator 43 UB-04 (Mid-Section) Qualifier = N4 NDC Units qualifier F2 - International Unit GR - Gram ML - Milliliter UN - Unit Units - as defined by qualifier

  38. CPT/HCPCS code (outpatient) Form locator 44 Line level date of service (outpatient) Form locator 45 - Line 23 = Bill Date UB-04 (Mid-Section) Units Form locator 46 Line level charges Form locator 47

  39. Other payer names Form locator 50 TPL/Medicare Payment Form locator 54 UB-04 (Mid Section) Billing Provider NPI Form locator 56 Atypical provider # Form locator 57

  40. Client ID Number Form locator 60 Prior Authorization Form locator 63 UB-04 (Bottom Half) Diagnosis Codes Form locator 66,67; A-Q POA Form locator 67; small gray box A-Q

  41. Admit Diagnosis Form locator 69 Cost Share Indicator Form locator 73 UB-04 (Bottom) ICD-9 (surgical) Procedures & dates (inpatient) Form locator 74; a-e

  42. Attending Provider Form locator 76 UB-04 (Bottom) *NPI of attending required for the following billing providers: -Inpatient Hospital -Outpatient Hospital -Rural Health Clinic -Freestanding Dialysis Clinic -Federally Qualified Health Center -Indian Health Service

  43. Operating Provider Form locator 77 - (NPI required) Other Provider Form locator 78-79 - (NPI required) UB-04 (Bottom) Billing Provider Taxonomy Codes Qualifier = B3 and Taxonomy Form locators 81CC a-d (required)

  44. Questions?

  45. Professional Claims:CMS-1500

  46. Client Name Field – 2 CMS-1500 (Top) Client ID: Field – 10d Field – 1a Field – 9a Field – 11a

  47. CMS-1500 (Mid-section) TPL Indicators: Field – 11c Field – 9d Field – 11d = Y

  48. Passport Field 17a Referring NPI Field 17b CMS-1500 (Mid-section) For Schools CSCT Team Number Field 19 Diagnosis Codes Field 21 Prior Authorization # Field 23

  49. NDC (National Drug Code) Shaded area above each line on which a physician administered is billed: CMS-1500 (Mid-section) Qualifier = N4 NDC Units Qualifier F2 – International Unit GR – Gram ML – Milliliter UN – Unit Units – as defined by qualifier

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