Indiana Health Coverage Programs

Indiana Health Coverage Programs

Learning Objectives

I. Outline the basics of Medicaid and Indiana Health Coverage Programs (IHCP)

II. Identify and define eligibility, goals and specifics of IHCP programs

III. Discuss the standard elements of Medicaid and IHCP Eligibility

IV. Examine eligibility notices, appeals and redeterminations for Medicaid and IHCP

• 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

What is Medicaid?

Indiana’s 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

Indiana’s 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 DFR’s Benefit Portal

• 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

New Eligibility Groups

• 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-Down—Eliminated June 1, 2014 • Breast and Cervical Cancer Programs

What are the Indiana Health Coverage Programs?

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.

What are Federal Poverty Guidelines (FPL)?

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 80,180100,225

120,270 160,360

2014 FPL for the 48 Contiguous States and the District of Columbia

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

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

Hoosier Healthwise

HHW PACKAGE DESCRIPTION

A—Standard Full-service plan for children, pregnant women and families

No premiums

C– Children’s 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

P—Presumptive Eligibility Ambulatory prenatal coverage for pregnant women who are determined “presumptively eligible” while their Indiana Application for Health Coverage is being processed

Services Available under Hoosier Healthwise

• 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

Medicaid provides coverage for the following:

Hoosier Healthwise

Family Size

Parents & Caretaker Relatives

Children Pregnant Women

1 n/a $2,432 n/a2 $247 $3,278 $2,7273 $310 $4,123 $3,4314 $373 $4,969 $4,1345 $435 $5,815 $4,838

Monthly Income Limits

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

Family FPL Monthly Premium for 1 Child

Monthly Premium for 2 or More Children

158% up to 175% $22 $33175% up to 200% $33 $50200% up to 225% $42 $53225% up to 250% $53 $70


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

Healthy Indiana Plan (HIP)

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

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 Threshold1 $9732 $1,3113 $1,6494 $1,9885 $2,3266 $2,6657 $3,0038 $3,441

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

• 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

Managed Care Entities (MCEs)


Some factors for beneficiaries to consider when selecting an MCE include the following:oProvider 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?oSpecial programs & enhanced services

• Is there a service or program offered by the MCE that is particularly important or attractive to the enrollee?

HIP enrollees can change MCE:In the first 60 days or until they make the first POWER Account contributionAnnually at eligibility redeterminationAnytime 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 MCE’s 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


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


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

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)

Care Select

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 State’s 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

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


• 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.

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



Provide full Medicaid for working people with disabilities

Ages 16-64 Fall below 350% FPL Disabled according to

Indiana’s 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

M.E.D. Works

M.E.D. Works

Monthly Income Premium

Single $1,459 - $1,702 $48$1,703 – $1,945 $69$1,946 - $2,432 $107$2,433 - $2,918 $134$2,919 - $3,404 $161

$3,405 $187

Married $1,967 - $2,294 $65$2,295 - $2,622 $93$2,623 - $3,278 $145$3,279 - $3,933 $182$3,934 - $4,588 $218

$4,589 $254

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

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

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

Diagnosis of Traumatic Brain Injury

Community Integration & Habilitation

Diagnosis of intellectual disability which originates before age 22

Individual requires 24 hours supervisionFamily Supports

Home and Community Based Waivers (HCBS)

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.

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 (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

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.

• Covers low-income Medicare beneficiaries

• Helps pay for out-of-pocket Medicare costs.

• Individuals must be eligible for Medicare Part AProgram Income

ThresholdResource Limit Benefits

Qualified Medicare

Beneficiary (QMB)

100% FPL Single: $7,080Couple: $10,620

Medicare Part A & B Premiums

Co-pays, deductibles, coinsurance

(Specified Low Income) SLMB


Part B Premiums

Qualified Individual (QI)


Part B Premiums

Qualified Disabled Worker

(QDW)


Part A Premiums

Medicare Savings Program


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 visitsPap 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

Family Planning Program

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


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

Breast and Cervical Cancer Program (BCCP)

Age Eligible Services40-49 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

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

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


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

Presumptive Eligibility for Pregnant Women

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

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

• 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

General Medicaid Eligibility and Requirements

• 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

Requirement: Residency

• Individual must be US citizen, a US non-citizen national or an immigrant who is in a qualified immigration status o Lawful permanent residents are eligible for full Medicaid after 5 years

• Electronic data sources through the Federal Hub verify statuso 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:o Individuals receiving SSI or SSDIo Individuals enrolled in Medicare o Individuals in foster care & who are assisted under Title IV-Bo Individuals who are beneficiaries of foster care maintenance or adoption

assistance payments under Title IV-Eo Newborns born to a Medicaid enrolled mother

Requirement: Citizenship/Immigration Status

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

• 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

Requirement: Provide Social Security Number

• 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

Requirement: File for Other Benefits

• 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

Requirement: Report and Use Other Insurance

• 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, Worker’s compensation and

Veteran’s benefits

Modified Adjusted Gross Income (MAGI)


Adjusted Gross Income

Tax Excluded Foreign Earned Income

Tax Exempt Interest

MAGI

Tax Exempt Title II Security Income

MAGI impacts:

New applicants: Adults Parents and Caretaker relatives ChildrenPregnant Women

MAGI does NOT impact:Aged BlindDisabled Those needing long-term care Former foster children under age 26 Deemed newborns


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



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:1. Calculate the average size of the disregards for individuals whose

net income falls within 25% of the FPL below the net income standard

2. Add this average disregard amount to the net income eligibility standard

3. Step 1 + Step 2 = MAGI eligibility standard for the

eligibility group

• 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

Indiana Application for Health Coverage

• 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

Authorized Representatives

• 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

Verifying Factors of Eligibility

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

Eligibility Notices

• Types of notices include, but not limited to:o Approvals o Denials o Terminations o Suspensions of eligibility o Changes in benefit package

or aid category

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

Eligibility Notices

• 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

Eligibility Appeals

• 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

Eligibility Redeterminations

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

mother’s Managed Care Entity (MCE)

Program Application ProcessAged & 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: MAXIMUS:1-866-963-7383Community 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 (1-800-304-0864), or in person at DFR office

Traditional Medicaid Apply at DFR office, online/phone, Community Enrollment Centers

IHCP Application Methods

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

Date post:	05-Jan-2016
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Indiana Health Coverage Programs

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