June 2018 Foundations: Expanding Only Updated For ... · Re-Visit Objectives: Can you? Identiigfy...

Overview

ExpandingFoundations:

Non-MAGIFor Reference Only Updated June 2018

Group Expectations

Stay Present

Respect each individual’s right to learn

Critique ideas, not individuals

Own your own learning

Challenge yourself

Take care of yourselfFor Reference Only Updated June 2018

Housekeeping

Location of bathrooms

Breaks and lunches

Safety

Computer use

Food and drink

Clean-up

Training materials

For Reference Only Updated June 2018

Objectives:After this module, participants will be able to: Identify eligibility differences between

MAGI and Non-MAGI Associate SSI, SSDI and SSA with Medicaid or

Medicare appropriately Recognize how CBMS applies the hierarchy

for eligibility determinations for MA programs

Non-MAGI OverviewGoal: To gain further understanding ofMedical Assistance programs, Social Security programs and how they relate.


MAGI vs. Non-MAGI

What do we remember from EF: MAGI?

5 Programs Tax Filing Statusand relationship

No Resource Check Client

StatementFor Reference Only Updated June 2018

MAGI vs. Non-MAGI

Non-MAGI Household is now Marital Status and

‘in the Home’ Introduction of resource limits Aged, Blind, and Disabled populations Programs were not part of ACA


Social Security Administration (SSA)

Social Security Retirement Social Security Disability Insurance

SSDI

Medicare Supplemental Security Income

SSIFor Reference Only Updated June 2018

SSDI and SSA retirementTitle II Work Quarters No Income and Resource

Checks Funded by payroll tax Medicare Disabled or Retired (62+)


SSITitle XVI Not enough work quarters

Or not insured

Income and Resource Checks Discretionary Federal funding Medicaid Disabled or 65+ Maximum benefit $750

(individual) $1,125 (couple)


Non-MAGI Programs

SSI related programs SSI Disabled Adult Child (DAC) Qualified Disabled Widow(er) Pickle

(QDW)


Non-MAGI Programs

Medicare related programs Qualified Medicare Beneficiary (QMB) Special Low-income Medicare Beneficiary (SLMB) Qualified Individual-1 (QI-1) Qualified Disabled Working Individual (QDWI) Low Income Subsidy (LIS)For Reference Only Updated June 2018

Non-MAGI Programs

Working Adults with Disabilities (WAwD) Children’s Buy-in with Disabilities (CBwD) Old Age Pension (OAP) Old Age Pension Health Care Plan (OAP-HCP) LTC programs Another class


Benefit Categories

1 through 7 Ranks groups of MA categories by overall

benefit. 1 is highest benefit


Medical Assistance Hierarchy, Benefit Category


Medical Assistance Hierarchy, Benefit Category Continued


Benefit Categories

1 for LTC 2 State plan Medicaid programs 3 Buy-in programs 4 QMB 5 Other MSP 6 HCP 7 LIS


MA Assistance Hierarchy

CBMS assesses eligibility for the highest benefit categories first. SLMB is #40,39 other categories are evaluated first


MA Assistance Hierarchy

Which category is the last program listed on the hierarchy and what are the benefits associated with this category?

LIS – Medicare Part D premium + co-pays anddeductibles


Review

Which two main SSA programs come with Medicare?

Retirement and SSDIFor Reference Only Updated June 2018

Review

Which SSA program comes with Medicaid?

SSI For Reference Only Updated June 2018

Non-MAGI?

What are three eligibility differences between MAGI and Non-MAGI programs?

Resource limits, Aged/Blind/Disabledpopulation, no MBU for Non-MAGIFor Reference Only Updated June 2018

Re-Visit Objectives:Can you? Identify eligibility differences between

MAGI and Non-MAGI. Associate SSI, SSDI and SSA with Medicaid or

Medicare appropriately. Recognize how CBMS applies the hierarchy

for eligibility determinations for MA programs

Non-MAGI Overview Goal: To gain further understanding ofMedical Assistance programs, Social Security programs and how they relate.


Expanding Foundations: Non-MAGI

Resources


Types of Resources and Data Entry

Objectives:After this module participants will be able to: Data enter different types of resources Identify exempt resources List references to aid in data entry

Goal: To understand resource eligibility rules and processes


Life insurance policies

Home

Accounts

Annuities

Estates


Estate Recovery

Estate Recovery allows Medicaid to recoup expenses from an estate prior to any inheritance disbursements.


Types of Resources

Bank Accounts (checking, savings, retirement etc.)

Vehicles Real Property Burials Life Insurance Cash Investments


Liquid Asset-Data Entry


Liquid Asset-Data Entry


Encumbrances


Vehicle

Exempt one if used for transportation Regardless of value Kelly Blue book or NADA are often used

to determine the fair market value


Equity

Equity is the Fair Market Value minus any loans against the asset.

$10,000 car - $8,000 loan= $2,000 equity


Vehicle


Intent to Sell

Exemption for vehicles and property Must be listed Client must accept reasonable offers Request updates/verification every 3

monthsFor Reference Only Updated June 2018

Example

Jane owns 2 cars, the first car is valued at$15,000 and is exempt.

The 2nd is worth $10,000, but Jane is tryingto sell that car.For Reference Only Updated June 2018

Example

If Jane provides the listing and is willing to accept a reasonable offer, that car will betemporarily exempt.

When it sells, the cash received iscountable.For Reference Only Updated June 2018

Real Property

Primary Home Secondary properties Mineral rights Other income producing property


Primary Home

Exempt up to $572,000 in equity Must be living in home or “Intend to Return”

Exempt if Spouse or dependent relative live in home (no limit)

Fair Market ValueFor Reference Only Updated June 2018

Secondary Property

Equity is countable Intent to sell can be applied Appraisals as guideline


Mineral Rights

Land appraisal if land is owned Mineral rights only appraisal if not Often low due to extraction costs Income producing property exemption


Income Producing Property

Exempt up to $6000 Business property must also produce a 6%

return on the excluded value Income is countable income


Real Property Data Entry


Real Property Data Entry


Burial Assets

Burial plots, and irrevocable policies are exempt

Additional $1500 set aside per person as revocable

Saves Medicaid burial costs later HCPF must be remainder beneficiaryFor Reference Only Updated June 2018

Burial Asset


Life insurance

Per Person (Applicant and Spouse)

If total face value of all policies are over $1500, all are countable.

If total face value of all policies are $1500 or less, all are not countable.


Life Insurance

Face value: Death benefit Cash Value: Investment component Cash Surrender Value: Amount received

to ‘cash out’ the policy


Term Life Insurance

Premium payments keep death benefit active (face value)

No cash value No cash surrender value


Whole Life Insurance

Also includes Universal or Variable Premium goes to death benefit and an

investment fund The investment fund is the cash value The cash surrender value is a separate amount


Life Insurance


Data entry - continued


AF vs. Medicaid

Countable forBoth

• Face Value over $100,000 and• Purchased within 48 months

Counts forMedicaid only

• Face Value greater than $1500 but less than $100,000• Or >$100,000 and purchased more than 48 months ago

Exempt forboth

• Total Face Value $1500 or lessFor Reference Only Updated June 2018

Data Entry Practice

Customer has the following: Checking Account One Vehicle (has a $2,000 loan) House (owes $200,000) Burial Policy 2 Life Insurance Policies


Data Entry of the Bank Account


Data Entry of Vehicle


Data Entry of Encumbrance for Vehicle


Data Entry of Real Property


Data Entry of Real Property


Data Entry of Burial Asset


Data Entry of Life Insurance Policy #1


Data Entry of Life Insurance Policy #2


Knowledge Check

What Resources are exempt?

1 vehicle

Primary Home

Irrevocable Burials

Personal Property

Some Life Insurance

Some Revocable BurialsFor Reference Only Updated June 2018

Spouse’s Income and Resources


Types of Resources and Data Entry

Re-Visit Objectives:Can you? Data enter different types of resources. Identify exempt resources. List references to aid in data entry.

Goal: To understand resource eligibility rules and processes



SSI BasedPrograms


SSI Related Programs

Objectives:After this module, Participants will be able to: Identify program resource limits Identify Household requirements and data

entry for SSI related Non-MAGI programs Data Enter an SSI mandatory case

Goal: To understand a group of Non-MAGI programs, and their eligibility rules.


Program List

SSI - Supplemental Security Income OAP (MA) - Old Age Pension PICKLE DAC - QDW -

Disabled Adult Child Qualified Disabled Widow(er)For Reference Only Updated June 2018

Commonalities

Benefit Category 2 State-plan Medicaid Resource Limits

$2000 Individual $3000 Couple

45 days to process, 90 days if disabilitydetermination is needed.For Reference Only Updated June 2018

Commonalities

Income limits (except OAP) $750 Individual $1125 Couple

Income Disregards $20 Unearned Income $65+ ½ (remaining earned income)-Earned incomeFor Reference Only Updated June 2018

Earned Income Disregard

Jimmy has $1065/month in earned income.

$1065-$65= $1000. ½ ($1000) = $500 ($65 + $500)= $565 is disregarded $500 is countable towards Non-MAGI.For Reference Only Updated June 2018

HouseholdLiving in the Home Case Individual

Complete the in the home radio button yes or no

Individual Demographics Complete Marital Status – no verification is

required unless questionable

▪ Household Relationship Complete the relationship information


Living in the Home


Marital Status


Household Relationship


SSI Mandatory

All individuals receiving an SSI cash benefit are eligible for Medicaid.

Benefit can be backdated to the day they 1st received SSI.


Let’s enter another case!You receive notification that an unmarried member has beenreceiving $300 in SSI benefits since January 14, 20XX

AI a case from XX/01/20XX Individual is born between 1955 and 1975 Make up a name and SSN Assume you have an SSN card and Birth Certificate

This is verified through SDXFor Reference Only Updated June 2018

SSI Details

Individual Demographics – SSI tab


SSI Income

Unearned Income


SSI Income

Income Received


Run EDBC


OAP

Covered in Expanding Foundations: Adult Financial

Individuals eligible for OAP AF will receive a MA benefit, Could be OAP-Med, OAP-HCP, QMB, WAwD or

even a MAGI program!For Reference Only Updated June 2018

Pickle


The Pickle Amendment

The Pickle Program keeps this population on Medicaid if they: Are eligible for and receiving a Title II

benefit Have countable income and assets below

current SSI limits ($2000/$3000) Submit an application


The Pickle Amendment

CBMS will check to ensure the client is only over-income because of the Title 2 increase.

These are rare occurrences to keep an eyeout for around COLAs. A data entry guideis in the book.


Data Entry


Disabled Adult Child (DAC)

Protect SSI’s Medicaid benefit from a SSADisabled Adult Child entitlement pushingan individual over the income limit.


Disabled Adult Child (DAC)

A DAC SSA entitlement is for individuals who were diagnosed with childhooddisability (prior to age 22)

Receiving SSI Because they were unable to collect work

credits of their own, they can draw on their parent’s claim…when their parent retires or becomes disabled


Terra was diagnosed with a childhood disability and was found disabled by SSA at age 14

Terra was unable to work as a result but was ineligible to collect SSI due to her parent’s income

At age 18 Terra started receiving an SSIbenefit and Medicaid.

DAC Benefits


In 2018 Terra’s parents retire, Terra qualifies for a DAC payment of $800 based on her parent’s work history.

SSA uses this income change to re-evaluate SSI eligibility.

$800-$20 disregard= $780 which is over income for SSI.

DAC Benefit Continued


DAC Benefit Problem

Terra loses SSI and SSI Mandatory Medicaid.


DAC Medicaid

DAC Medicaid keeps this population on Medicaid if they: Meet the $2000/$3000 resource limit Would be income eligible for SSI if they

did not receive the DAC benefit


DAC Medicaid

This is also a rare population. CBMS will read the DAC benefit from the

SSA interface and run income/resource calculations.


Data Entry for DAC income


Qualified Disabled Widow(er)

Age 50-64 Lost SSI and/or OAP due to receiving SSA

benefits as a disabled widow No Medicare Part A Meets all other MA requirementsFor Reference Only Updated June 2018


Valerie is 52 years old, disabled and receives SSI.

She is married to Rob Rob passes away


The widow’s benefit she receives fromRob totals $920/month

She is no longer eligible for SSI due to being over income

Valerie will be eligible for QDW if shemeets all other MA requirements.



Data Entry for QDW


SSI Related Programs

Re-Visit Objectives:Can you? Identify program resource limits Identify Household requirements and

data entry for SSI related Non-MAGI programs

Data Enter an SSI mandatory case

Goal: To understand a group of Non-MAGI programs, and their eligibility rules.


Expanding Foundations Non-MAGI

Buy-inPrograms


Buy-In Programs

Objectives:After this module participants will be able to: Explain the coverage difference between

Buy-in Programs and State plan Medicaid. Identify difference between Working Adults

with Disabilities (WAwD) and Health First Colorado Buy-In Medicaid program forChildren with Disabilities (CBwD)

Goal: To understand Medicaid Buy-In programsand their eligibility rules.


Buy-in programs

There are 2 categories of Medicaid that allow individuals who are disabled, but are otherwise ineligible, to buy-in to Medicaid.

Working Adults with Disabilities (WAwD)

Children Buy-In with Disabilities (CBwD)


Working Adults with Disabilities Household

Individual only Requirements

Working Earned income Self-employment income Job attached Take client statement

Age 16-64 Disability

Can be full or limited from ARG or SSA


Working Adults with Disabilities

No resource limit Income limit

450% FPL ($4,553/mo.) after disregards $20 unearned disregard $65 + ½ (earned income) disregard applies


Premiums

Members on WAwD pay a premium from approval month forward.

Can have Retro Med, no premium is required for retro months.


2018 WAwD Premiums


Children’s Buy-in

Under the age of 18 300% FPL after disregards 33% of total income is disregarded An additional $90 earned income

disregard No resource limit


MAGI and Non-MAGI

HH composition still uses MAGI rules Tax filer status

Everything else is Non-MAGI rules Ineligible for 16-18 year olds who are

working They should be on the WAwD ProgramFor Reference Only Updated June 2018

CBwD 2018 Premiums


Buy-In Programs

Re-visit Objectives:Can you? Explain the coverage difference between

Buy-in Programs and State plan Medicaid. Identify difference between Working

Adults with Disabilities (WAwD) and Health First Colorado Buy-In Medicaid program for Children with Disabilities (CBwD)

Goal: To understand a group of Non-MAGIprograms, and their eligibility rules.



Disability


DisabilityObjectives:After this module, participants will be able to:▪ Perform data entry on the Disability

Determination screen in CBMS▪ Identify when the disability requirement is

met, and when the disability app is necessary▪ Gather, complete and submit a disability

application

Goal: To gain further understanding ofDisability, and the associated businessprocesses to meet this requirement


Disability Definition

Resulting in multiple‘markedly’ or at leastone ‘severely’ limited

functional domain

Resulting in an Inability to perform substantial

gainful activity

Medically Determinable Impairment,

Lasting 12 months ormore,

Adults

Children


Disability Criteria

▪ Age 65+▪ SSA Determination▪ State Contractor Determination


Disability Determination ProcessIf there is no disability determination from SSAand the customer is under 65:▪ Complete Disability application and Medical

Release Forms▪ State Disability Contractor will make

determination


Title XVI


SDX/Bendex


Title II


Disability Application


Comments Page


Release Form


ARG Contact Information

Mailing Address:Arbor E&T, Action Review GroupP.O. Box 340Olyphant, PA 18447

Application Status (pending, new orin appeal): Email address:

[email protected]

Phone number: (877) 265-1864 Fax number: (877) 672-2077


mailto:[email protected]

Determination Notice


Disability Criteria

Full vs. Limited DisabilityFull Disability (All programs)

Meets the SSA disability criteria

All LTCwaivers

Limited Disability(WAwD)

Meets the SSA disability criteriawithout consideration of substantial

gainful activity

WAwD clients:CMHS and EBD waivers only


Full or Limited

FULL

LimitedFor Reference Only Updated June 2018

Data Entry Info


Disability Data Entry


Medical Conditions Screen


Disability Determination VCLCBMS will mail the disability app for you when a VCL is generated!


Once Received, send to ARG immediately


ARG Approval

EBD: Retro dateOnset date: Retro date for ARG, Onset date for SSA. Status date: Date status was last changedResult date: Date the last decision on disability was made.Diary Date: Date case will be re-reviewed for ongoingdisability.


Data Entry Practice

Let’s enter the ARG approval

▪ Effective Begin Date: 01/01/2018▪ Onset Date: 03/01/2018▪ Status Date: 05/01/2018▪ Result Date: 05/01/2018▪ Diary Date: 05/01/2028For Reference Only Updated June 2018

ARG Decision Data Entry


Disability Wrap-upRe-visit Objectives:Can you?▪ Perform data entry on the Disability

Determination screen in CBMS▪ Identify when the disability requirement is

met, and when the disability app is necessary▪ Gather, complete and submit a disability

application

Goal: To gain further understanding ofDisability, and the associated businessprocesses to meet this requirement


Remember your SSI Case

What must happen to change that person to the WAwD program?

Enter those changes effective today andRun EDBCFor Reference Only Updated June 2018


MedicareSaving

ProgramsFor Reference Only Updated June 2018

Medicare Based Programs

Objectives:After this module participants will be able to: Perform accurate data entry on the

Medicare Expense Page. Explain the coverage difference between

MSP programs and State-plan Medicaid.



MSP Programs

Benefit Categories 4 and 5 State contribution to Medicare

costs. May pay for Medicare

premiums, coinsurances and deductibles.

Health Insurance coverageremains Medicare.


MSP Categories

QMB SLMB QI-1 QDWI

LIS* - Benefit Category 7For Reference Only Updated June 2018

MSP Categories

Eligibility Eligible for Medicare Part A Income and Resource limits


Medicare Part A

Hospital/emergency coverage Typically free

Part B Primary Care Has a premium $134+ based on

income

Part D Prescription Coverage Variable premium based on plan


QMB

Benefit Category 4 QMB individuals have their Medicare

premiums, deductibles, co-pays, and coinsurance covered by the state.


SLMB and QI-1

Benefit Category 5 SLMB and QI-1 individuals only have their

Medicare B premiums covered by the state.


SLMB and QI-1

What’s the difference? QI-1 is an expanded income bracket that

requires active renewal each year by Congress.


QDWI

Benefit Category 5 QDWI individuals don’t have a free part

A.They have lost their SSDI and Free Part A because they have too much earned income and are under 65.

QDWI will pay for Part A.For Reference Only Updated June 2018

But Wait…This population is covered by WAwD.

The program is close to obsolete becauseof the WAwD category.If a working disabled individual opts out of WAwD or fails to pay a premium, they mightfall into the QDWI category if SSA has identified them as a QDWI eligible.


Income and Resource limits

Resources•$9,060 Individual•$14,340 Couple

QMB

SLMB

QI-1

QDWI

Income•$1,032 Individual•$1,392 Couple








Medicare expenses

Interfaces for existing cases. required for new cases.

Part A section

Data entry

Usually Payment method Other and Free Part A Include approval date- Part A eligibility is

required formany programs.

Find this info in BENDEX or SVES.


Medicare Data Entry


Medicare expenses

Part B Section Enter the actual premium and approval date. Monthly Deduction is paid for by beneficiary. State payment and paid by state buy-in if

state is already paying.


LIS

Low Income Subsidy. Benefit category 7. Managed by SSA. Provides a partial subsidy for Part D costs


LIS

Approvals for LIS have their info sent to SSA to provide the subsidy

Because it’s the last program on the hierarchy, it will display denied when applicants are not eligible for any program.For Reference Only Updated June 2018

Fun with MA categories Application date 05/01/2018

60 years old Single $1100 SSDI –Verified by Bendex Part A eligibility – approval date 3.1.18 Part B premium of $134 – approval

date 3.1.18

Which Category displays in wrap-up?For Reference Only Updated June 2018

Display Individual Eligibility Summary


Fun with MA categories

Reduce income to $900/month

Which Category displays in wrap-up?





Add any countable resource worth$10000

Which Category displays in wrap-up?


Display Individual EligibilitySummary


Display Reason



Add $1250 earned monthly income Run EDBC

What category of MA displays in wrap up?For Reference Only Updated June 2018



Medicare Based Programs

Re-visit Objectives:Can you? Perform accurate data entry on the

Medicare Expense Page. Explain the coverage difference between

MSP programs and State-plan Medicaid.



Course Evals

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June 2018 Foundations: Expanding Only Updated For ... · Re-Visit Objectives: Can you? Identiigfy...

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