Medicaid Eligibility

Transcription

1 Medicaid Eligibility

2 North Dakota Medicaid Douglas Boknecht, LICSW Manager, Analytics and Priority Projects Additional Resource: Brenda Finn, MBA, BS.RT (R) Medicaid Tribal Projects Lead

3 Although likely under-reported, the 2017 census estimates that AI/AN populations comprise 5.5% of ND s population Tribal enrolled members comprise 20% of the state s Medicaid population. Interest and attendance at the quarterly tribal consultation work group meetings continues to grow How can an individual apply for ND Medicaid or CHIP services? Eligibility workers in each of North Dakota s 53 county social service offices assist with eligibility to economic assistances programs and Medicaid programs.

4 Who is Eligible for Medicaid Parents and Caretaker/relatives of deprived children under age 18 (through the month they attain age 18) and their spouses with adjusted gross income less than 54% of the Federal Poverty Level (FPL). Pregnant Women with adjusted gross income less than 152% FPL. Children ages 0 through 5 with adjusted gross income less than 152% FPL. Children ages 6 through 18 with adjusted gross income less than 138% FPL.

5 Who is Eligible for Medicaid Individuals ages 19 through 64 not eligible as children, parents, caretakers or pregnant women whose adjusted gross income is less than 138% FPL (Adult Medicaid Expansion Group). Individuals under age 19 who are residing in foster homes or private child care institutions licensed or approved by the Department of Human Services, irrespective of financial arrangements (non-iv-e Foster Care). Individuals who were in North Dakota foster care (Title IV-E, state-funded (non-iv-e) or tribal) in the month they turned age 18 must be covered through the month in which they turn age 26 with no budget test, provided they remain a resident of ND.

6 Countable Income Only TAXABLE income is considered. Most common types: Gross taxable wages, salaries, tips (must deduct pre-tax deductions) Interest income, including tax exempt Dividend income, including tax exempt Taxable refunds of state income taxes Gross Alimony received Adjusted net income or loss from self-employment

7 Countable Income Only TAXABLE income is considered. Most common types: Net Capital Gains (capital gains minus capital losses), if expected to recur in the current year Taxable amounts of IRA distributions Taxable Amount of Pensions and annuities Gross unemployment compensation Gross Social Security income Veteran s Administration (VA) Retirement Pensions Casino winnings

8 Disregarded Income All NON-taxable income is disregarded except the following: Non-taxable foreign earned income Non-taxable interest or dividend income The non-taxable portion of Social Security Benefits

9 Disregarded Income Money received by American Indians from the lease or sale of natural resources, and rent or lease income, resulting from the exercise of federally-protected rights on excluded Indian property, are NOT considered as income (even if the money is taken out of the IIM account in the same month it was deposited into the account). This includes distributions of per capita judgment funds or property earnings held in trust for a tribe. Note: This does not include local Tribal funds that a Tribe distributes to individuals on a per capita basis, but which have not been held in trust by the Secretary of Interior. Also excluded are items with religious, spiritual, traditional or cultural significance or used to support subsistence or a traditional lifestyle according to tribal law or custom. Note: While not income, monies retained as cash from these exempted sources may be considered as resources for the Non-ACA Coverage Groups.

10 Contact information: Joyce Johnson, Policy Director

11 Healthy Steps insurance is for children who: are North Dakota residents are U.S. citizens or qualified aliens do not have health insurance coverage (IHS is not considered health insurance) are 18 years of age or younger do not qualify for the North Dakota Medicaid Program live in families with qualifying incomes

12 Family Size Annual Modified Adjusted Gross Income Monthly Income 1 $21,105 $1,758 2 $28,420 $2,368 3 $35,735 $2,977 4 $43,050 $3,587 5 $50,365 $4,197 6 $57,680 $4,806 7 $64,995 $5,416 8 $72,310 $6,025 9 $79,625 $6, $86,940 $7,245

13 Inpatient hospital, medical, and surgical services Outpatient hospital and clinic services Prescriptions Mental health services Preventive well-child exams Vaccines Dental and vision services

14 You can apply for coverage in one of three ways: Fill out an online application and mail it to a county social service office or the North Dakota Department of Human Services - Medical Services Division. Call toll-free KIDSNOW ( ) to request an application by mail or phone in an application. Visit a county social service office or the North Dakota Department of Human Services.

15 Contact information: Jodi Hulm, Administrator

16 North Dakota Medicaid Expansion

17 ND Medicaid Expansion Provides healthcare coverage for individuals who, in general, were not previously eligible for Medicaid Eligibility based on the following: Household Size Household s Modified Adjusted Gross Income (MAGI) at or below 138% FPL Ages 19 to 64 Years Old North Dakota Resident U.S. Citizen or Qualified Alien Do not have Medicare Not eligible for any other ND Medicaid Coverage Group Coverage Provided & Managed by a Managed Care Organization (MCO) - Sanford Health Plan

18 ND Medicaid Expansion Cost Sharing Amount which the member has to pay out-of-pocket for services, as with other ND Medicaid Coverage/Groups this is limited to nominal or minimal amounts. American Indians or Alaska Natives may be exempt from having to pay any out-of-pocket costs, such as co-pays. Member of federally recognized tribe; Receiving or have received services from Indian Health Services; or Eligible to receive services from Indian Health Services 18

19 ND Medicaid Expansion Service Area- Medical Services include the state of ND and the Contiguous counties that border ND with MN, SD, MT Pharmacy Services include the state of ND, MN, SD, and MT Network Provider- Contracted with Sanford Health Plan or Express Scripts (Sanford Health Plan s Pharmacy Benefit Manager) Enrolled with the ND Medicaid Program(with enrollment this does not mean having to provider services for ND Traditional FFS Medicaid recipients if not wanting to) Located with the ND Medicaid Expansion Service Area 19

20 ND Medicaid Expansion Out-of-Network Provider & Coverage Services from an Out-of-Network Provider will only be considered for possible Network Coverage if one of the following is applicable: Emergent or Urgent Service; Family planning service :or Medically Necessary Service in which access to a Network Provider is not available or feasible and authorization has been obtained by Sanford Health Plan NOTE: Indian Health Care Providers (IHCPs) with or without a Sanford Plan contract are considered to be Network Providers but MUST be enrolled with the ND Medicaid Program. IHCPs outside of the ND Medicaid Expansion Service Area would be considered Out-of-Network Providers and services must meet above criteria for possible Network Coverage. 20

21 Medicaid Expansion Contact Stephanie Waloch Medicaid Expansion Administrator

22 Health Tracks (EPSDT)

23 Early and Periodic Screening, Diagnosis & Treatment The federally-mandated health care benefit package Administered in partnership with each state Essentially for ALL Medicaid enrolled children (Birth through 20 years)

24 Any child who is Medicaid-enrolled is eligible for benefits up until their 21 st birthday, as long as they have Medicaid eligibility.

25 Birth 2 to 4 days after birth, if the newborn leaves the hospital less than 48 hours after delivery. By 1 Month 2 Months 4 Months 6 Months 9 Months 12 Months 15 Months 18 Months Once / year ages 2 to 20 A child should be seen by a dentist starting at first tooth eruption or for sure by age 1.

26 Contact information: Jodi Hulm, Administrator

27 ND Medicaid Pharmacy Services

28 IHS submits claims through Point-of-Sale (POS) system o First payable claim per patient per day is paid the encounter rate o Remaining payable claims that day are paid at $0 Result: IHS is paid the encounter rate for the patient for pharmacy services

29 All claims go through prospective drug utilization review o Early refills are denied o Duplicate therapy is denied Eligibility is confirmed / IHS payment is confirmed All claims go through retrospective drug utilization review o Providers for patients see WHOLE history of patient

30 If the claim for the encounter rate is reversed, the pharmacy will have to reverse a zero paid claim and rebill it to receive an encounter payment. ND Medicaid Payer Sheet informs IHS pharmacies what code they should submit if the primary insurance if Tribal Insurance. Patients with remaining recipient liability (RL) are denied as their monthly RL has not yet been met.

31 Contact information: Brendan Joyce, Pharm.D. Administrator

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33 NORTH DAKOTA HEALTH ENTERPRISE MMIS (NEW) OFFERS PROVIDERS A USER FRIENDLY SELF-SERVICE WEB PORTAL THAT HAS MANY NEW FEATURES AND BENEFITS. PROVIDERS NEED TO ENROLL ELECTRONICALLY, WHICH IS REQUIRED FOR ALL NEW AND EXISTING (LEGACY) PROVIDERS. TO ENROLL AS A PROVIDER FOR NORTH DAKOTA MEDICAID, PLEASE SUBMIT YOUR APPLICATION ONLINE AND SEND IN THE REQUESTED DOCUMENTATION TO SUPPORT THE APPLICATION WITH THE APPLICATION TRACKING NUMBER.

34 Online Provider Enrollment Application:

35 Provider Enrollment Required Documents checklist: Provider Toolkit for reference and help you complete the online enrollment. Provider updates available at Additional Provider Information:

36 Provider Enrollment Contact information: Dawn Mock, CFE Program Integrity Administrator

37 Statistic show that when a patient has a single provider who manages their comprehensive medical needs, they receive more appropriate medical services.

38 The PCCM program (or Primary Care Provider program) is available as the Managed Care Program within the state. This program functions Statewide. Certain Medicaid populations are required to enroll in the PCCM program. Recipients either choose or are assigned to a Primary Care Provider (PCP). The PCCM program functions to provide: adequate access to Primary Care; to provide coordination and continuity of health care services, to avoid duplication of services, to focus on delivering high quality, and to ensure efficient and effective health care service

39 Our ND Managed care web page is an excellent source of information with important links that can help you learn more about the PCCM program. anagedcare.html

40 Approximately 60% of all those that are enrolled in Medicaid are enrolled in the PCCM program. 1. All members, upon enrollment, receive a letter notifying them that they have 14 days from enrollment to choose a PCP or one will be auto assigned. 2. When they choose a PCP, or if one is assigned they receive another letter informing them who the PCP is along with other related information.

41 Every 12 months of a PCP assignment there is a 60 days (2 months) open enrollment period. The member receives a letter prior to this open enrollment period to notify them that it is coming up and that during the open enrollment period they can change their PCP without a good cause reason. If no change is made during the annual open enrollment period, the system automatically updates the current PCP for another 12 month PCP span for the member.

42 Who can be a PCP? In the PCCM program a PCP is a Primary Care Provider (not physician only). The PCP may be a physician, nurse practitioner, physician s assistant, a Rural Health Clinic(RHC), Federally Qualified Health Clinic(FQHC) or an Indian Health Service Clinic(IHS). These are the provider types(pt) that are selectable PCP.

43 For Provider types to be selectable as a PCP, they need to have a provider specialty (PS) in a general field that indicates the provider will be able to take care of the majority of the member s health care needs. Provider specialty areas that make the provider selectable as a PCP are, general practice, internal medicine, OB/GYN, pediatrics or family medicine. When a clinic is the PCP, like an IHS, there is no need for a referral if the member is seen by any PCP type providers that are providing services in that facility/building.

44 Full Providers: As a courtesy to providers, we don t allow assigning of more members with out the PCP s prior approval if the provider has requested to have a status of Full (not taking on new members, but keeping the members they have). Adding a member to a full provider: Eligibility workers will need to get verification, or have the member get verification, that PCP has given approval to take on a member in spite of their Full Status. This documentation has to be kept on file at the county office and does NOT need to be sent to the State unless requested.

45 Adding a member to a full provider (continued): When approval is documented at the county, the eligibility worker need to send a request to dhsmci@nd.gov to add this PCP for the member. In this , please state that you have documented approval from a Full provider (list name and provider NPI) to take on the member ( list member name and ID number) in spite of PCP s full status. State staff have to go into the providers file and increase the providers Maximum # of Members, in the PCCM Participation span field set, before the system will allow them to add this provider as PCP for another member. EWs will not be able to add a member to a full PCP.

46 Questions about the PCCM program should be sent to

47 PURPOSE: Assist with ADLs/IADLs Maintain independence and stay at home, not to improve medical condition Intermittent or daily basis Self-directed care Compliments informal care network Not limited to any targeted population, not appropriate for individuals whose needs fall within normal stages of development. Not primarily for homemaker services

48 Eligibility Requirements: Financial Medicaid eligible Functional Base on results of Comprehensive Assessment Other * Tribal Member

49 Eligibility for Level A-(up to 480 units), Basic Care and Daily rate Medicaid eligible AND Impaired in ONE ADL Bathing, Dressing, Eating, Toileting, Continence, Transferring, Mobility OR Impaired in 3 of 4 IADLs Meal Preparation, Housework, Laundry, Taking Meds

50 More intensive supports are available depending on ADLs and Functional Assessment Level B can involve over 480 units up to 960 units Level C can involve over 960 units up to 1200 units Additional Program Information can be found at:

51 Link to tribal consultation work group resource page: aid/tribal-health.html Questions?