Medicaid Hot Topics. Amanda Bryant and Angela Hartman Technical Assistance and Compliance March 2 nd, 2016

Transcription

1 Medicaid Hot Topics Amanda Bryant and Angela Hartman Technical Assistance and Compliance March 2 nd, 2016

2 Objectives PE Denials Aided on Another System Medicaid Basics Applying/Verifications Seasonal Employment/TPL Managed Care CHIP Medicaid 2/24/2016 2

3 System Issues For system issues with PE or deemed newborn applications, please contact us at For MITS access issues, please contact the provider call center at /24/2016 3

4 PE Denied Individual Aided in Another System Known defect in Ohio Benefits» Related to span details stored in the Master Client Index (MCI)» Plan in place with a solution coming, expectation of when is unknown at this time What can be done in the meantime?» Applications completed as thorough as possible Contact Information» Use appropriate enumerations (i.e. name/ssn/dob)» Ensure ongoing Medicaid application is completed 2/24/2016 4

5 How To Apply For Medical Assistance Benefits.Ohio.gov *self service portal Medicaid.Ohio.gov Odjfsbenefits.ohio.gov The Medicaid Hotline: In person at local CDJFS Via mail or facsimile 2/24/2016 5

6 Ohio Residency Individual must be a resident of Ohio» Self declaration is acceptable unless contradictory information is provided Individual must not be eligible for and receiving coverage in another state» Not ineligible for assistance merely due to processing delays in terminating coverage in the other state If the individual has coverage in another state, the Ohio provider can become a Medicaid provider for the other state If the individual is now an Ohio Resident, coverage in the other state should be terminated» Individual can call and request case be closed» Counties can use National Directory to assist PE CAN be explored for individuals who self declare Ohio residency

7 Verification Process OAC 5160:1 2 01(H) Not require an individual to provide verification of unchanged information Not request duplicate copies of previously submitted information Verify relevant eligibility criteria through electronic sources» HUB Ping, TALX, SAVE, other data interfaces If eligibility criteria cannot be verified electronically, manual verification process is used» 2 requests in writing» 2 nd request must be sent no more than 20 days from the date of application

8 Changes with Seasonal Employment/Private Health Insurance Transitional Medicaid» Individual must have been eligible for and enrolled in MAGI Parent/Caretaker Medicaid for at least three of the six months immediately preceding loss of eligibility» Loss of eligibility for Medicaid must be due to increased earned income Reporting Responsibilities» Individuals are responsible to report any changes which could affect their eligibility within 10 days OAC 5160:1 1 55(B)(1)(d) Income Third party responsibility for the individual s health care costs 2/24/2016 8

9 Federal Marketplace and Medicaid coverage Individuals must have Minimum Essential Coverage (MEC)» Medicaid is considered MEC and reported on form 1095B» Individuals who do not have MEC may have to pay a shared responsibility payment Individuals who have a Marketplace plan, but then become eligible for Medicaid should cancel their Marketplace plan as soon as possible» Individuals who receive coverage from both a Marketplace plan and Medicaid may have to pay back any tax subsidies Individuals with Medicare are not eligible to receive coverage from the Marketplace Individuals should contact the Marketplace about purchasing insurance after a Medicaid denial:» For being over income» Because a change has now caused ineligibility for Medicaid» Ineligible for Medicaid because of Immigration status

10 Managed Care Enrollment Most individuals are required to enroll in a Managed Care Plan (MCP) An MCP is chosen by the individual after Medicaid approval Open enrollment is in November each year MyCare dual enrollees can change their MCP anytime Individuals can change their plan for any reason during the initial 3 months in an MCP Just Cause requests allow an individual to change MCPs outside of open enrollment If an individual loses Medicaid eligibility but then regains it within 60 days or less, the individual will be re instated to the previous MCP

11 What is CHIP Medicaid? Children s Health Insurance Program Children must fall under the 206% FPL (no insurance) or under 156% FPL (other insurance) to be eligible for Medicaid FPL levels determine what aid code children will get based on age and status of other insurance» The aid code determines the federal matching funds the state might receive» All behind the scenes, base eligibility is determined the same Full Coverage Medicaid» Immunizations, doctor visits, prescriptions, dental and vision 2/24/

12 Children Without Other Medical Insurance No Insurance 5% disregard If a child does not have insurance, there are 4 possible FPL limits: CHIP 2 Title 21 Uninsured CHIP Child Aid Codes P1, P2 1. A child who falls into the CHIP 2 aid category will have a maintenance need at 206% FPL. 2. A child who falls into the CHIP 1 aid category will have a maintenance need at 156% FPL. 3. A child who is less than 6 and falls into a MAGI Child aid category will have a maintenance need at 141% FPL. 4. All other children who fall into a MAGI Child aid category will have a maintenance need at 107% FPL FPL Limits 156% 141% 107% 0 C1, C2, DC <1 D1, D2, DD <6 CHIP 1 Title 21 Uninsured CHIP Child Aid Codes O1, O2 Age Ranges Medicaid Title 19 Aid Codes E1, E2, DE <19 2/24/

13 2015 Medicaid FPLs Chip Child

14 Are Incarcerated Individuals Eligible for Medicaid? OAC 5160:1 1(B)(10) & OAC 5160: (B)(1) & 42 CFR (a) Individuals who are confined or living in a public institution are not eligible for payment of services by Medicaid» Confined serving time for a criminal offense, or placed involuntarily in a prison, jail, detention facility, or other penal facility» Public Institution is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, as evidenced by final administrative control, including ownership and control of the physical facilities and grounds Incarceration Decision Tree Desk Aid» Determining Whether an Individual in the Custody of a State or Local Facility Should Be Considered Incarcerated» Determining if the facility is connected to courts or law enforcement» 2/24/

15 ODM/DRC/DYS Initiatives 90 Day Pre Release» To allow offenders at the Department of Rehabilitation and Correction (DRC) to be eligible for Medicaid, Managed Care, and Care Coordination upon release 24 Hour In Patient Hospitalization» To have in patient and associated professional services covered by Medicaid for inmates who are admitted to the hospital for at least 24 hours DYS Presumptive Eligibility» To provide youth who are currently under DYS custody temporary Medicaid coverage upon release 2/24/

16 Questions