llf~ll~~ Medicaid Eligibility 00 Are under age 19 C Yes

Transcription

1 State Name:IL1n_d~i~an_a ~ Transmittal Number: IN llf~ll~~ 42 CFR (a)(!O)(AXi)(III), (IV), (VI) and (VII) 1902(a)(lO)(AXii)(IV) and (IX) 193l(b) and(d) OMB Control Number: Expiration date: [!] Infants and Children under Age 19 -Infants and children under age 19 with household income at or below standards established by the state based on age group. 12] The state attests that it operates this eligibility group m accordance with the following provisions: ~ Children qualifying under this eligibility group must meet the following criteria: 00 Are under age Have household income at or below the standard established by the state. [i] MAGI-based lncome methodologies are used in calculating household incoine. Please refer as necessary to SlO MAGl Based Income Methodologies, completed by the state. ~ Income standard used for infants under age one [!] Minimum income standard The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July I, 1989, had authorizing legislation to do so. C Yes (<;.No The minimu1u income standard for infants under age one is 133% FPL. [!J Maximum income standard TI1e state certifies that it has submitted and received approval for its converted income standard(s) for ijlfants 0 under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants trn.der age one. The state's 1naximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(IO)(A)(i)(ill) (qualified children), 1902(a)(IO)(A)(i)(IV) (mandatory poverty level-related (0 infants), l 902(a)(l O)(A)(ii)(IX) (optional poverty level-related infants) and l 902(a)(l O)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGIequivalent TN: IN MM1 Approval Date: 9/16115 Effective Date: Aprll 1, 2015

2 The state's highest effective income level for coverage of infants under age one under sections 1931 (low-inco1ne families), 1902(a)(l O)(A)(i)(IIl)(qualified children), 1902(a)(l O)(A)(i)(IV) (mandatory poverty level-related C infants),!902(a)(l O)(A)(ii)(IX) (optional poverty level-related infants) and l 902(a)(l O)(A)(ii)(IV) (institutionalized children}, in effect under the Medicaid state plan a' of Decen1ber 31, 2013, converted to a MAGI-equivalent ('- The state's. effective ll1come level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 201 O, converted to a MAGI-equivalent l The statc 1 s effective income level for any population of infants under age one under a Medicaid 1115 ' demonstration as of December 31, 2013, converted to a MAGI-equivalent C 185% FPL Enter the amount of the maxjmum income standard: ~ o/o FPL [!] Income standard chosen The state's income standard used for infants under age one is:.(e'.", The maximu1n income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902( a)( 10)( A )(i)(ill) (qualified children). 1902( a)( 10) Cc (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(!O)(A)(ii)(IX) (optional poverty level-related infallts) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent if not chosen as the maximum income standard; the state's highest effective income level for coverage of infants C under age one under sections 1931 (low-income families), 1902(a)(!O)(A)(i)(Ill) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants),!902(a)(lo)(a)(ii)(ix) (optional poverty level-related infants) and 1902(a)(l O)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent lfhlgher than the highest effective income level for this age group under the state plan as of March 23, and r if not chosen as the maximum income standard, the state 1 s effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent r if not chosen as the maximum income standard, the state's effective in.come level for any population of infants under age one under a Medicaid 11 [5 demonstration as of December 31, 2013, converted to a MAGI-equivalent r Another income standard in-between the minimum and 1naximu1n standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, Income standard for children age one through age five, inclusive ~ Minin1um income standard TN: JN MM1 Approval Date: Effective Date: April 1, 2015

3 The 1ninimu1n inoome standard used for this age group is 133% FPL, ~ Maximum income standard The state ce!'tifies that it has submitted and received approval for its converted income standard(s) for children 0 age one through five to MAGI-equivalent standards and the determination of the maxin1um inco1ne standard to be used for children age one through five. The statets n1aximum income standard for children age one through five is: The state 1 s highest effective income level for coverage of childr.en age one through. five under sections 1931 (low (0 income families), l 902(a)(IOXA)(i)(III) (qualified children), 1902(a)(l O)(A)(i)(VI) (mandatory poverty levelrelatcd children age one through five), and!902(axjoxaj(ii)(n) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent The state's highest effective income level for coverage of children age one through five under sections 1931 {lowincome families), 1902( )(10)(A)(i)(III) (qualified children),! 902(a)(IO)(A)(iXVI) (mandatory poverty level- (' related children age one through five), and 1902(a)(!OXA){ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent l The state's effective income level for any pnpulation of children age one through five under a Medicaid 1115 demonstration as of March 23~ 2010) converted to a MAGI~equivalent \:- The: state's effective income level for any population of children age one through five Wlder a Medicaid 1115 demonstration as ofdecember-31, 2013, converted to a MAGI-equivalent Enter the amount of the maximutn income standard: ~ % FPL 00 Income standard chosen The state's income b'i:andard used for children age one through five is: {e'. The maxin1um inco1ne standard If not chosen as the maximum income standard, the state 1 s highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(I OXAXi)(IJI) (qualified children), C 1902(a)(lO)(A)(iXVIJ (mandatory poverty level-related children age one through five), and 1902(a)(!O)(A)(ii) (N) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent if not chosen as the maximum income standard, the state's highest effective inco1ne level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(l O)(AXiJ(III) (qualified children), <: 1902(a)(lOXA)(iXVI) (mandatory poverty level-related children age one through five), and 1902(a)(!OXA)(ii) (N)(institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, e-0nverted to a MAGI-equivalent percent of.fpl. Approval Date: Effective bate: April 1,2015

4 ('. If hlgher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGIequ1 valent percent of FPL if not chosen as the maximum income standard, the state's effective income level for any population of chlldren C age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to amagiequivalent (~- Another income standard jn-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, [@ Income standard for children age six through age eighteen, inclusive 00 Minimum income standard The minimum income standard. used for this age group is l33o/g FPL. Iii Maximum income standard The state certifies that it has submitted and received approval for its converted income standard.(s) for children age [Z] six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. The state's maximum income standard for children age six through eighteen is: The state's highest effective incotne level for coverage of children age six. through eighte.en under sections 1931 (low-income families), 1902(a)(l OXAJ(i)(Ill) (qualified children), 1902(a)(10XA)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(aX!O)(A)(ii)(N) (institi1tiona\ized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent ll"fcent offl'l, The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), l902(a)(lo)(a)(ixi11) (qualified children), 1902(aX1 O)(A)(i)(Vll) (mandatory poverty (' level-related children age six through eighteen) and 1902(a)(l0XAJ(ii)(N) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent The state's effective Jncorne levei for any population of children age six through eighteen under a Medicaid 1115 r demonstration as of March 23, 2010, converted to a MAGI-equivalent percent offpl. C The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent C l33% FPL Enter the amount of the maximum income standard: ~ % FPL ~ Income standard chosen 1 15

5 The state's income sta~dard used for children age six through eighteen is: ~-The maximum income stai.-idard If not chosen as the maximum income standard, the state's highest effective income level fof coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(lO)(A)(i)(Ill) (qualified children), ('"!902(a)(i0)(A)(i)(VI!) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(iv) (institutionalized children)~ in effect under the Medicaid state plan as of March 23, 2010, c-onverted to a MAGI-equivalent if not chosen as the maxirnu1n income standard~ the state's highest effective income level for coverage of children C age six through eighteen under sections 1931 (low.income families), 1902(a)(lO)(A)(i)(lil) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and l902(a)(10)(a) (ii)(iv) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI"equivalent if not chosen as the maximum income standard, the state 1 s effective income level for any population of children C age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGIequivalent if not chosen as the maxitnum lncome standard. the state 1 s effective income level for any population of children C age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGIequivalent C A:hother income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 20m ~ There is no resoillce test for thls eligibility Presumptive Eligibility The state covers children when determlned presumptively eligible by a qualified entity. lo" Yes C No 1902(a)(47) 1920A 42 CFR CFR435.l102 ~ The state provides Medicaid coverage to children when determined presumptive1y eligible by a qualified entity 111 under tjie following provisions: TN: IN MM1 Approval Date: 9116/15 Effective Date: April 1, 2015

6 If the state has ele<;ted to cover Optional Targeted Low-Income Children ( 42 CFR ), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR ), for that child's age. If the state has not elected to cover Optional Targeted Low Income Children (42 CFR ), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age l 9 eligibility group (42 CFR ), for that child's age. Iii Children un<ler the following age may be determined presumptively eligible: Underage~ ~ The presmnptive period begins on the date the determination is made. ~ The end date of the presumptlve period is the earlier of: The date the eligibility detennination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made~ if no application for Medicaid is filed by that date. 00 Periods of presumptive eligibility are limited as follows: \._,No more than one period within a calendar year. r~ No more than one period within two calendar years. le No more than one period within a twelve-month period, starting wlth the effective date of the initial 0 presumptive eligibility period. r Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative; as appropriate. (0, Yes ('. No C: The state uses a single application form for Medicaid and presum.ptive eli&ribiiity. approved by CMS. fe> The state 1rnes a separate application form for presmnptive eligibility, approved by CMS. A copy of the, application form is included. ~ The presumptive eligibility determination is ba.'ed on the following factors: Ii:] Household inco1ne must hot exceed the applicable income standard describr.d above. for the child 1 s age.!is] State residency t8j Citizenship, status as a national, or satisfactory immigration status Iii The state uses qualified entities, as dermed in section J 920A of the Act, to determine eligibility!!!. presumptively for this eligibility group. TN:

7 ,_ ; A qualified entity is an entity that is detern1ined by the agency to be capable of making presumptive eligibility determinations based on an individual's household income and other requirements, and that : meets at least one of the follo\ving requirements. Select one or more of the following types of entities '. used to determine presumptive eligibility for L1tis eligibility group: D Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan D Is authorized to determine a child 1 s eligibility to participate in a Head Start progra1n under the Head Start Act D ls authorized to determine a child's eligibility to receive chhd care services for which financial assistance is provided under the Child Care and Development Block Grant Act of\ 990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental 0 Food Program for Women, InfanlB and Children (WIC) under section 17,ofthe Child Nutrition Act of1966 D Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) D ls an elementary or secondary school, as defined in section of the Elementary and Secondary Education Act of 1965 (20 U,S,C 8801) 0 Is an elementary or secondary school operated or supported by the Bureau oflndian Affairs 0 Is a state or Tribal child support enforcement agency under title IV-D of the Act O Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act D Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHJP, or title IV-A of the Act Is an organization that detennines eligibility for any assistance or benefits provided under any program O of public or assisted housing that receives Federal funds, including_the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or underthe Native American Housing Assistance and Self Determination Act of 1996 (25 U.S,C 4101 et seq.) O ls a health facility operated by the Indian Health Service~ a Tribe, or Tribal organization, or an Urban Indian Organization [gl Other entity the agency determines is capable of making presumptive eligibility determinations: I I Name of entity I Description I I - TN: IN MM1 Approval Date: 9/16115 Effective Date: April 1, 2015

8 Name of entity Qualified Provider Description Provider types eligible to enroll as a presumptive eligibility QuaLified Provider (PE QP) include: Acute Care Hospitals, Psychiatric Hospitals, community mental health centers (CMHCs), rural health clinics (RHCs), federally qualified health centers (FQHCs), and local health departments. To be eligible, an acute care hospital, psychlan ic hospital, CMHC, RHC, local health department or FQHC must:.. Participate as a provider under the Indiana State Plan or under a de1nonstration program under Section 1115 of the Social Security Act. Local county health departments are not required to participate as a Medicaid provider. Notify the FSSA of the provider's intention to make presumptive eligibility determinations. Agree to make presumptive eligibility determinations consistent with state policies and procedures. Guide individuals in the process for completing and submitting the Indiana Application for Health Coverage paperwork to the FSSA. Complete and submit PE QP eligibility attestations through the PE enrollment process on Web interchange. CMHCs, RHCs, FQHCs, and local health departments that wish to enroll as PE QPs are provided Web interchange training. During the Web interchange training session~ the CMHC, RHC, FQHC, or local health department also receive a printed copy of the HPE/PE Process Guide. The state assures that it has communicated the requirements for qualified entities, at 1920A(b )(3) of the 0 Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included. TN: IN MM1 Approval Date: 9/16/15 Effective Date: April