Medicaid Eligibility and Appeals

Transcription

1 Medicaid Eligibility and Appeals Heidi Bramson, Esq. Health Law Unit September 12, 2017

2 The Legal Aid Society Criminal Practice Primary provider of indigent defense services in New York City Juvenile Rights Practice Represents 90% of the children who appear before the Family Court in New York City on child protective, termination of parental rights, PINS (person in need of supervision), and juvenile delinquency petitions. Civil Practice Operates out of a network of 16 neighborhood and courthouse-based offices in all five boroughs and 22 specialized units and projects.

3 Health Law Unit HLU assists clients and advocates on issues related to public health programs including: Denials of health care services Barriers to enrollment in and retention of health insurance plans Coordination of benefits Immigrant access to health care

4 Agenda Public Health Insurance: Medicare Medicare Savings Program Medicaid Essential Plan MA Eligibility for Individuals with Excess Income Managed Care Options and Requirements Medicaid Appeals 4

5 Public Health Insurance 5

6 Medicaid & Medicare Medicaid and Medicare were added to the Social Security Act in Medicare and Medicaid are public health insurance program with different rules. Medicare Federal program with no income limits Medicaid Federal/State program for low-income people 6

7 Medicare Basics Three ways to get Medicare Be over 65 Receive Social Security Disability for two years or more Have end-stage renal disease Assistance for low-income beneficiaries Medicare Savings Program Can pay for Part A and/or Part B premiums and cost sharing Extra Help (also called Low Income Subsidy) Can pay for Part D (drug) coverage and cost sharing 7

8 Original Medicare Administered directly by the federal government & has 2 parts: Part A (hospital insurance) Covers most medically necessary hospital, skilled nursing facility, home health and hospice care. If worked more than 40 quarters, then there is no premium. If not, then you may have to pay a premium depending on work history. Deductibles and copays apply. Part B (Outpatient insurance) Covers most medically necessary doctors services, preventative care, and some home health & ambulance services. $121.80/month for new enrollees (no cost for low-income people). Medicare pays 80% of bills, recipient pays remaining 20%. 42 C.F.R. 406, 409 ; 42 C.F.R

9 Original Medicare does not cover: Vision Dental Non-emergency transportation Long-term services and supports Outpatient prescription medication Part D (outpatient prescription drug insurance) - provided only through private insurance companies that have contracts with the government it is never provided directly by the government 20% of the cost of care 9

10 Medicare Managed Care Medicare Part C Medicare Advantage plans are Medicare-approved private health insurance plans for individuals eligible for or enrolled in Original Medicare, Part A and Part B Enrollees remain in Medicare and must continue paying Part B premium There is sometimes a monthly premium in addition to Part B premium; pricing varies by plan Plans often have provider networks Plans generally offer additional benefits such as dental, vision and hearing Some offer Part D prescription drug coverage 42 C.F.R. 422; 42 C.F.R. 423

11 Medicaid Comprehensive health insurance program for low-income people Jointly funded by federal government, NYS, and local counties (Human Resources Administration in NYC) Pays for all medically necessary covered services, including: Hospitalization Outpatient care Mental health care Physical therapy Diagnostic tests Durable medical equipment Pharmacy Medicaid is an entitlement program, not a block grant: once applicants are found eligible, their Medicaid cases are opened, no wait list Co-pays for some services, but providers cannot refuse services for failure to pay co-pay 42 C.F.R

12 Medicare Savings Program (MSP) Medicaid-administered program available to Medicare consumers with limited income that pays cost-sharing obligations (Medicare Part B premiums and deductibles and co-insurance under QMB) Qualified Medicare Beneficiary (QMB) Specified Low Income Medicare Beneficiary (SLMB) Qualified Individual (QI-1) No resource limit

13 Medicare Savings Programs All three pay for Part B premiums (currently $121.80) QMB pays for deductibles and co-insurance All provide Special Enrollment Periods which allow consumer to enroll in Part B if they failed to do so when eligible and will waive late enrollment penalties Enrollment renders consumer eligible for Low Income Subsidy Full Extra Help (coverage for Medicare Part D)

14 Enrolling in a MSP Automatic for those receiving any amount of SSI Automatic MSP screening for Medicaid applicants when they are already Medicare eligible Apply for MSP directly with the local Medicaid office Or fill out paper application and send it by mail

15 Medicaid Who s eligible? There are many mandatory categorically eligible groups including: Individuals receiving public assistance Individuals receiving SSI Individuals who lost eligibility for SSI due to OASDI COLA increases since April CFR 435.4; ; ;

16 Medicaid Eligibility To be eligible for Medicaid in NY, recipients must: Be a NYS resident Have adequate immigration status Undocumented eligible for Emergency Medicaid only Be at or below the income limit Income limits are based on the individual s category (categories and limits are listed in next slide) Resources Disabled, blind, or 65+ have a resource test 42 CFR 435.4; ; ;

17 2017 Income/Resource Limits Household Size (Monthly Income Limits) MAGI Category FPL Each Add'l Person Pregnant Women and Infants 223% $2,208 $2,978 $3,747 $4,516 $5,286 $774 Children 154% $1,525 $2,056 $2,588 $3,119 $3,650 $534 Parents and Childless Adults 138% $1,367 $1,843 $2,319 $2,795 $3,650 $479 Non-MAGI Category (Disabled, blind, 65+) 1 2 Non-MAGI Category (MBI-WPD) 1 2 Income $825 $1,209 Income $2,475 $3,338 Resources $14,850 $21,750 Resources $20,000 $30, U.S.C. 1396a(a)(10)VII); 42 C.F.R (a)(j); N.Y. Soc. Serv. L. 366(b). 17

18 Dual Eligible Beneficiaries People who are covered by both Medicare and Medicaid: low-income seniors and disabled people Medicare pays first, Medicaid picks up the remainder Duals are among the poorest and sickest and often have complex and costly health care needs Duals represent a small percentage of both programs but account for more than 1/3 of the cost of each program

19 Essential Plan Essential Plan is a New York State public health insurance program set up in 2015 pursuant to the Affordable Care Act. Available for some low-income New Yorkers who are ineligible for MAGI Medicaid due to: a) immigration status; or b) income that is above the MAGI Medicaid limit Yearly income up to $23,540 for 1; $31,860 for 2 19

20 Enrolling in Medicaid 20

21 New York State of Health: New York s Health Insurance Marketplace Marketplace offers health coverage for Medicaid and Essential Plan Only people who are under 65 and not disabled can enroll through the Marketplace You can enroll online, over the phone, or with the help of a Navigator or in person assistor Locations and availability of navigators found online 21

22 What Documents do Applicants Need to Apply? Proof of Identity and Immigration/Citizenship Status Undocumented immigrants do not need to have an SSN; eligible for Emergency Medicaid Other immigrants do not need a SSN if they are not eligible for one due to their immigration status Proof of Age (Birth Date) Proof of Employment/Income Sources Policy numbers for any current health insurance Information about any other available insurance 22

23 Medicaid Enrollment for Disabled, Blind, Aged 65+ Individuals Medicaid is administered through New York City Human Resources Administration (NYC HRA) Applications can be made through: Local Medicaid office Managed Care Plan Hospital Mail 23

24 Retroactive Coverage Medicaid coverage (for ALL categories) can be retroactive up to three months if the applicant was eligible. Advocate Tip: Indicate that applicant wants retroactive coverage on the application 24

25 Over-Income Options 25

26 Options if Over Income Limit MAGI Enroll in the Essential Plan (up to 200% of poverty) Qualified Health Plan through the Marketplace Advanced Premium Tax Credits for people earning up to 400% FPL (silver level) Cost sharing reductions for those earning up to 250% FPL (silver level) Non-MAGI (over 65, disabled, blind) Spend-down Program Supplemental Needs Trust Medicaid Buy-in for Working People with Disabilities (MBI-WPD) Medicare Savings Programs 42 U.S.C. 1396a(a)(10)VII); 42 C.F.R (a)(j); N.Y. Soc. Serv. L. 366(b). 26

27 Spend-down Program If an individual s income is above the Medicaid limit, they can get Medicaid by paying or incurring medical bills in an amount that equals their monthly spend-down amount. Spend-down is like an insurance deductible, but the spend-down must be met each month, not once a year. If a person meets their spend-down on a month-tomonth basis, there will only be outpatient coverage. They must meet six months of spenddown for inpatient coverage. 27

28 MBI-WPD The MBI-WPD can eliminate the spend-down for people ages 16 through 64 if they are certified disabled and work. No minimum monthly wage or hour requirement, and individuals are not required to file taxes. Can take grace periods in months a person cannot work, but no more than 6 every 12 months. Income (2016) Resources (2016) Household = 1 $2,475 $20,000 Household = 2 $3,338 $30,000 Individuals may have gross income as high as $60,000 per year (couple, up to $80,000) because of very favorable income and resource disregards. The exact maximum amount depends on how much of income is earned v. unearned. 28

29 Supplemental Needs Trusts (SNTs) Enables a person with a disability to maintain eligibility for Medicaid Purpose is to enhance the quality of life of a disabled individual by permitting the SNT to pay for expenses not paid for by public benefits, such as rent Money put into trust is not counted under the Medicaid rules Only applies to non-magi cases 29

30 Medicaid Managed Care 30

31 Managed Care Medicaid and Medicare were initially set up under a fee-forservice model, which meant that recipients could access services from any provider that accepted Medicaid or Medicare. Move towards managed care systems, which allows private health insurance companies to manage public health insurance benefits. Medicaid Most New York residents who are covered by Medicaid are required to join managed care plans. Medicare Most still have original Medicare but have option to receive their Medicare benefit through a plan. N.Y. Soc. Serv. L. 122, 131, ; 18 N.Y.C.R.R. 360, 505; N.Y. Soc. Serv. L. 364-j; 18 NYCRR et seq.; 42 C.F.R

32 Medicaid Managed Care N.Y. State Department of Health pays private health plans to provide medical insurance coverage to Medicaid beneficiaries. Unlike fee-for-service Medicaid (also called straight Medicaid or regular Medicaid), in MMC beneficiaries must: Select a primary care physician See in-network providers Get prior authorization Get referrals to specialists Adhere to a medication formulary N.Y. Soc. Serv. L. 364-j; 18 N.Y.C.R.R et seq.; Medicaid Managed Care Model contract, available at 32

33 Mainstream Medicaid Managed Care (MMC) 33

34 Who has Mainstream Medicaid Managed Care (MMC)? Almost all Medicaid enrollees who do not have any other insurance must be enrolled in MMC. Excluded: Consumer enrolled in Medicare (a dual eligible ) Consumer enrolled in a waiver program Consumer Medicaid-eligible with a spend-down 34

35 What does MMC Cover? Model Contract, Appendix K Inpatient Hospital Services Physician Services Radiology Drugs (prescription and OTC) Rehabilitation Early and Periodic Screening, Diagnostic, and Treatment Home Health Care Emergency Services Vision Dental DME Long Term Care Services 35

36 Managed Long Term Care (MLTC) 36

37 Managed Long Term Care insurance plans are paid a monthly premium per member ( capitation rate ) by the NY Medicaid program to provide home care and other community based long term care services (CB-LTC) Mandatory Enrollment: Dual eligible individuals who are Age 21 and older, and Reside in a mandatory county (now statewide), and Require 120 days or more of Community Based Long Term Care Services 37

38 Two MLTC Models Partial Capitation MLTC Plans do not cover most acute and primary care or Medicare-covered services Full Capitation combine Medicare and Medicaid, and Medicaid Long-Term Care PACE MAP FIDA Not all plans (or plan types) are available in each county Directory of service area by plan and plan type is posted on the NYSDOH website, available at: 38

39 MLTC Benefit Package Home Care Personal care - home attendant and housekeeping Consumer Directed Personal Assistance Program (CDPAP) Certified Home Health Agency (CHHA) - Personal Care Home Health Aide, PT, OT Private duty nursing Adult Day Services - medical and social Personal Emergency Response System (PERS), home-delivered meals, congregate meals Medical equipment, supplies, prostheses, orthotics, hearing aids, eyeglasses, respiratory therapy, home modifications Medical Specialties: Podiatry, Audiology, Dental, Optometry Non-emergency medical transportation Nursing home care 39

40 MEDICAID APPEALS 40

41 Appeals Process Differs by Administrative Agency NYC HRA (or other local districts) NYSOH

42 Fair Hearing: HRA Appeals Immediate option for Mainstream Medicaid Managed Care and MLTC Internal appeal Mandatory prior to Fair Hearing for: FIDA, PACE, Medicaid Advantage Plus(MAP) This requirement will eventually include Mainstream Medicaid Managed Care If denial upheld on Internal: External Appeal (DFS) AND/OR Fair Hearing (OTDA) All Medicaid recipients may request a fair hearing and an internal and external appeal. The fair hearing decision trumps. 42

43 Aid to Continue Services continue unchanged pending a fair hearing decision Must be requested within 10 days of the notice alerting you to the Plan s decision Instructions to request must be included in notice 43

44 External Appeal via DFS Option when internal appeal upholds denial as: Not medically necessary Experimental Investigational Medical Reviewer Expedited options: "delay would seriously jeopardize the Enrollee s life or health or ability to attain, maintain or regain maximum function. * Standard Timeframe: 30 days *Partial Capitation Contract App. K Sec. I.B 44

45 What is a Fair Hearing? Adversarial, administrative hearing in front of an objective Administrative Law Judge (ALJ).

46 Requesting a Fair Hearing Must be requested within 60 days from the date of the initial adverse determination notice If this deadline is missed, the State cannot review the action. If there is no notice issued or if the notice is sufficiently deficient, this clock does not start ticking.

47 Documents Received Prior to the Fair Hearing Acknowledgment of request for fair hearing Scheduling notice Evidence packet

48 Evidence Packet Appellants have a right to receive copies of the evidence packet (copies of anything the plan will use to justify its determination at the Fair Hearing) and to request specific documents from their case record that would help them prepare for their Fair Hearing. Evidence packets should be provided automatically from mainstream Medicaid managed care plans to the appellant and any listed representative. Request these from from HRA Appellants also have the right to examine their entire case records prior to the Fair Hearing.

49 Denials: At the Fair Hearing Appellant s burden to prove by substantial evidence that the denial was incorrect. Reduction: Plan s burden. Proving medication/service/procedure is medically necessary requires documentation from provider. Plans often appear on paper, not in person. Appellant may have a representative If not a lawyer, bring documentation permitting representation.

50 Fair Hearing Decisions Issued by a DOH commissioner s designee. Unfavorable decisions can be appealed to State Supreme Court

51 If favorable: Fair Hearing Decisions Look closely at the order. May order the plan to: reconsider the request. take into consideration certain facts when reconsidering the request. provide the coverage for the service.

52 Request: NYSOH Appeals Phone: Fax: Mail: NY State of Health, P.O. Box 11729, Albany, NY Timeframe to file: 60 days Aid to Continue if appeal requested within 10 days of notice date Appeal Process: ~90 days Fast-track option: only if delay will jeopardize health. 52

53 NYSOH Appeals Impartial Hearing Officer Telephone Hearing Appellant may have a Representative Complete & upload Authorized Rep Designation Form May have witnesses May have documentary evidence Upload to your account Language Access 53

54 Health Law Unit (referrals) Access-to-Benefits Helpline Tuesdays 9:30 am 12:30 pm (888)