TennCare Redetermination. Chris Coleman, Staff Attorney

Transcription

1 TennCare Redetermination Chris Coleman, Staff Attorney

2 What the law requires

3 Periodic Redetermination of Medicaid Eligibility By federal law, all Medicaid (TennCare) enrollees must have their eligibility redetermined every 12 months. 42 CFR (a) and (b)

4 Periodic Review Periodic renewal of Medicaid eligibility. (a) Renewal of individuals whose Medicaid eligibility is based on modified adjusted gross income methods (MAGI). (1) Except as provided in paragraph (d) of this section, the eligibility of Medicaid beneficiaries whose financial eligibility is determined using MAGI-based income must be renewed once every 12 months, and no more frequently than once every 12 months. 42 CFR (a)

5 Reconsideration (iii) Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination, or a longer period elected by the State, without requiring a new application. 42 CFR (a)

6 According to the TennCare Rules: REDETERMINATION shall mean the process by which [DHS] evaluates the ongoing eligibility status of TennCare Medicaid and TennCare Standard enrollees. This is a periodic process that is conducted at specified intervals or when an enrollee s circumstances change. The process is conducted in accordance with TennCare s, or its designee s, policies and procedures. TennCare Rule

7 The State is Required to Extend coverage for all enrollees whose current eligibility can be determined by review of records already available to the state. ( Ex parte review ) Send to enrollees notices that are prepopulated with any information already available to the state.

8 The State is Required to Afford enrollees an opportunity to provide any missing information or documentation. Provide assistance in person & by phone. Assess enrollees eligibility in all open categories of TennCare.

9 The State is Required to If ineligible for TennCare, determine eligibility for other insurance affordability programs (CoverKids, PTCs, CSRs). Electronically transfer files to the Marketplace for those determined eligible for other insurance affordability programs. Notify enrollees of the state s determination.

10 The Enrollee is Required to Keep TennCare informed of any changes in contact information. Report changes in income and/or household composition. Fill out and return redetermination packets within 40 days. Provide supporting documentation, as requested by the state.

11 Redetermination Process

12 Three Phases Phase 1: SNAP match (May & September 2015) Phase 2: confirmation mailing (October-December 2015) Phase 3: renewal packet (December 2015, January 2016, & present)

13 Phase 3 December 2015: Pilot group of 10,000 June 2016: Process resumed February 2016: Redetermination halted Now: Redetermination of 100,000+ people

14 Challenges in Completing the Renewal Packet

15 Six Challenges: 1. Extensive requests for information 2. Enrollees may not receive the redetermination packet 3. Individualized barcodes on packets 4. Eligible immigration statuses 5. Resources/assets 6. Enrollees may fail to take timely action

16 Challenge 1: Extensive requests for information

17 Renewal Packet The state still lacks a functioning computer system for determining eligibility. TennCare is mailing massive 98-page Renewal Packets to families to complete and return. NOT pre-populated with information already available to the state.

18 What s in the 98-page packet? English version 47 pages Notice (includes deadline for returning packet) 3 pages Renewal Packet 13 pages Appendix A (screening for some non-magi categories) 4 pages Appendix B (for American Indian or Alaska Native family members) 1 page Instruction packet 26 pages Spanish version 51 pages

19 LTSS Renewal Packet Long-Term Services and Supports (LTSS) redetermination packets are 119 pages. The state said they resumed LTSS redeterminations in August.

20 Challenge 2: Enrollees May Not Receive the Redetermination Packet

21 Enrollees May Not Receive the Redetermination Packet Census Bureau s research shows that at least one third of enrollees are likely to have moved since their eligibility was last determined. Even if they reported a change in address, they can t be sure the new address made its way into the system.

22 Change of Address Form TennCare Change of Address Reporting Form English: ts/changeofaddressform.pdf Spanish: ts/changeofaddressformsp.pdf TJC recommends reporting changes by fax and saving fax receipt.

23 Was I supposed to get a packet? 1. Call Tennessee Health Connection (TNHC) and ask what address they have on file. Update address if needed. 2. Ask TNHC if you were supposed to get a redetermination packet. 3. If yes, request that TNHC sends you a new redetermination packet.

24 Challenge 3: Individualized Barcodes

25 Individualized Barcode Barcode on bottom, left-hand side is unique to each renewal packet & on every page.

26 Do NOT make copies of the redetermination packet for other people to use.

27 Individualized Barcode Do not make copies of the packet for others to use if their TennCare or CoverKids ended! Renewal Packet, page 1 of 13

28 What if multiple family members receive a packet? Each family member who receives a packet must fill it out in its entirety. If some family members get a packet and others do not, call Tennessee Health Connection (TNHC) and ask who was supposed to receive the packet. If someone was supposed to receive a packet but didn t, ask TNHC to send another one.

29 Challenge 4: Eligible Immigration Statuses

30 Eligible Immigration Statuses Renewal Packet, page 3 of 13

31 Instruction Packet: Eligible Immigration Statuses Instruction Packet, page 4 of 26

32 Qualified Immigrants LPR: Lawful Permanent Residents (green card) Refugees Asylees Aliens paroled in the U.S. Aliens whose deportation is being withheld Battered immigrants and children Cuban/Haitian entrants Aliens granted conditional entry Victims of a severe form of trafficking, e.g. human trafficking

33 Treated like Qualified Aliens for TennCare & CoverKids Eligibility Amerasian Immigrants Aliens who are members of a Federally-recognized Indian tribe American Indians born in Canada Aliens who are honorably discharged veterans or active duty members of the U.S. Armed Forces, plus their spouse and dependent children Afghani and Iraqi aliens granted Special Immigrant Status Aliens who are victims of a severe form of trafficking

34 Time-Related Requirements 5-year bar: period of ineligibility for all federally-funded benefits, including full TennCare and CoverKids Only applies to certain groups of qualified immigrants

35 Included in the 5-Year Bar Legal Permanent Residents (LPR) admitted on or after 8/22/96 I-551 with various codes Aliens paroled for at least 1 year I-94 with code 212(d)(5) or other language indicating parole status Battered immigrants and children Petition for: Immediate relative status; Classification to immigrant status based on relationship to a lawful permanent resident alien; or Suspension of deportation and adjustment to lawful permanent resident status.

36 Exempt from the 5-Year Bar LPRs (admitted before 8/22/1996) LPRs who first entered the country under another exempt category (i.e. as a refugee) and who later converted to LPR status Victims of a severe form of trafficking Refugees, asylees, and other humanitarian immigrants Aliens who are discharged veterans Aliens who are on active duty in the U.S. military Aliens who are the spouse or unmarried dependent child of an veteran or active member of the U.S. military Members of a Federally-recognized Indian tribe American Indians born in Canada

37 Challenge 5: Resources/Assets

38 Resources: Property No designation of homestead Homestead Appendix A, Page 3 of 4

39 Challenge 6: Enrollees May Fail to Take Timely Action

40 Timeframes 40 days to fill out and return the redetermination packet. Failure submit packet or document eligibility will result in termination of TennCare. 10 days to respond to request for more information.

41 What if an enrollee s TennCare is terminated? 10 days from notice of termination to request an appeal with continuation of benefits. (Save fax receipt!) 90 days from date of termination to submit the redetermination packet and additional information (if applicable) in order to be reinstated.

42 WARNING! TennCare has sent termination notices to people who were included in the December and January redetermination mailings and who did not respond to the packet.

43 How can an enrollee get help with the Renewal Packet?

44 Resources/Assistance This year s redetermination process looks different than in previous years. Enrollees do not have a case worker they can contact.

45 Resources/Assistance Renewal Packet, page 11 of 13

46 Resources/Assistance

47 Resources/Assistance

48 Safety Nets

49 TennCare Standard Children under 19 who are on TennCare Medicaid but become ineligible due to increase in earned household income can sometimes roll into TennCare Standard. No access to employee health insurance. Eligible if they are either Below 217% FPL, or have a qualifying health condition

50 TennCare Standard Renewal Packet, page 11 of 13

51 Transitional TennCare For low-income families who lose TennCare due to income. Details under new eligibility rules are still unclear. Categorical: Must have been covered in TennCare for at least 3 of the last 6 months. Income: Must have income below 185% FPL. Transitional TennCare available to family for up to 12 months.

52 Gap-Filling Rule (i) If the household income of an individual determined in accordance with this section results in financial ineligibility for Medicaid and the household income of such individual determined in accordance with 26 CFR 1.36B- 1(e) is below 100 percent FPL, Medicaid financial eligibility will be determined in accordance with 26 CFR 1.36B-1(e). 42 CFR (i)

53 Gap-Filling Rule Why: Because eligibility for TennCare and premium tax credits use different methodologies, the same income can be computed differently for different insurance affordability programs. Household composition varies as well. Purpose: To keep you from losing TennCare due to an income calculation that makes you ineligible for premium tax credits. Effect: Seamless eligibility for insurance affordability programs.

54 Screening for the Gap-Filling Rule 1. Is the person currently categorically eligible in a MAGI category? 2. If yes, does their monthly income make them eligible for TennCare? 3. If no, is the person s projected household yearly income below 100% FPL? 4. If yes, the person remains eligible for TennCare under the Gap-Filling rule.

55 Gap-Filling Rule Flowchart Yes Categorically eligible under MAGI? No Yes Eligible monthly income? No Apply for TennCare! Projected annual household income below 100% FPL? Yes No Eligible under gapfilling rule

56 How to Apply the Gap-Filling Rule 1. Return the redetermination packet. Provide supplemental income documents and a letter explaining that the enrollee is eligible under the Gap-Filling Rule. Save proof of sending. 2. If the person s TennCare is terminated, file an appeal and ask for continuation of benefits (COB). Say they are eligible under the Gap- Filling Rule. 3. Call TJC.

57 Gap-Filling Rule Main Takeaway If the individual 1. Is categorically eligible for MAGI (e.g. parent/caretaker relative, children), AND 2. Has annualized income below 100% FPL THEN they maintain TennCare eligibility.

58 Main Takeaways

59 Main Takeaways Contact Tennessee Health Connection to make sure they have the correct address on file, and report any changes. If you have not received a packet, ask Tennessee Health Connection if you were due to receive one. Make copies of all documents you send to TennCare, and ask the post office for proof of mailing.

60 Document everything! Main Takeaways Complete and return all forms by the deadlines. If terminated, appeal with continuation of benefits within 10 days of the termination notice. If an enrollee has a disability, call Tennessee Health Connection and tell them. Ask them for help completing the forms. Keep a record of the call.

61 Call TJC! If an enrollee has trouble getting assistance with filling out and returning the packet. If you think the individual is eligible under the Gap-Filling Rule. If you encounter any other problems with the redetermination process, especially for enrollees with high medical needs.

62 Closing the Coverage Gap Katie Alexander, Field Director

63 Closing the Coverage Gap What is the coverage gap, and how does it affect Tennessee? What s the solution? How do we get there?

64 What is the Coverage Gap? 280,000 Tennesseans have no access to health care coverage. 31 other states have closed their gap.

65 How is Tennessee Impacted? our health care infrastructure our neighbors our economy

66 Our Neighbors

67 Low-income, AND Child Parent Pregnant woman Woman with breast/cervical cancer Some with federallydetermined disabilities Income over $12,000 for 1 $16,000 for 2 $20,000 for 3 $24,000 for 4

68 280,000+ Tennesseans 54% work at low wage jobs 24,000 uninsured veterans Many can t work, but would if they could Our Neighbors

69 Our Neighbors Reduced use of timely preventive care services Medical Debt Catastrophic illness

70 Our Health Care System

71 Our Health Care System Hospitals Why are our hospitals more at risk now?

72 Hospitals At least 7 hospitals have closed or drastically cut services 4 counties have been left without a hospital 27 more at risk

73 Our Health Care System Cost of Uncompensated Care

74 Our Health Care System Preventive Care It is estimated that closing the gap would result in 16,000 more diabetics receiving diabetes medications 10,000 fewer people with catastrophic medical expenses 9,000 more women receiving mammograms 300 fewer deaths per year

75 Our Economy

76 Our Economy

77 Our Economy Plan to Close the Gap

78 Our Economy 100% 95% 94% 93% 90% 90% 90% 90%

79 Our Economy Hospitals Local taxes? Federal Government $0

80 Our Economy per year

81 Our Economy

82 Our Economy Janitors Construction workers Deli owners Landscapers Local businesses

83 Our Economy KY vs. TN Kentucky accepted the federal dollars to expand coverage, and has already seen: $1.16 billion infusion into economy Reduction of $1.15 billion in uncompensated care charges 5,400 new jobs in health care services 12,000 new jobs in administrative and support services

84 Who else is for this? 64% Tennesseans support closing the gap 19% oppose 49% Republicans support 28% oppose 42% Tea Partiers support 40% oppose

85 Who else is for this? Hospital Leaders

86 Business Leaders Who else is for this?

87 Who else is for this? Advocacy Groups

88 We need to close the gap. Whatever it s called, Tennessee needs a solution: A plan created by Tennesseans A plan approved by the federal government A plan that can pass in the legislature

89 3-Star Healthy Pilot Created by task force of 6 legislators Closes coverage gap in 2018 Work in progress Phase 1 Veterans, mentally ill under 138% federal poverty line months Circuit Breakers Phase 2 Remainder of people in coverage gap

90 What s the deal with it? It s more conservative than Insure TN. But Task force members are sincere CMS and TennCare are working on circuit breakers together It closes the gap Only ship leaving the harbor

91 What s the process now? Task force and TennCare work with CMS CMS will only approve a plan that will close the gap Task force brings the plan to the legislature in early 2017 If it passes, the coverage gap is to close in 2018 If it fails, we don t know when the next opportunity will be

92 Let s make sure it passes. We need to do everything we can to make sure that by 2017, our legislators pass a plan to close the gap. This will require all hands on deck.

93 Navigators and CACs You have a powerful voice in this. Stories make the difference. You can help others advocate, tell their story, and change the health care system in our state.

94 Use the Consent Form! Make copies and keep them on you! Need the clinic logo on it? We ll send you the word doc! Need us to make a HIPAA pitch to your clinic? You bet!

95 What does TJC do? Provide trainings Help clients one-on-one Advocate for Tennesseans

96 Join TJC for a FREE 2-day training on Navigating TennCare When: Monday, October 24, 1:00 PM 5:00 PM Tuesday, October 25, 8:00 AM 1:00 PM Where: Curb Medical Learning Center St. Thomas West Hospital 4220 Harding Road Nashville, TN For more information or to register, go to:

97 Technical Assistance TJC will help troubleshoot complex cases that you have not been able to resolve on your own. You can refer complex cases to TJC for expert case management. Keila Franks at

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99 What is TJC s Independence Initiative? Independence helps seniors and adults with disabilities live independently Independence includes two areas of advocacy: CHOICES Long Term Services & Supports Public Benefit Enrollment

100 Public Benefit Enrollment Goal = help 1,000 Tennessee Seniors and adults with disabilities enroll in five core services: 1. Medicare Savings Programs (MSPs): help with paying Medicare copays and premiums 2. Medicare Part D Extra Help (LIS): help with paying for medication 3. TennCare: Tennessee s state Medicaid health insurance 4. Supplemental Nutrition Assistance Program (SNAP): Formerly called food stamps. Help with monthly food & groceries 5. Low Income Home Energy Assistance Program (LIHEAP): help with home heating and cooling bills

101 Public Benefit Enrollment We help seniors and adults with disabilities across the entire state of Tennessee We help with all enrollment steps from start of application to receiving of benefits All services are free! Please Contact: Jana Hall, Senior Outreach & Enrollment Coordinator , ext.203 toll free

102 Thank you for joining us! Of all the forms of inequality, injustice in health care is the most shocking and inhumane. -Martin Luther King, Jr.