illinois medicaid updated september 2015 © ageoptions 2015. all rights reserved. 1

Illinois Medicaidupdated September 2015

© AgeOptions 2015. All rights reserved.

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What We Will Cover Today

What is Medicaid?

Medicaid Eligibility

Categories of Medicaid Coverage

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Medicare & Medicaid

Medicaid Waiver Programs

What We Will Cover Today (continued)

Medicaid Spenddown

Applying for Medicaid

Maintaining Medicaid Coverage

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Medicaid Coordinated Care

What is Medicaid?

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What is Medicaid?

Health insurance program Health insurance program Must have low incomeMust have low income

Federal government

Federal government

State government

State government

Payer of LAST RESORTPayer of LAST RESORT

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What is Medicaid?

IL Department of Healthcare

& Family Services (HFS)

IL Department of Healthcare

& Family Services (HFS)

IL Department of Human Services (DHS)

IL Department of Human Services (DHS)

MEDICAIDCARD

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• Low income - based on federal poverty levels (FPL)

• Prior to the Affordable Care Act (ACA), Medicaid required that you fit into a “vulnerable” category group in addition to being low income

• Affordable Care Act Medicaid now has coverage for individuals who have low incomes but do not fit into one of the prior categories

• New “ACA Adult” Medicaid category added to the old Medicaid categories - it does not replace them.

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• In order to qualify for most Medicaid programs, a person must be a U.S. citizen or “qualified non-citizen.”– Exceptions: AllKids, Moms and Babies

• Qualified Non-Citizens must be either a Lawful Permanent Resident (LPR) in U.S. legally for 5 years or more or a member of a special immigrant group such as:

– Refugee or Asylee– U.S. military or veteran and their dependents– Admitted under VAWA (Violence Against Woman Act)– Cuban or Haitian– And More…

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Categories of Medicaid Coverage

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• Children up to age 19• Covers unauthorized non-citizen children• Income threshold = 300% FPL

– Premium required if income over 150% FPL– Will have a higher share of costs (copays, etc.) if

higher income

• www.allkids.com • 1-866-ALL-KIDS (1-866-255-5437)

All Kids

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• Covers pregnant women - outpatient and inpatient hospital services while pregnant and insurance for 60 days after baby is born

• Covers child born while on Moms & Babies up to age 1 (then transferred to All Kids)

• Covers unauthorized non-citizens• Income threshold = 200% FPL• www.allkidscovered.com/pregnant.html

Moms & Babies

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• Covers parents and caretakers (must be living with child up to age 18)

• Must be U.S. citizen or qualified non-citizen (legal permanent resident for at least 5 years or member or another qualified immigrant group)

• Income threshold = 138% FPL– Small co-pays and premiums at certain levels of

income

• www.familycareillinois.com

Family Care

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• Covers people who are age 65 or older, blind, or disabled

• Must be U.S. citizen or qualified non-citizen (legal permanent resident for at least 5 years or member or another qualified immigrant group)

• Must Meet income AND asset standards*– Income threshold = 100% FPL– Assets: < $2,000 individual, < $3,000 couple– *AABD spenddown program explained later

AABD/SPD Medicaid

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• Health Benefits for Workers with Disabilities• People with disabilities (age 19-64) who are

working• Allowed to keep higher income/assets than others

– Income up to 350% FPL– Assets up to $25,000

• monthly premium $0 - $119 (depends on person’s income)

• www.hbwdillinois.com

HBWD Medicaid**HBWD eliminated in Governor’s proposed FY16 budget

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• Special Medicaid category for people who have received Supplemental Security Income (SSI) for at least one month, meet Social Security’s disability requirement, and need Medicaid to be able to keep working

• Individuals on 1619 Medicaid are allowed to keep AABD Medicaid, even if they have higher income/assets than the regular AABD or SSI limits

More information about 1619 Medicaid available here: https://www.socialsecurity.gov/disabilityresearch/wi/1619b.htm

1619 Medicaid

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Affordable Care Act (ACA) Adult Medicaid

New Adult Medicaid Program created by the ACA for individuals who meet the following requirements:

– age 19-64– Does not qualify for existing Medicaid programs– income less than 138% of the Federal Poverty

Level (FPL)– Citizen or qualified non-citizen

NOTES: NO asset/resource test; no “disability test”

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Medicaid for Former Foster Children

• New Medicaid program created by the ACA for individuals who lost medical coverage as a result of aging out of the foster care program at age 18 or older

• No income/asset limit for this group

• To be eligible, must be:• Age 19-25

• Not qualified for Medicaid benefits under Family Health Plans or AABD Medicaid

• A recipient of foster care assistance through the Department of Child and Family Services (DCFS) until they aged out at age 18 or older

• Illinois resident with a Social Security number or proof of application for a Social Security number

• U.S. citizen or qualified noncitizen

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Medicaid Waiver Programs

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Medicaid Home and Community-Based Service (HCBS) Waiver Programs

• “A waiver is a program that provides services that allow individuals to remain in their own home or live in a community setting. Illinois has nine HCBS waivers. Each waiver is designed for individuals with similar needs and offers a different set of services.”

Quote from Illinois Healthcare and Family Services website: http://www2.illinois.gov/hfs/MedicalPrograms/HCBS/Pages/default.aspx

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• 9 Illinois HCBS Waiver Programs:– Children and Young Adults with Developmental Disabilities – Support Waiver– Children and Young Adults with Developmental Disabilities – Residential Waiver– Children that are Technologically Dependent/Medically Fragile– Persons with Disabilities– Persons with Brain Injuries– Adults with Developmental Disabilities– Persons who are Elderly– Persons with HIV or AIDS– Supportive Living Facilities

• Fact sheets on each waiver program (who is affected, services included, etc.) available here: http://www2.illinois.gov/hfs/MedicalPrograms/HCBS/Pages/default.aspx#HCBSwaivers

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Medicaid Home and Community-Based Service (HCBS) Waiver Programs

Medicare & Medicaid (“Dual Eligibles”)

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What is Medicare?

• Federal health insurance program• To qualify, must be:

– Citizen or Qualified Non-Citizen– 65 or older

OR– Under 65 with a qualifying disability

• Lou Gehrig’s disease (ALS)• End Stage Renal Disease (ESRD)

OR• Receiving Social Security Disability Insurance

(SSDI) for at least 24 months

NOTE: Disabled Adult Children (DAC’s) may also qualify for Medicare based on their parents’ work record

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People with both Medicare and Medicaid – Healthcare Coverage

If you have Medicaid and:

• Original Medicare -You may go to any doctor that accepts Medicare

and Medicaid and you will pay only Medicaid co-pays for covered services.

• A Medicare Advantage Plan HMO- If you go to doctors and hospitals that are in that

plan’s network and accept Medicaid- You will pay low co-pays or coinsurance for

covered services.

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People with both Medicare & Medicaid – Drug Coverage

• Most drugs covered by Medicare Part D plan• Automatically qualify for Medicare Extra Help

program (federal program that helps with Part D plan drug costs) – do not need to apply

• Join a Part D plan or one will be assigned

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Medicaid Spenddown

(AABD/SPD Medicaid ONLY)

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Medicaid Spenddown

• Only available to adults on AABD/SPD Medicaid, children, and pregnant women

• Works like an insurance deductible – if an individual’s income/assets are too high to qualify for Medicaid outright, Medicaid will pay for medical care when the person can show that he owes or has paid medical bills in the amount of the difference

• EXAMPLE: individual with monthly income $100 higher than Medicaid income limit monthly spenddown = $100

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Medicaid Spenddown

• Must meet spenddown amount at least one time every three months to stay enrolled in the program • Note: An individual must also meet his/her spenddown

amount each of the three months if s/he wants Medicaid medical benefits for those months.

• An individual who does not meet spenddown at least once in three months must reapply for Medicaid

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Medical Expenses that can be used to meet Spenddown

• Unpaid medical bills

• Receipts for medical services and supplies

• Health insurance premiums– including Part B premiums

• Transportation to and from medical services

• Any co-pays and deductibles on medical care

• Cost of services received through Medicaid waiver programs

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Pay-In Spenddown

• Pay the spenddown amount to meet the spenddown requirement– Must enroll to participate in Pay-In Spenddown

• https://www.dhs.state.il.us/page.aspx?item=33904• To enroll, must submit enrollment form. Call HFS

Health Benefits hotline (800-226-0768) and ask for Pay-in Spenddown Unit.

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Medicaid Spenddown and Extra Help

• If someone with Medicare also has Medicaid (even for 1 month through “spenddown” program), s/he will be automatically enrolled in full Extra Help/LIS

– Meets spenddown at least one month between January and June = qualifies for Extra Help for the remainder of the calendar year

– Meets spenddown at least one month between July and December = qualifies for Extra Help for the remainder of the calendar year AND all of the next calendar year

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Medicaid Spenddown Resources

• Illinois Department of Healthcare and Family Services brochure on Medicaid spenddown: http://www2.illinois.gov/hfs/MedicalPrograms/Brochures/Pages/HFS591SP.aspx

– How spenddown works– Medical expenses that can be used to meet spenddown– Using unpaid medical bills– Using receipts for medical expenses– Pay-in spenddown– Etc.

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Applying for Medicaid

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Medicaid Applications and Income

• All Medicaid categories except for AABD and HBWD now use Modified Adjusted Gross Income (MAGI) calculations to determine someone’s eligibility for Medicaid– Based on the tax filing unit (if an individual is a tax

dependent, need to include parents’ income, even if the individual is on SSI)

• AABD and HBWD still use the same methodology as pre-ACA

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Applying for Medicaid• Application for Benefits Eligibility (ABE):

www.abe.illinois.gov (800)843-6154

• Can apply for multiple benefits through ABE:• Existing Medicaid programs (AABD, HBWD,

AllKids, Family Care, Moms and Babies)• New Adult Medicaid• AABD and TANF cash benefits• Food Stamps (SNAP)• Medicare Savings Programs

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Applying for Medicaid (if not applying through ABE)

• Download the application: http://www.dhs.state.il.us/page.aspx?item=33698

• Follow the directions on the form. Type in as much information as you can. If you cannot answer all of the questions, that is ok. You must include your name and address. You may print out the application and write on it if you prefer. You must sign the form.

• Once you've completed the application, carry, mail or fax it to your local DHS Family Community Resource Center. Use the DHS Office Locator to locate your local office: http://www.dhs.state.il.us/page.aspx?module=12

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Applying for Medicaid (if not applying through ABE)

• While ABE is the fastest and easiest way to apply for Medicaid for most populations, aper applications may work better for certain people. Two examples are:

– People are 18+ newly approved for SSI and applying for Medicaid for the first time

– Children and adults who participate in Medicaid waivers (i.e. the three waivers that waive parental income for children) and are applying for Medicaid for the first time.

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ABE Verification

• Proof of age

• Proof of income and resources

• Proof of U.S. Citizenship or legal residence

• Medical proof of disability or blindness (if applicable)

• Proof of state residency

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ABE Tips

• If an individual age 18+ has a court-appointed guardian and is not able to fill out application on their own, must submit guardianship paperwork with application

• If an individual is age 18+ and does not have a court-appointed guardian but is not able to fill out application on their own, must have a designated Power of Attorney (POA) and submit POA forms with application

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ABE Resources• Cook County Benefits Access ABE Toolkit:

– ABE Training Materials– Useful forms for accessing DHS benefits– Tips and Best Practices– Links to Important DHS Policy Manual pages– Additional Resources

http://www.ageoptions.org/services-and-programs_ABEToolkit.html

• Cook County Benefits Access Cover Sheet for ABE applications:

http://www.ageoptions.org/services-and-programs_MMW-MedicaidandManagedCare.html#DHSCoverSheet

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ABE Resources• Guide to ABE for consumers:

http://www2.illinois.gov/hfs/SiteCollectionDocuments/CompletingABEApplication.pdf

• Guide to ABE for professionals: http://www2.illinois.gov/hfs/SiteCollectionDocuments/GuideABECommPartners.pdf

• Department of Healthcare and Family Services (HFS) webinar on ABE: https://www.youtube.com/watch?v=BK_qS6zTXFc

• HFS ABE FAQ: http://www2.illinois.gov/hfs/sitecollectiondocuments/aca_faqapplicationformedicalassistance.pdf

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ABE Resources

• Starting Strong Collaborative ABE webinar:http://ilmaternal.org/docs/webinars/20131121_ACA%20_%20ApplicationforBenefitsEligibility(ABE).wmv (webinar produced by Health & Disability Advocates and EverThrive)

• Starting Strong Collaborative ABE webinar slides:http://ilmaternal.org/docs/webinars/ACA_&_ABE112013.pdf

• Starting Strong Collaborative ABE Q&A:http://www.ilmaternal.org/docs/webinars/QuestionsandAnswersfromtheABEWebinar.pdf

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• Report changes in address, income, or household size right away– Call ABE call center (800)843-6154 or local DHS

FCRC to report changes– HFS/DHS send important communications via mail

– if address is not up to date, could miss important notices (e.g., redetermination notices)

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• Everyone with Medicaid will receive an annual “redetermination”

Medicaid ONLY:

Illinois Medicaid Redetermination Project (IMRP) - (855)458-4945

Medicaid + SNAPLocal DHS Family and Community Resource Center (FCRC)

Medicaid + Cash BenefitsLocal DHS Family and Community Resource Center (FCRC)

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• Watch mail for redetermination letters; mail back right away (usually only have about 10 days to respond)– Can request more time if needed – call IMRP or DHS office

• If person does not respond, Medicaid will be cancelled

• If letter is lost, can request a new one– Call IMRP call center or DHS FCRC, depending on who sent

the letter

• If cancelled, can be reinstated within 90 days– Contact IMRP call center or DHS FCRC, depending on who

sent the letter

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Find a Medicaid Provider or Get Information about Covered Services

If someone is in a Medicaid managed care plan, contact the plan to find network providers.

Illinois Health Connect Hotline: (877)912-1999

Illinois Health Connect Hotline: (877)912-1999

Find a provider:

Covered Services:

HFS Health Benefits Hotline: (800)226-0768

HFS Health Benefits Hotline: (800)226-0768

DentaQuest:(888)286-2447DentaQuest:

(888)286-2447

Dental Providers/Services:

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• “Managed Care” vs. “Coordinated Care”• In certain geographic areas of Illinois, some

individuals with Medicaid coverage may be enrolled in managed care plans or coordinated care entities– Several different programs:

• Managed Care Programs – Integrated Care Program, Medicare Medicaid Alignment Initiative, Family Health Plans/Affordable Care Act Health Plans

• Coordinated Care Projects – Accountable Care Entities, Care Coordination Entities

– Map of Medicaid managed and coordinated care projects: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCExpansionMap.pdf

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Integrated Care Program (ICP)

• Individuals on AABD Medicaid or HBWD Medicaid who are:– Age 19 or older

– On FULL Medicaid (no spenddown)

– NOT on Medicare

– NOT on other private insurance (that covers hospital & doctor visits)

– NOT in the Illinois Breast and Cervical Cancer program

– Living in one of the program’s impacted counties

• Mandatory Program – will be automatically enrolled into a plan if they do not choose one *American Indians/Alaskan Natives will not be automatically enrolled into ICP but can voluntarily enroll if they wish

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Medicare Medicaid Alignment Initiative (MMAI)

• Individuals with full Medicare and full AABD Medicaid benefits who are:

– Receiving both Medicare Parts A and B– NOT enrolled in Medicaid with a spenddown– Age 21 or over– NOT enrolled in private insurance that provides health coverage (e.g.,

retiree or employer coverage)– NOT enrolled in a Medicaid waiver program for individuals with

Developmental Disabilities– Living in one of the program’s impacted counties

• NOT a mandatory program. People eligible for MMAI can enroll, change plans, or opt out of the program at any time.

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Family Health Plans/Affordable Care Act Adult Plans (FHP/ACA)

• Individuals who are enrolled in ALLKIDS, FamilyCare, or ACA Adult Medicaid and live in one of the impacted counties

• Mandatory Program – will be automatically enrolled into a plan if they do not choose one

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Care Coordination Entities (CCE’s) and Accountable Care Entities (ACE’s)

• Provider-based entities who provide care coordination to members (in most cases, the state has still been paying for medical services on a fee-for-service basis, while these entities received a capitated care coordination fee to provide care coordination services)

• Only available to certain populations in certain areas – children with special needs, certain groups of adults with disabilities, certain groups of older adults, etc.

– Not everyone has an option of joining a CCE/ACE

• Currently transitioning – must either achieve full capitation status on their own or partner with a managed care organization

– Members will receive letters explaining transition and options

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Illinois Health Connect

• Individuals who are NOT eligible for managed or coordinated care will receive information about Illinois Health Connect. Illinois Health Connect helps people with Medicaid in Illinois find and choose a “medical home” and primary care provider. – Information about Illinois Health Connect is available here:

https://www.illinoishealthconnect.com/clients/home.aspx

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Medicaid Managed Care Resources

• Make Medicare Work Coalition Resources on Medicaid Managed Care - Frequently Asked Questions documents for Professionals, recorded webinars, toolkit on navigating the plans, etc: http://www.ageoptions.org/services-and-programs_MMW-MedicaidandManagedCare.html#ManagedCareToolkit

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Impact of 2015 State Budget Impasse on Medicaid

• July 10 - HFS issued a provider notice saying that Medicaid claims will be paid once budget is passed: http://www.hfs.illinois.gov/assets/071015n.pdf

• July 23 – federal judge ruled that Medicaid must continue paying Medicaid providers who serve children in Cook County (Memisovski v. Wright and Beeks v. Bradley)– State decided to apply this ruling to all Medicaid providers

throughout the state– 8/27 – judge gave the state until September 16 to become

current with payments

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Impact of 2015 State Budget Impasse on Medicaid

• August 18 – federal judge ordered Illinois to pay for services entitled to Ligas class members (more than 10,000 people with developmental disabilities living in CILA’s, ICF-DD’s, or Community-Based Settings, or living at home but in need of community-based services)– September 1 – providers being paid

• Lawyers from Shriver National Center on Poverty Law are also currently in court regarding payment for Community Care Program services for people with Medicaid (Persons who are Elderly Waiver)

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Thank you!

For more information and resources, visit our MMW webpage about Medicaid and Managed Care at:http://www.ageoptions.org/services-and-programs_MMW-MedicaidandManagedCare.html

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