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1) What is 209(b) status?
209(b) status refers to a state’s method for determining Medicaid eligibility under the aged, blind, and disabled coverage category. Specifically, this term refers to a section of a Social Security Act amendment. In a “209(b) state,” the Medicaid agency uses at least one standard that is more restrictive than the criteria used in the Social Security Administration’s (SSA’s) disability determination method. States with 209(b) status have a separate or additional process for determining disability Medicaid eligibility.
2) What is 1634 status?
1634 status refers to a state’s method for determining Medicaid eligibility under the aged, blind, and disabled coverage category. 1634 is a section of the Social Security Act. In a “1634 state,” the Medicaid agency uses the same definition of disability as the Social Security Administration (SSA) for the purposes of determining eligibility for the Medicaid disability coverage category. When determining Medicaid eligibility for the disabled, the 1634 state accepts and gives precedence to SSA disability determinations for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI). With 1634 status individuals deemed eligible for SSI by SSA are automatically enrolled in Medicaid.
3) What is the difference between a state that has 209(b) status and a state that has 1634 status?
The two types of states use different definitions of disability to determine eligibility for the Medicaid program. In a 1634 state, individuals eligible for Supplemental Security Income (SSI) are automatically enrolled in Medicaid, and Social Security Disability Insurance (SSDI) disability determinations are accepted. In a 209(b) state, individuals granted SSI or SSDI by the Social Security Administration (SSA) must complete a separate Medicaid application and disability determination process. Finally, 209(b) states are required to operate a Medicaid spend down program, while 1634 states are not required to do so.
4) What is a spend down program?
A spend down program allows individuals who have income over the eligibility threshold but otherwise meet the requirements for Medicaid under the aged, blind, or disabled (ABD) categories to receive coverage. In a spend down program, individuals with income over the limit for eligibility are assigned a ‘spend down’ or an amount of medical expenses they must incur each month prior to receiving Medicaid benefits. An individual’s ‘spend down’ is equal to the amount his or her income exceeds the eligibility limit after accounting for applicable income deductions.
5) What are the key issues associated with the spend down program?
The spend down program is burdensome for both members and providers. Members do not have continuous coverage for services, and providers sometimes experience difficulty collecting member payments before the individual’s spend down amount has been met.
6) Why is Indiana transitioning from 209(b) to 1634 status?
As Medicaid accepts disability determinations from the Social Security Administration, this transition will eliminate the duplicative requirement that aged, blind and disabled applicants – who receive Supplemental Security Income (SSI) also complete a second application and go through an eligibility determination with Indiana Medicaid
It also eliminates the unpopular “spend down” program, which is administratively cumbersome for both members and providers. By converting to 1634 status the state will no longer be required to operate the program. Individuals enrolled in the spend down program are not eligible for the new premium tax credits available to purchase health insurance on the federal Marketplace, and eliminating spend down will ensure the state is not duplicating federal assistance programs.
The transition should also result in significant net savings for the State of Indiana and a net increase in the number of Hoosiers with disability coverage.
7) Why has the state not transitioned to 1634 status previously?
Converting to 1634 status requires elimination of the current spend down program. A conversion prior to 2014 would have left current spend down recipients who do not have Medicare without health coverage options. The federal programs implemented as part of the Affordable Care Act provide new coverage options for current spend down participants and transitioning them to other coverage creates savings that can be used to accommodate the additional Supplemental Security Income recipients.
8) Will the State save money because of the 1634 transition?
Yes. Estimated state and federal savings from the 1634 transition are $35.7 million in State Fiscal Year 2015 and each subsequent fiscal year.
9) When will the 1634 transition take place?
The transition is scheduled to occur on June 1, 2014. All coverage, policy, and operational changes will be effective on that date.
10) How many people use the spend down program today?
A total of 76,010 people use the spend down program as of December 2013. This figure excludes long-term care and waiver Medicaid recipients who may currently participate in the spend down program but will be able to continue to qualify for similar coverage with a Miller trust. Please see the Transition Plan for Waiver and Institutionalized Individuals FAQ below for more information.
11) What is the State doing to prepare for the 1634 transition?
To prepare for the 1634 transition the State has developed new programs to address possible coverage gaps for spend down members. In addition, the State is preparing for enrollment shifts and working through changes to operational and administrative processes and applications. The State has also focused on developing outreach strategies for Medicaid enrollees and key stakeholders and will communicate directly with them regarding the specific impacts.
12) What will happen to the people using the spend down program today? Will they lose coverage?
The specific impact to current spend down beneficiaries depends on their income and whether they are eligible for Medicare. The state is making eligibility changes to existing programs to expand the number of individuals that will be eligible. For some individuals this will result in increased benefits. Additionally, the state has created a new program to minimize the impact to participants with severe mental health issues. The changes will result in services being targeted to more vulnerable low-income Hoosiers. There are four main groups of individuals that may experience changes in coverage: individuals dually eligible for Medicare and Medicaid, individuals only eligible for Medicaid, individuals below 100 percent of the Federal Poverty Level and individuals with mental illnesses. Each group will be impacted differently depending on what services they utilize today within the spend down program and their current income.
13) What will happen to current spend down beneficiaries with income below 100 percent of the Federal Poverty Level (FPL) after the transition?
The State is increasing the income eligibility threshold for full aged, blind or disabled Medicaid coverage to 100 percent of the FPL ($11,670 annually for an individual, $15,730 for a couple, and there may be a maximum annual deduction of income for a qualifying child of $4,432). All individuals eligible under the aged, blind or disabled category with income at or below that level are eligible for full Medicaid benefits. These individuals do not need to take any action. They will be automatically enrolled in full Medicaid effective June 1, 2014, and their spend down requirement will be eliminated.
14) What will happen to the dually eligible whose income exceeds 100 percent of the Federal Poverty Level and who are not eligible for full Medicaid benefits?
Many individuals dually eligible for Medicare and Medicaid will be eligible for the Medicare Savings Program, which provides coverage for the costs of Medicare coverage. Currently the spend down program provides support for qualified Medicare enrollees by paying for members monthly Medicare premiums and covering additional cost sharing when the members meet their spend down. As the current spend down program is being eliminated, the Medicare Savings Program’s income eligibility thresholds will be expanded in concert with the transition. This program will provide support for the costs of Medicare coverage for current qualifying spend down enrollees. See the Transition Plan for Duals FAQ section below for more information.
15) What will happen to individuals who are not dually eligible and whose income exceeds 100 percent of the Federal Poverty Level (FPL) and who are not eligible for full Medicaid benefits?
Individuals eligible only for Medicaid spend down with income in excess of 100 percent FPL will be eligible to purchase a qualified health plan on the federal Marketplace. Most will be eligible for premium tax credits and cost sharing reductions which will make this coverage more affordable than spend down. Some individuals with incomes slightly more than 100 percent FPL may qualify for the Healthy Indiana Plan. See the Transition Plan for Duals FAQ section below for more information.
16) What will happen to individuals with severe mental illness whose income exceeds 100 percent of the Federal Poverty Level and who are not eligible for full Medicaid benefits?
Many of these individuals will be eligible for the newly created Behavioral and Primary Healthcare Coordination program (BPHC).
17) What is the Behavioral and Primary Healthcare Coordination program (BPHC)?
Effective June 1, 2014, the BPHC program is a new home and community-based benefit for adults with serious mental illness who demonstrate impairment in self-management of healthcare needs. It is designed to assist individuals who do not otherwise qualify for Medicaid or other third party reimbursement for the level of intense services they need to function safely in the community.
18) What services does the Behavioral and Primary Healthcare Coordination program (BPHC) cover?
The primary purpose of BPHC is to provide continued Medicaid eligibility for Medicaid Rehabilitation Option (MRO) utilizers who currently qualify for Medicaid under spend down. Individuals who meet the eligibility criteria for BPHC and do not qualify for any other Medicaid category can gain access to Medicaid coverage, and therefore continued coverage of MRO, through this program.
For more information about the BPHC program, including eligibility and application process, please see the BPHC website.
19) Why will current members have changes in coverage? Is it possible to maintain current member status so that the new policies will not impact them?
Becoming a 1634 state means that the state is no longer eligible to operate its current spend down program. The elimination of this program impacts current member eligibility. Due to the implementation of other options, many current members will receive less costly more comprehensive coverage after the transition. In addition, the 1634 transition requires Indiana Medicaid to recognize the Social Security Administration’s disability determination as final. This means that most members that have disability denials or who do not have an SSA determination will need to seek them prior to their next progress report to ensure this factor does not impact eligibility. An SSA disability determination will grant eligible members additional benefits from SSA.
20) Since the State will accept Social Security Administration (SSA) disability determinations under 1634 status, do current members need to get an SSA determination to maintain coverage?
Current members do not need a disability determination with SSA to continue Medicaid coverage after the state’s transition to 1634 status. However, members currently receiving Medicaid who do not receive Supplemental Security Income or Social Security Disability Insurance (SSDI) are encouraged to apply for these benefits as they may be eligible for coverage. In addition, not having a determination of disability from the SSA may jeopardize future eligibility as most members will be required to have an SSA determination to pass their Medical Review Team progress report.
After June 1, 2014, new applicants who have not applied for SSA disability benefits will be required to file an application with SSA as part of their Medicaid application process. Please see the Post-1634 Transition Application Process for Individuals Seeking Disability Benefits FAQs below for more information.
21) If a current member does not have an SSA disability determination, how will that affect future eligibility for Indiana Medicaid?
Current members will be transitioned automatically without regard to their disability status with SSA. However, during all members’ next regularly scheduled Medical Review Team (MRT) progress report, disability status with SSA will be taken into account. To maintain eligibility most members will need an SSA disability determination at the time of their MRT progress report. Many current members already receive disability benefits from SSA, but it is recommended that current members without SSA disability status start the SSA application process prior to their next scheduled MRT progress report.
22) What individuals are dually eligible and how will they be impacted by the transition and loss of spend down?
Dually eligible individuals are eligible for Medicare and Medicaid. Such an individual could be eligible for Medicare due to being over the age of 65. In addition, individuals that are under the age of 65 and have a disability, as deemed by the Social Security Administration, may become eligible for Medicare benefits after two years. In concert with the transition, Indiana is increasing the income eligibility threshold for full aged, blind or disabled (ABD) Medicaid coverage to 100 percent of the Federal Poverty Level (FPL) or an income up to $11,670 annually for an individual, $15,730 for a couple, and $23,850 for a family of four. Therefore, current dually eligible spend down enrollees with incomes at or below this amount will be automatically enrolled in full ABD Medicaid coverage effective June 1, 2014. Current dually eligible spend down enrollees with income over the FPL (up to 185 percent of the FPL) will be eligible for the Medicare Savings Program.
23) How many dually eligible individuals use the spend down program today?
The total number of “duals” that use the Medicaid spend down program is estimated at 65,642 as of December 2013.
24) What services do dually eligible individuals use the spend down program today?
Dually eligible individuals primarily use the spend down program for assistance paying for Medicare premiums and cost sharing coverage. Members’ Medicare Part B premiums are always paid by spend down, however, their other cost sharing requirements are rarely large enough to allow them to meet their monthly spend down obligation and receive Medicaid coverage. On average, these individuals meet the monthly spend down amount only one or two months of the year.
25) With the income threshold for aged, blind or disabled Medicaid increasing to 100 percent of the Federal Poverty Level (FPL), how many duals will transition from spend down to full Medicaid coverage?
As of December 2013, there were 23,869 dually eligible individuals currently on the spend down program that have income below 100 percent FPL. As of June 1, 2014, these individuals will receive full Medicaid benefits without the requirement to spend down.
26) Do dually eligible spend down members with incomes at and below the Federal Poverty Level need to take action?
No action is required for current spend down members with incomes at or below 100 percent FPL. These individuals have been identified by Indiana Medicaid and will automatically be transitioned to full aged, blind or disabled Medicaid June 1, 2014.
27) What is the State doing to address the impact of the elimination of the spend down program on dually eligible individuals that will not be eligible for full aged, blind or disabled Medicaid?
The State has raised the income eligibility thresholds for the Medicare Savings Program to allow more dually eligible individuals to qualify. The majority of these individuals currently enrolled in the spend down program will be able to benefit from these programs that help pay for Medicare premiums, deductibles and cost-sharing.
28) What is the Medicare Savings Program?
The Medicare Savings Program is a Medicaid program that helps support Medicare out-of-pocket expenses for individuals. There are different categories within the Medicare Savings Program, and benefits vary. All categories offer payment for Medicare Part B premiums, and the most generous category also covers Medicare Part A and B deductibles, copayments and coinsurance for eligible beneficiaries.
29) What benefits do Medicare Savings Program Beneficiaries Receive?
Effective June 1, 2014, Medicare-eligible individuals with incomes between 100 and 150 percent of the Federal Poverty Level (FPL) will be eligible for and automatically enrolled in a program where they will receive payment for Part B Medicare premiums, the annual Part A and B deductibles and Medicare copayments/coinsurance. These individuals will be transitioned to coverage and will no longer be required to spend down each month to receive coverage for Medicare copayments, coinsurance or deductibles but will not be eligible for services that are not covered by Medicare. As of December 2013 there were 26,879 dually eligible spend down members with incomes between 100 and 150 percent FPL.
Dually eligible individuals with income between 150 and 185 percent FPL will be eligible for and automatically enrolled in a program where Medicaid pays Part B Medicare premiums. These members will continue to receive coverage for their Medicare Part B premiums but will no longer be eligible to spend down to receive coverage for Medicare cost-sharing and services not covered by Medicare. As of December 2013 there were 6,906 dually eligible spend down members with incomes between 150 and 185 percent FPL.
30) Do dually eligible spend down members with income between 100 percent and 185 percent of the Federal Poverty Level need to take action to enroll in the Medicare Savings Program?
No. Dually eligible members with income between 100 percent and 185 percent FPL do not need to take action. These individuals have been identified by Indiana Medicaid and will be automatically enrolled under the applicable category. Individuals will receive notice about program changes, and their new benefits and coverage will be effective June 1, 2014.
31) Will individuals that do not currently use the spend down program be eligible for the Medicare Savings Program?
Yes. Any dually eligible individual whose income is between 100 and 185 percent of the FPL and who meets the Medicare Savings Program resource limits (of $7,160 for an individual and $10,750 for a couple) will be eligible, effective June 1, 2014, regardless of whether he/she currently uses the spend down program. However, only those individuals transitioning from spend down will be auto-enrolled; others will need to submit an application to Indiana Medicaid to gain eligibility.
32) How many new individuals does the state estimate will be eligible for and enroll in the Medicare Savings Program (MSP)?
Changes to the MSP programs are estimated to make over 100,000 additional individuals eligible. Those individuals that gain eligibility and are not currently enrolled in the spend down program will need to apply for MSP and meet the income and resource requirements. Based on the rate at which eligible Hoosiers currently utilize these programs, the state expects to enroll 28,000 new individuals into the MSP.
33) Will there be some individuals that lose spend down benefits and are not eligible for the Medicare Savings Program?
Yes. About 7,997 dually eligible individuals will lose spend down benefits and have income that exceeds 185 percent FPL, so they are not eligible for the Medicare Savings Program.
34) What are the coverage options for dually eligible individuals that lose spend down benefits and are not eligible for the Medicare Savings Program?
These individuals may be able to purchase a Medicare Advantage plan to reduce out-of-pocket costs, and those over 65 will have access to Medigap supplemental coverage. Members with income up to 300 percent of the Federal Poverty Level with serious mental illnesses currently utilizing Medicaid Rehabilitation Option (MRO) services may maintain eligibility through the Behavioral and Primary Healthcare Coordination (BPHC) program. For free and unbiased counseling about their options, these members may call the State Health Insurance Assistance Program (SHIP) at 1-800-452-4800 (TTY: 1-866-846-0139) for more information on the BPHC program please see the BPHC website.
35) What are the options for dually eligible individuals on the spend down program that believe they should be eligible for a different coverage option than identified by the State?
These individuals will have the option of providing additional information on their current income and resources to have their eligibility reassessed for full aged, blind or disabled Medicaid, or a Medicare Savings Program. A modified redetermination notice will be included with member communications, which should be completed and returned to the State for re-assessment. Members will not be required to reapply for Medicaid to receive this assessment.
36) How many members use the spend down program today who are not also eligible for Medicare?
As of December 2013 there were 10,368 individuals using the spend down program who did not also have Medicare coverage.
37) How will individuals that only have Medicaid as a source of coverage and have income at or below 100 percent of the Federal Poverty Level (FPL) be impacted by the transition?
Members with income at or below 100 percent FPL will automatically be enrolled in full aged, blind or disabled (ABD) Medicaid coverage. As of December 2013, it was estimated that 2,882 members that are not eligible for Medicare and currently use the spend-down program as their primary coverage source will be eligible for full Medicaid coverage.
38) Do Medicaid only members on the spend down program with income at and below 100 percent of the Federal Poverty Level (FPL) need to take action to enroll in full aged, blind or disabled (ABD) Medicaid?
No. No action is required for current spend down members with income at or below 100 percent FPL. These members have been identified by Indiana Medicaid and will automatically be transitioned to full ABD Medicaid June 1, 2014.
39) How will Medicaid only members with income that exceeds 100 percent of the Federal Poverty Level (FPL) be impacted by the transition?
Members with incomes in excess of 100 percent of the FPL that use Medicaid spend down as their primary coverage source and who do not have Medicare coverage will be eligible to purchase a qualified health plan on the federal Marketplace.
40) How will Marketplace coverage compare with Medicaid coverage obtained via the spend down program?
Unlike the current spend down program, Marketplace coverage provides the opportunity for continuous coverage without interruption. Marketplace members are not required to meet a monthly spend down amount to receive coverage. Marketplace coverage options require payment of a monthly premium and cost-sharing when members receive services. However, with the application of available premium tax credits and cost sharing reductions, Marketplace plans will be more affordable than if individuals received coverage each month by meeting their current Medicaid spend down amount.
41) Will members receive the same services in Marketplace coverage that they can receive on spend down?
Marketplace plans are required to offer comprehensive coverage of the essential health benefits. This coverage will include the vast majority of services currently accessed by spend down members. Marketplace plans do not cover non-emergency transportation costs and members interested in dental services will need to elect to add them and pay the additional premium. Marketplace plans include some service limits for physical, occupational and speech therapies and home health but have no lifetime or annual maximum dollar limits on services.
42) Who is eligible for premium tax credits to help pay for a Marketplace plan?
Individuals and families with annual income up to 400 percent of the 2013 FPL ($45,960 for an individual, $62,040 for a couple or $94,200 for a family of four) may be eligible for premium tax credits.
43) How do individuals apply for coverage on the Marketplace?
Individuals may apply for coverage, premium tax credits, and cost sharing reductions and compare available qualified health plans by visiting http://www.healthcare.gov/. Trained navigators are available to help consumers with this process. Local navigators can be found at www.in.gov/healthcarereform. Individuals may also call the federal Marketplace for assistance with the application process at any time at 1-800-318-2596 (TTY1-855-889-4325).
44) When do non-duals with income over 100 percent of the Federal Poverty Level (FPL) need to apply for Marketplace coverage?
Spend down coverage will end June 1, 2014. To ensure that there is no gap in coverage, individuals should enroll in Marketplace coverage by May 15, 2014. Members that enroll after this date will not have coverage for the month of June. Individuals that were on the spend down program before will qualify for the 60 day Marketplace special enrollment period and will have until July 30, 2014, to enroll in a Marketplace product.
45) What are the options for non-duals on the spend down program who believe they should be eligible for a different coverage option than identified by Indiana Medicaid?
Non-duals who believe that their income is below 100 percent FPL and that they should be eligible for full aged, blind or disabled Medicaid may submit this information to Indiana Medicaid for consideration. Members do not have to reapply to Medicaid to have this determination completed. Non-duals that believe their income is different than assessed by the federal Marketplace should contact the Marketplace at http://www.healthcare.gov/ or 1-800-318-2596 (TTY1-855-889-4325).
46) How will individuals in the spend down program that receive home and community-based or institutional services be impacted?
Individuals currently using the spend down program to help pay for institutional or home and community based services will keep their current benefits. However, if a beneficiary’s monthly income exceeds $2,163 for an individual he or she will need to take action to establish a Miller trust as soon as possible to maintain eligibility.
47) What is a Miller trust?
A Miller trust is a legal arrangement for holding funds. It allows an individual with income over the Medicaid limit for institutional or home- and community-based services to qualify for Medicaid coverage. The Medicaid agency disregards income placed in the trust for the purpose of eligibility.
48) How does a Miller trust work?
An individual must place the portion of his or her monthly income that is greater than the current income standard of $2,163 into the trust. Individuals may apply certain deductions to these funds, and the remaining amount in the trust is paid to the institution or healthcare providers. On a monthly basis Miller trust funds will be used to pay for the cost of care, and Medicaid will pay for the care not funded by the trust. Upon the recipient’s death, any and all funds remaining in the Miller trust, up to the total cost of care, would be paid to Indiana Medicaid.
49) How many individuals currently receiving home- and community-based or institutional services may need to set up a Miller trust?
As of December 2013 the state has identified 226 members receiving home- and community-based services and 3,197 individuals receiving institutional services that may need to establish a Miller trust.
50) How will members know if they need a Miller trust to maintain Medicaid coverage for institutional or home and community-based services?
The members identified by Indiana Medicaid as needing to establish a trust will be notified. These members should take action as soon as possible to establish a Miller trust.
51) How is a Miller trust set up?
First, a Miller trust must be established as a legal entity. Then a trust account must be set up with a financial institution to receive the funds directed into it each month.
52) Is an attorney needed to set up a Miller trust?
FSSA has designed a Miller trust packet that provides step-by-step instructions and a template that members can use to establish a Miller trust. However, the agency recommends that members seek legal counsel to ensure that the template is completed properly and that all implications are understood. If a member does not have or cannot afford an attorney, he or she may also contact their institution’s business office or local Area Agency on Aging for a referral to a local attorney who can help for free or for a nominal fee. Members may also visit Establishing a Miller Trust website to access more information about a Miller trust, get step-by-step instructions on establishing a Miller trust, access a state-approved legal template, and locate additional free and low-cost legal resources.
53) When should impacted members establish a Miller trust?
Those members needing a Miller trust should take action to establish one as soon as possible to help pay for institutional care or home and community-based services.
54) What is the impact to member eligibility if they do not establish a Miller trust?
If income exceeds $2,163 monthly for an individual, a Miller trust must be established for individuals to be eligible for Medicaid. Members over this income limit that do not establish a Miller trust will lose their Medicaid eligibility. New applicants with income above this level must establish the trust before they apply for Medicaid.
55) If member income changes, is an adjustment needed to the amount of my income that is contributed to the Miller trust?
Yes. If a member’s income increases or decreases, the amount that member is required to contribute to his or her Miller trust will change. Most often, these changes happen around the first of the year when members may receive a cost-of-living increase in Social Security and/or pension payments. Around the first of the year members will receive a notice from the State notifying them about the new income eligibility thresholds for the year and providing instructions about how to calculate the amount they must contribute in order to continue eligibility. Members that receive this notice should take action to comply as soon as possible. It is the member’s responsibility to ensure the proper level of contribution to the Miller trust to maintain eligibility.
56) How will current Supplemental Security Income (SSI) recipients be impacted by the transition to 1634 status?
As part of the conversion to 1634, current SSI recipients will automatically be enrolled in Indiana Medicaid effective June 1, 2014, and will receive a notice advising them of their new eligibility. These individuals will not have to file a separate Medicaid application to receive benefits.
57) What Medicaid benefits will individuals receive if they have Supplemental Security Income (SSI) benefits from the Social Security Administration?
Members with SSI will receive full Medicaid benefits and will be placed in the MASI aid category. The benefits covered for these individuals are described here. These benefits are not provided through a Medicaid Managed Care Plan, but are provided directly through Medicaid using a fee-for-service model. Due to this, members with SSI will not be required to choose a health plan. Unlike members eligible for other categories of Medicaid, members with SSI will not be subject to the annual redetermination requirement as long as they continue to receive SSI benefits from the Social Security Administration.
58) How many Supplemental Security Income (SSI) recipients are there in Indiana that will be impacted by the 1634 transition?
The state estimates that approximately 14,000 current SSI recipients will gain Medicaid eligibility as a result of the 1634 transition. These individuals currently receive SSI but are not enrolled in Medicaid.
59) How will future Supplemental Security Income (SSI ) applicants be impacted by the transition to 1634 status?
After June 1, 2014, those determined eligible for SSI by the Social Security Administration (SSA) will automatically be enrolled in Indiana Medicaid and will not have to file a separate application to receive health coverage. In 1634 states, SSA automatically enrolls SSI individuals in the Medicaid program.
60) How can Hoosiers apply for Medicaid disability benefits after Indiana transitions fully to 1634 status?
Individuals may apply for Medicaid based on disability in two different ways. Applications to the Social Security Administration for Supplemental Security Income are treated as applications for Medicaid under 1634 status. Individuals that are found eligible for SSI will automatically receive Medicaid. SSA determinations may take longer than the 90 days required for Medicaid eligibility determinations. All members may also apply to Indiana Medicaid to ensure they receive a timely eligibility determination. Members that are not eligible for SSI must apply to Indiana Medicaid to have their eligibility determined.
61) What will change for new applicants after the transition?
For applicants who have never applied at SSA, Indiana Medicaid may require these applicants to apply for benefits with the Social Security Administration as part of the Medicaid application process. An application to SSA will need to be filed for Indiana Medicaid to complete the eligibility process.
For individuals who have an SSA disability determination the state will use this determination for Medicaid eligibility purposes. Individuals considered disabled by SSA will be considered disabled by Indiana Medicaid.
62) Will individuals have to be considered disabled by the Social Security Administration receive Medicaid?
In most cases, yes. However, by law, Indiana Medicaid will determine eligibility for individuals that apply to Indiana Medicaid without having received a Social Security Administration disability determination. Indiana Medicaid may require application to SSA as part of the eligibility process. Members that are found eligible for Indiana Medicaid may be required to have a Social Security Administration disability determination by their next regularly scheduled Medical Review Team progress report.
63) What if there is a difference between the Social Security Administration’s (SSA) and Indiana Medicaid’s disability determination?
In the case that the SSA’s disability determination differs from Indiana Medicaid’s, the SSA determination is considered final. As a 1634 state Indiana is required to defer to all SSA disability determinations. For example, if the Medicaid agency’s Medical Review Team deemed an individual to be non-disabled but SSA later determined that same individual to be disabled and eligible for Supplemental Security Income (SSI), Indiana Medicaid would automatically enroll the individual. Individuals that were later found eligible for Social Security Disability Income would need to reapply, but the SSA disability determination would be accepted and the member would be eligible if he or she met the other eligibility requirements.
64) Do individuals still have to apply to Medicaid agency for benefits?
All individuals except those that receive Supplemental Security Income (SSI) need to apply directly to Indiana Medicaid. Individuals receiving SSI will be automatically enrolled into Medicaid and do not need to file a Medicaid application.
65) How will Medicaid process new applicants if the applicant has previously obtained a disability determination from Social Security Administration (SSA)?
Under 1634 status, the State must accept SSA determinations of disability for Medicaid eligibility purposes. Starting June 1, 2014, Indiana Medicaid will defer to this decision if it exists. If the SSA had determined an individual is disabled and the individual meets all other eligibility criteria, he or she will be enrolled in Indiana Medicaid. If SSA’s decision was unfavorable, the applicant will not be enrolled unless he or she meets certain conditions. The majority of applicants with determinations from SSA will not have to undergo the separate Indiana Medical Review Team (MRT) process to determine disability.
66) If a new applicant has received an unfavorable disability determination from the Social Security Administration (SSA), is he or she ineligible for Indiana Medicaid under the disability category?
Generally, individuals with a disability denial from SSA will be ineligible for Indiana Medicaid after the transition. There are, however, two cases in which the State must still process a Medicaid application if the applicant has an unfavorable SSA disability determination on file under 1634 status:
67) How will the Medicaid application process for new applicants under the disability category change if the applicant has not previously obtained a disability determination from the Social Security Administration (SSA)?
If the State believes the applicant would be eligible for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), the State will require him or her to apply to SSA, and produce evidence of having done so, as part of the Medicaid application process. When that SSA disability determination is rendered, the State will accept it for Medicaid eligibility purposes.
68) If a new applicant is denied disability status through Social Security Administration (SSA) and appeals that decision, can he or she be eligible for Medicaid if the appeal is pending?
Under 1634, the State will defer to SSA’s most recent disability decision for the purposes of Medicaid eligibility, so if the appeal is pending, the State will deny the application based on the SSI denial unless the applicant:
· Alleges a new disabling condition or a change or worsening of his or her prior condition since the unfavorable SSA determination and more than 12 months have passed since the SSA denial, or
· The applicant alleges a change of condition within the last 12 months and SSA has refused to consider new evidence.
If the applicant meets one of the above conditions Indiana Medicaid will determine if the individual is disabled and eligible for Medicaid even though the applicant has an SSA denial on file. In general, effective June 1, 2014, the SSA’s disability determination will override the State’s determination for Medicaid eligibility purposes.
69) Under 1634 status, who handles member appeals?
Applicants denied Medicaid may always file an appeal. However, applicants denied Medicaid eligibility because of an unfavorable disability determination on file with the Social Security Administration (SSA) must appeal to SSA if they wish to see that decision reversed. The Medicaid appeals process cannot reverse an SSA disability denial. For applicants appealing a disability determination rendered by Indiana Medicaid or who were denied for a reason other than disability (for example, having too much income or resources), the appeal will be processed by Indiana Medicaid following the current appeal process.
70) Must a person age 65 or older applying for Medicaid go through the disability determination process?
Individuals age 65 or older meet the categorical requirements for Medicaid for the Aged and do not need to have a disability determination made by the Social Security Administration or the Indiana Medical Review Team. These members may continue to file a standard application for Medicaid as they do today. The applicant may be required to apply for Social Security benefits as part of the application process if they are eligible but not currently receiving such benefits.
71) Will individuals age 65 or older be required to do anything to continue to be Medicaid eligible?
Individuals that are eligible for Medicaid on the basis of age will not need to seek a Social Security Disability determination. Members will need to continue to meet all eligibility criteria including the income and asset guidelines to maintain Medicaid eligibility.
72) If a person over 65 loses Medicaid, can the supplemental Medicare policy be purchased without regard to preexisting conditions?
There are two types of supplemental Medicare policies available for Medicare eligible individuals: Medicare Advantage, also known as Medicare Part C, and Medicare supplement or Medigap coverage. Both types of supplemental coverage will help individuals limit their out of pocket expenses and may provide additional benefits beyond what is covered by Medicare.
For free and unbiased counseling about these options, FSSA is encouraging members who are losing spend down but do not qualify for a Medicare Savings program to call the State Health Insurance Assistance Program (SHIP) at 1-800-452-4800 (TTY: 1-866-846-0139).
73) Will Medicaid continue for MED Works enrollees, or will they be referred to the Marketplace?
There are no direct changes to the MED Works program as a result of the 1634 transition and current MED Works members will not be referred to the Marketplace.
74) Can you provide more detail on how individuals currently in MED Works will have their income and Medicaid eligibility handled?
There will be no changes to the MED Works eligibility criteria or process or to how income is considered for the MED Works program. The only change in eligibility is that as with other members, MED Works members who are required to complete a progress report will need to have a pending application or approved disability status with the Social Security Administration (SSA). MED Works applicants seeking eligibility on the basis of improved disability will not be required to have pending or approved disability application with SSA but will be assessed by Indiana’s Medical Review Team.
75) By “Federal Marketplace,” do you mean the general insurance or specifically the ACA Market?
The term federal Marketplace refers to the ACA market or Exchange that can be accessed at http://www.healthcare.gov/ . For individuals that want to access subsidies this is the only source of coverage available.
76) When dealing with the Marketplace, they seem to be telling people that they qualify for Medicaid when they do not and are over the income guidelines. What is being done to address this?
Members transitioning off of spend down will have already been determined not eligible for Medicaid by the Agency. This should help prevent the Marketplace from assessing them to be potentially Medicaid eligible.
77) Do you see a smooth transition between spend down and the Marketplace?
SSA continues efforts to assure the smoothest possible transition for all members.
78) Our local hospital is refusing some plans in the Marketplace. Is this being addressed at the local level so people know not to choose those plans?
All qualified health plans offered on the federal Marketplace are certified by the federal Center for Consumer Information and Insurance Oversight (CCIIO) as meeting network adequacy and essential community provider standards. When individuals seek coverage in the Marketplace either by themselves or through a Navigator, they can use the Marketplace website to request more information about the providers that are in a plan’s network. The State is including in its member communications information about how to find a Navigator to assist with the transition to the Marketplace. Individuals may also call the health plans directly to find out what providers are in their network.