1. Monica Lewis, BSN, RN Keyra White, MBA
Chuck Lalonde, M.Ed Wendy Watkins, RN, MS
Jason Lacy, MBA Raymond Turner, LMSW-AP
MEDICAID 101
TEXAS
2. TODAY’S OBJECTIVES
• Provide insight in which the Medicaid Program is administered within Texas
• State the original intentions of Title 19 to the Social Security Act
• Discuss percentages related to the Texas Medicaid Program
• Explain eligibility requirements for Texas Medicaid Program
• Explain the “Estate Planning” part in reference to Medicaid
• Explain the benefits and challenges of the Texas Medicaid Program
• Assign a letter grade to the current Medicaid Program and offer our professional advice to
program administrators going forward
3. HOTOff The Press
TEXAS MEDICAID NUMBERS
In fiscal year 2011, Texas expects to spend $24.7
billion on Medicaid, including $16.6 billion in
federal funds.
More than 60 percent of nursing home residents
in Texas have Medicaid coverage that covers at
least part of their nursing home costs. As of April
2010, there were 52,235 Medicaid clients in
nursing homes.
There currently are 3.1 million Texans on
Medicaid. That includes:2.2 million children who
qualify based on their age and income.
Source: Health and Human Services Commission
4. MEDICAID FACTS
• The intention of Title 19 (Medicaid)
is to provide “medical assistance”
part or all payment of health care
services
• Payment will be made based upon
meeting primary qualifying criteria of
people who are below the 250%
poverty level
5. • Medicaid was designed to literally
provide AID to persons receiving
welfare and for comparable groups of
persons who were defined as
medically indigent
• Longer term prospects protect and
optimize Medicaid funding
• Reduce the number of uninsured
Texans
• Focus on keeping Texas Healthy
• Establish infrastructure to facilitate
accomplishment of reform goals
IMMEDIATE AND LONGER TERM PROSPECTS
FOR MEDICAID PROGRAM
Source: Department of Health and Human Services (2006) Center for Medicare and Medicaid Services
6. • Consider options to facilitate the
availability of affordable insurance
benefits for all Texans and
administrative simplicity for employers
• Build public-private partnerships for
employer sponsored insurance,
individual and small group market
insurance, and multi-share programs
• Optimize and improve upon current
Medicaid operations to ensure efficient
integration of reform
• Help individuals transition from being
uninsured or receiving public
assistance to become insured in the
private market
PUSHING AND PRESERVING
MEDICAID FOR THOSE
WHO NEED IT
Source: Department of Health and Human Services (2006) Center for Medicare and Medicaid Services
8. • Inpatient hospital services
• Outpatient services
• Labs
• Home Health
• Private Duty
• Clinics
• Dental Services
• Therapy
• Medication
• Psychiatric
• Hospice
• Respiratory
• Community Care / Personal Care
• Long-Term Care
MEDICAID WILL PAY FOR . . .
9. UNDERSTANDING THE ORIGINAL INTENTIONS – 1935 Social Security Act
Announced by FDR
Source: Youtube video, “1935 Social Security Act Announced by FDR”
11. ESTATE PLANNING
• A person takes the steps to make sure that when
they pass on their wishes are honored when it
comes to their personal property, life insurance
policies, stocks, and home
• Estate Planning in reference to Medicaid is when a
person or couple gets rid of all assets in order to
qualify for long term Medicaid. These include:
1. IRA
2. Certificate of Deposits
3. Savings Bonds
4. Cash
5. Investment Property
6. Burial Spaces
7. Vehicles
8. Nursing Home Trust funds
9. Savings Account
10. Checking Account
12. THE DEFICIT REDUCTION ACT OF 2005 (DRA)
Two major changes:
1. Anyone applying for Medicaid must be US citizen or qualified immigrant
2. Financial eligibility rules for long-term Medicaid
Changes:
• Those who have homes valued above $500,000 are not eligible
• Once the equity in the home is less than $500,000, the applicant is eligible
• If a transfer is made and the reason is to qualify for long term Medicaid, the transfer can
make the person ineligible
• If a gift or charitable contribution is over $207 a month, the applying applicant must
provide convincing evidence that the purpose was not to qualify for Medicaid
• The department will look back 5 years for any transfers, etc…
Source: Medicaid Changes as a result of the DRA of 2005 (n.d.) Retrieved from: www.vtlawhel.org/home/publicweb/pages/health/medicaidchangesDRA#1
13. Estate Planning and Medicaid
Program Integrity
People are going to lie about what
they have to in order to qualify for
benefits
Consider the monthly costs
associated with staying in a nursing
home
Source: Medicaid Estate Planning (n.d.) retrieved from www.ultratrust.com/medicaid-estate-planning.html
14. LIFE WITHOUT MEDICAID
Earlier onset of death due to lack of funds
to obtain treatment
Emergency room would be forced to treat
illnesses that could be treated with a routine
office visit
17. DIFFERENCES IN STATE SPENDING ON
MEDICAID 2008
$0
$5,000,000,000
$10,000,000,000
$15,000,000,000
$20,000,000,000
$25,000,000,000
$30,000,000,000
$35,000,000,000
$40,000,000,000
$45,000,000,000
$50,000,000,000
New York California Texas Wyoming
$47,618,463,035
$38,747,885,430
$21,461,296,293
$492,700,594
18. Texas MCD Budget
2008 & 2009 Budget- $167.8 billion
2008 & 2009 spending on MCD- $45
billion
MCD accounts for 26.82% on total
budget
19. • Increase provider base
• Decrease paperwork for
renewal
• Increase rates
• Provide better training for
facility staff
ADVICE FOR ADMINISTRATORS OF MEDICAID
GOING FORWARD
20. MEDICAID ELIGIBILITY
• Based on income and assets
• Potential Applicants – any adult who lives with an uninsured child and provides care for
that child can apply including:
1. Parents (including adoptive parents)
2. Step-parents
3. Grandparents
4. Other relatives
5. Legal Guardians
6. Adult Siblings
21. CITIZENSHIP AND MEDICAID
• Citizenship status is one factor used to determine which pregnancy related program the
woman may qualify including:
1. Regular Medicaid
2. Medicaid for Pregnant Women
3. CHIP
4. CHIP Perinatal
• Medicaid for pregnant women proves full Medicaid benefits for eligible women
• Income limit is based on family size, including the unborn child
• The income limit for Medicaid for pregnant women is higher than for regular Medicaid
because it included the needs of the unborn child
22. • Household income reported is income
received by – parents, step-parents,
working children
• Income from working children who
attend school is not counted toward
family income; however, it must be
reported within the household income
section
• The most common mistake seen is
that the verification provided does not
reflect amounts. The amount listed
should be the same or close to the
amount listed on the application
HOUSEHOLD INCOME
23. MEDICAID PROGRAMS FOR THE ELDERLY AND
PEOPLE WITH A DISABILITY
• For individuals living in a facility,
Medicaid will pay for:
A. Facility Care – bed, medical staff
B. Medication
Individuals eligible for institutional or
waiver services:
① Reside in an approved facility
② Meet functional eligibility requirements
③ Have income below $2022 for
individual and $4044 for a couple
④ Have resources below $2000 for
individual and $3000 for a couple
• People who are elderly or have a
disability and don’t receive SSI may
qualify for assistance when they live in
these environments:
1. Nursing facility
2. Intermediate care facility for people
with mental retardation (ICF/MR)
3. State school
4. State hospital
24. MEDICAID PROGRAM
LETTER GRADE
BY GROUP ONE
• User Friendly
• Resourceful
• Had a good list of specialist
• Opened a gateway to care
• Made life easier for our elderly
25. RECOMMENDED WEBSITES FOR MORE
INFORMATION
• http://www.yourtexasbenefits.com
• http://www.hhsc.state.tx.us/medicaid/index.html
• http://www.hhsc.state.tx.us/medicaid/contacts.html
• http://www.tmhp.com/Pages/default.aspx
• https://www.oag.state.tx.us/forms/mfcu/
Editor's Notes
The topic of Medicaid in Texas recently came up in a November 14th article in The Houston Chronicle that discussed Republicans talking about opting out of Medicaid Program
Federal Medicaid rules require HHSC to determine the citizenship status of all Medicaid applicants.
Medicaid is available to all US citizens who meet all other eligibility criteria. Medicaid MAY be available to individuals who are LEGAL Permanent residents.
CHIP is available to citizens and legal permanent residents who meet all other criteria.
CHIP Perinatal is available to undocumented pregnant immigrants who meet all other eligibility criteria.
US Citizenship or Immigration Status documentation includes:
Front and back of Permanent Resident Card (I-551)
Arrival/Departure Form (I-94) from US Citizenship and Immigration Services
US birth certificate
US Passport
The only income reported is income earned from a parent, step-parent, and working child. If the child lives with anyone besides a parent or step-parent, the only income reported is the child’s income.
Individuals who reside in a facility or participate in certain waiver programs may have an applied income or co-payment. The amount is based on their income each month. The recipient is allowed a personal needs allowance.
