Changes to Medicaid Spend-down: A Closer Look at the Complex Transition
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Big changes are coming for Ohioans who are 60+ and Ohioans with disabilities. The Ohio Department of Medicaid has announced changes to streamline the Medicaid program by eliminating spend-down after August 2016. The changes will bring a greater number of people into Medicaid but will also result in some people losing their benefits. The transition is complex, continues to evolve, and holds severe repercussions for many Ohioans’ health care coverage. Speakers include: -Jeanne Carroll, Assistant Director, Ohio Jobs and Family Services Directors' Association -Beth Kowalczyk, Chief Policy Officer, Ohio Association of Area Agencies on Aging -Teresa Lampl, Associate Director, The Ohio Council of Behavioral Health and Family Services Providers -Steve Wagner, Executive Director, Universal Health Care Action Network -Zach Reat, Director of Work Support Initiatives
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Changes to Medicaid Spend-down: A Closer Look at the Complex Transition
- 3. Ohio should be a great place for ALL Ohioans to live and work. Participate in the economy Be healthy and safe Afford the basics 6/22/16
- 4. Advocate with us! • You’ll receive a follow-up email from this webinar • Look for “Act Now” email alerts, webinar invita:ons, and new resources • Unsubscribe any :me 6/22/16
- 7. Overview and Timelines for Medicaid Disability Determination Redesign Jeanne Carroll Ohio Job and Family Services Directors Association 6/22/16
- 8. Overview q Section 209 of the Social Security Act requires states to provide Medicaid to anyone who receives Supplemental Security Income (SSI) q Section 209b allows states to choose to be more restrictive in their income and resource methodologies. Ohio chose to be more restrictive. q States choosing to be more restrictive are required to allow individuals to “spenddown” to the more restrictive income limit 6/22/16
- 9. Ohio is moving from the 209b option to the 1634 option q This option allows states to accept the Social Security Administration’s decision for SSI q SSI beneficiaries will be automatically enrolled in Medicaid via a nightly data exchange q Individuals with income less than 75% FPL will no longer need to spenddown to 64% FPL and will obtain full Medicaid coverage 6/22/16
- 10. Timelines q Medicaid ABD 1634 changes will go-live on August 1, 2016 q This policy change will happen at the same time as the change from the old CRIS-e eligibility computer system to the new Ohio Benefits system q At 5:00 pm on Thursday, July 28, 2016, the CRIS-e system will close in order to prepare for the conversion of all ABD cases (including Long Term Care and Waiver cases) to the new system. The eGateway system will also be down. The self-service portal will remain open for applicants to submit new applications. At this point no new applications will be accepted by CRIS-e and all of the current and pending ABD applications will be transferred to Ohio Benefits q Ohio Benefits will open on Monday 8/1/16 at 6:00 am and from that time forward ALL Medicaid cases will be processed in the Ohio Benefits system 6/22/16
- 11. How will spenddown cases be converted? q Any individual who met spenddown in at least one month between August 1, 2015 and July 31, 2016 will have full Medicaid coverage after the August 1, 2016 conversion and will be converted to the Ohio Benefits system q Those individuals will remain eligible for full Medicaid until their next renewal or until there is a major change to their case q The Ohio Department of Medicaid has requested a waiver of all ABD renewals until January 1, 2017. This means that if a person has a scheduled renewal between August 1, 2016 and January 1, 2017, their renewal will be delayed. At the time of their renewal, converted spenddown cases will have their eligibility for Medicaid determined based on the new 1634 eligibility requirements. 6/22/16
- 12. Spenddown Populations q Based on information from CRIS-e, approximately 34,043 individuals met their spenddown at least once in the past year and will be converted to full Medicaid until their next renewal q 11,804 SSI recipients not previously enrolled in Medicaid will now be automatically enrolled q 3,943 single adults who do not otherwise qualify for Medicaid ABD or Medicare but have monthly income below $1,367 (the expansion group limit) will be eligible under the expansion group q 5,527 individuals with Severe and Persistent Mental Illness will now qualify for the SRS program 6/22/16
- 13. Spenddown Cont… u Based on the new 1634 eligibility requirements, there are a number of people who no longer qualify for Medicaid. u Some may qualify for: • Medicare Premium Assistance, • Medicare only, • the federal Marketplace Exchange • some will need to seek private health insurance 6/22/16
- 14. Long-Term Care q Income eligibility criteria for individuals needing Medicaid Long Term Care Services will not change as a result of the redesign. Individuals with income up to $2,199 will qualify as they do today q Individuals with income over the limit will need to establish a Qualified Income Trust (QIT) to qualify for Medicaid q This includes all individuals who need long term care residing in a nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF-IDD), or receive home and community based services (HCBS) on waiver programs like PASSPORT, Assisted Living, Ohio Home Care, Individual Options, and MYCare Ohio 6/22/16
- 15. Ohio Association of Area Agencies on Aging Disability Determination Redesign: QITs and Medicare Beth Kowalczyk June 22, 2016 Beth Kowalczyk kowalczyk@ohioaging.org (614) 481-3511 Ohio Association of Area Agencies on Aging www.ohioaging.org Facebook: o4aadvocacy Twitter: @o4aadvocacy 6/22/16
- 16. Ohio Association of Area Agencies on Aging Qualified Income Trusts • Includes MyCare Ohio, PASSPORT, Assisted Living, Ohio Home Care and DD waivers, NFs, ICFs. • Individuals receiving long-term care services (nursing facilities or home and community-based services) with an income over 225% FPL ($2199/month). • Will remain eligible for Medicaid by depositing excess income into a Qualified Income Trust (QIT). • Eligibility starts when income is deposited into trust. 6/22/16
- 17. Ohio Association of Area Agencies on Aging Qualified Income Trusts • A special legal arrangement to disregard an individual’s income over certain thresholds. • An individual, their legal guardian, or their power of attorney may open a Qualified Income Trust. • Trust is irrevocable. Once established, it cannot be changed or canceled. • Make monthly deposits of income into trust. • Pay bank fees, medical expenses, patient liability and monthly personal or maintenance needs allowance. • State is beneficiary. 6/22/16
- 18. Ohio Association of Area Agencies on Aging • Notices went out in May. • State has template. • Automated Health Systems has contract with state to help with QIT (documents, banking) – lawyer on staff. Call 1-844-265-4722 or email OhioQIT@automated-health.com . • Medicaid website: http://medicaid.ohio.gov/INITIATIVES/DisabilityDeterminationRedesign.aspx Qualified Income Trusts 6/22/16
- 19. Ohio Association of Area Agencies on Aging Qualified Income Trusts • Additional resources for help - Ø ProSeniors legal hotline for seniors age 60 and older - www.proseniors.org or (800) 488-6070 Ø Disability Rights Ohio Voice: 1-800-282-9181 (toll-free in Ohio only) TTY: 1-800-858-3542 (toll-free in Ohio only) http://www.disabilityrightsohio.org/need-our-help Ø Legal Aid - Legal Aid 1-866-LAWOHIO (1.866.529.6446) www.ohiolegalservices.org/public/legal_problem 6/22/16
- 20. Ohio Association of Area Agencies on Aging Medicare and Medicaid • Not receiving or eligible for long term services and supports via nursing facility or waiver. • If income greater than 75% FPL, not eligible for Medicaid. • Not eligible for Group 8 (Medicaid expansion) coverage. • May be eligible for Medicare assistance programs: http://medicaid.ohio.gov/Portals/0/Resources/Publications/Materials/mpap- fact-sheet-2014-12-online.pdf 6/22/16
- 22. Specialized Recovery Services (SRS) Program Recognizing a substan:al number of individuals with mental illness use Medicaid spenddown to access Medicaid coverage, Ohio Medicaid developed the SRS Program to preserve access to comprehensive behavioral health services provided under Ohio’s Medicaid program. THE SRS PROGRAM CREATES A NEW MEDICAID ELIGIBILITY CATEGORY • 1915(i) State Plan Amendment • Specific eligibility criteria MUST be met to ACCESS Medicaid coverage • Requires “conflict free case management” • Requires the individuals home to be evaluated and cannot be “ins:tu:onal” like 6/22/16
- 23. Specialized Recovery Services (SRS) Program Once determined eligible… 1. The individual has access to the FULL Medicaid benefit • Enrollment in Medicaid managed care or • Enrollment in MyCare Ohio (Medicare-Medicaid) AND 2. The individual will have access to three new Medicaid covered services: • Recovery Management • Individual Placement and Support - Supported Employment (IPS-SE) • Peer Support 6/22/16
- 24. Specialized Recovery Services (SRS) Eligibility ELIGIBILITY FOR SRS PROGRAM (MEDICAID ELIGIBILITY) • Monthly income between $743 and $2,199 • Age 21 or older • Disability Determina:on by the Social Security Administra:on/ Medicare • Diagnosis of a qualifying MENTAL ILLNESS • Func:onal impairments requiring assistance with daily living ac:vi:es • History of mental health service u:liza:on 6/22/16
- 25. Specialized Recovery Services (SRS) Eligibility ELIGIBILITY FOR SRS PROGRAM (MEDICAID ELIGIBILITY) • Agree to accept a new “Recovery Management Service” • This includes accep:ng a new “Recovery Manager” (case manager), par:cipa:on in an assessment, and development of a “person centered care plan” for purposes of SRS enrollment. • Live in a “home and community” segng • Individual cannot live in a nursing home, ICF-IDD, or segng that is “ins:tu:onal like”. • Addi:onal evalua:on required in individual’s home is “owned” by a service provider. • Individual cannot be receiving other home and community based waivers 6/22/16
- 26. New SRS Program Services • Recovery Management • Coordina:on of all specialized recovery service program services and assistance in gaining access to needed medical services as well as social, educa:on, and other resources regardless of funding source. • Face to face evalua:on of individuals needs to determine SRS Program eligibility and service needs. • Person centered care planning, monitoring, and upda:ng to assure iden:fied needs are met. • Facilita:on of community transi:ons from ins:tu:onal segngs. 6/22/16
- 27. New SRS Program Services • Individual Placement & Support – Supported Employment (IPS-SE): • Evidence-based prac:ce that helps people with severe and persistent mental illness and/or co-occurring substance use disorders iden:fy, acquire, and maintain integrated compe::ve employment in their communi:es. • Employment is integral to recovery NOT an end goal of treatment • 19 BH providers currently OhioMHAS Cer:fied for IPS-SE • hjp://mha.ohio.gov/Portals/0/assets/Supports/Employment/Qualified-IPS- Providers.pdf • Peer Recovery Support • Peer Services are provided by individuals in recovery from mental illness and/ or addic:on who use their lived experience as a tool to assist others by sharing their personal journeys and knowledge. • OhioMHAS is developing a NEW Peer Cer:fica:on Process • Cer:fica:on will be required to deliver Peer Recovery Support Services 6/22/16
- 28. SRS Program Implementation Consumer NoTficaTon • 5,660 individuals iden:fied as POTENTIAL eligible for SRS Program. • Lejer sent to these individuals informing them a Recovery Manager will be contac:ng them to discuss accessing these “new services”. • Recovery Managers from state designated vendors will begin outreach to consumers soon. • Community behavioral health provider organiza:ons are sending Ohio Medicaid lists of clients currently served that have a Medicaid spenddown and qualifying diagnosis to support program referral. • Consumers are encouraged to talk to their community behavioral health provider if they have ques:ons. 6/22/16
- 31. www.ohiofoodbanks.org www.ohiobenefits.org Changes to Medicaid: Elimination of Spend Down for People in the Community Zach Reat 6/22/2016 6/22/16
- 32. Medicaid Transition: Non-Long-term Care • People receiving aged, blind and disabled (ABD) services with income below 64% Federal Poverty Level (FPL) and people with income above 64% FPL who met their spend-down between August, 1 2015 and July 30,2016 will continue to receive Medicaid. 6/22/16
- 33. Medicaid Transition • People receiving SSI, but not Medicaid, will be automatically added to the Medicaid program. • People with income above 75% FPL and below 138% FPL will be automatically enrolled in Group 8 Medicaid coverage. 6/22/16
- 34. Medicaid Transition • People with income above 138% and no Medicare will have to find other coverage will lose coverage effective August 1, 2016. • People who lose access to Minimum Essential Coverage are eligible for a Special Enrollment Period to shop for insurance on the Health Insurance Marketplace; depending on income may be eligible for subsidies 6/22/16
- 35. Options for the 18,000+ losing coverage • Employer-Sponsored Insurance • Exchange with or without financial assistance • Other private insurance • Going without coverage Special Enrollment Period and Spend-Down According to guidance from CMS dated November 7, 2014: “Medicaid for aged, blind, and disabled individuals eligible for mandatory coverage under CFR 435.121 with or without having to meet spend-down is considered government-sponsored MEC under section 5000A(f)(1)(A)(ii) and the implementing IRS regulations. 6/22/16
- 36. Help is Available Self-Serve • Healthcare.gov • Marketplace Call Center – 1-800-318-2596 In-Person Help • Localhelp.healthcare.gov • Get Covered Connector • Ohio Association of Foodbanks Consumer Assistance Hotline: 1-800-648-1176 6/22/16
- 37. How to identify people losing coverage • PARTNERSHIP • CDJFS Offices • Area Agencies on Aging • Aging and Disability Resource Network • Local Payee services • Local SSA offices • Medicaid agreed to provide geographic breakdown of population (pending). • Information about Navigators on Medicaid termination notices (pending). 6/22/16
- 39. References • Centers for Medicare & Medicaid Services. SHO# 14-002 Re: Minimum Essential Coverage. November 7, 2014. Accessed from https://www.medicaid.gov/federal-policy-guidance/downloads/sho-14-002.pdf • Office of Health Transformation. Disability Determination Redesign Overview. 4/8/2016. Accessed from http://www.healthtransformation.ohio.gov/LinkClick.aspx?fileticket=nwrdhnOoQqo %3d&tabid=117 • Ohio Department of Medicaid. Medicaid Eligibility Manual. Various Dates. Accessed from http://medicaid.ohio.gov/Portals/0/Resources/Publications/Guidance/Policy/Medicaid- EligibilityManual.pdf. (ABD begins on page 303). • Ohio Department of Medicaid. Disability Determination Redesign Presentation. 4/19/2016. 6/22/16