Medicaid Eligibility Overview

1. Department of Medical Assistance Services Medicaid Eligibility Overview For the Department of Veterans Services DMAS Eligibility and Enrollment Unit January 2013 www.dmas.virginia.gov 1

2. Department of Medical Assistance Services Agenda • Medicaid At a Glance • History • Medicaid Eligibility Overview • Medicaid Facts for Veterans • Affordable Care Act • Helpful Medicaid Links • DMAS Contact Information www.dmas.virginia.gov 2

3. Department of Medical Assistance Services Medicaid At a Glance • Virginia offers two Medical Assistance Programs: the Medicaid Program and the Family Access to Medical Insurance Security Plan (FAMIS). • Medicaid and FAMIS have different financial and non-financial eligibility requirements. • Eligibility is determined for all appropriate Medical Assistance programs based on age, income, financial resources, and other information. www.dmas.virginia.gov 3

4. Department of Medical Assistance Services Medicaid At a Glance • Application for Medical Assistance • Applications are completed and submitted to the local department of social services office serving the city or county in which the applicant resides. • Applications • Available online: https://commonhelp.virginia.gov/access/ • At local Department of Social Services (LDSS) offices • Call LDSS office to request application to be mailed www.dmas.virginia.gov 4

5. Department of Medical Assistance Services Medicaid At a Glance Application Processing Timelines: • The LDSS processes Medicaid applications: • Within 45 calendar days from the date of receipt for most applications • Within 10 calendar days for pregnant women if all verifications have been received • Within 90 calendar days for applicants who are referred to Disability Determination Services for a disability determination or as soon as possible after the disability determination is completed www.dmas.virginia.gov 5

6. Department of Medical Assistance Services Medicaid At a Glance The LDSS in the area where the individual resides may be contacted for assistance with applications or to check on the status of an application. A listing of LDSS offices along with contact information can be found at: http://www.dss.virginia.gov/localagency/ www.dmas.virginia.gov 6

7. Department of Medical Assistance Services Medicaid At a Glance • VA Medicaid population in state fiscal year 2011: • 591,360 children • 178,909 parents or caregivers of children & pregnant women • 82,885 person 65+ • 207,686 persons disabled per Social Security criteria • In addition, FAMIS (Family Access to Medical Insurance Security) and FAMIS Moms covered • 103,590 children • 1,251 pregnant women www.dmas.virginia.gov 7

8. Department of Medical Assistance Services Medicaid Eligibility Eligibility is based on meeting: • Medicaid covered group • Non-financial requirements • Financial requirements www.dmas.virginia.gov 8

9. Medicaid Covered Groups Department of Medical Assistance Services • Aged, Blind, or Disabled (ABD): • SSI/Auxilliary Grant Recipients, ABD with income < 80% of the federal poverty level (FPL), Medically Needy ABD, Institutionalized with income < 300% of SSI • ABD Limited Benefit Groups: • Hospice, Medicaid Works, Medicaid Savings Plans, Plan First (family planning services) • Families and Children Groups: • Pregnant Women & Newborns, Children < Age 19, Low-Income Families with Children (LIFC) • Additional Groups: • Breast and Cervical Cancer Prevention and Treatment (BCCPTA), Foster Care, Adoption Assistance www.dmas.virginia.gov 9

10. Medically Needy - Spenddown Department of Medical Assistance Services • Spenddown • Individuals who meet all Medicaid requirements except income can “spenddown” to become eligible for Medicaid • Works like an insurance deductable • VA is one of ten states that allows spenddowns, it is a last resort for eligibility. www.dmas.virginia.gov 10

11. Medicaid Non-Financial Requirements Department of Medical Assistance Services • Citizenship/Alien Status • Assignment of Rights • Social Security Number (SSN) or Proof of Application • Virginia Resident • Not in an Ineligible Institution (such as prison) • Application for Other Benefits www.dmas.virginia.gov 11

12. Medicaid Financial Requirements Department of Medical Assistance Services • Income within established limits appropriate for covered group met by individual • Resources within established limits appropriate for covered group met by individual • Asset transfer for individuals needing long-term care www.dmas.virginia.gov 12

13. Medicaid Financial Rules - Resources Department of Medical Assistance Services • Resources are cash, personal or real property that an individual (or spouse, if any) owns, has the right, authority, or power to convert to cash, and is not legally restricted from using for support and maintenance. • Resource Limits • ABD covered groups have a resource test • Most Families and Children covered groups do not have a resource test www.dmas.virginia.gov 13

14. Medicaid Financial Rules-Income Department of Medical Assistance Services • Income is Earned or Unearned: • Earned Income Example: • Wages, Salaries and/or Commissions, Self Employment Income, Severance Pay • Unearned Income Examples: • Annuities or Pensions, Child or Spousal Support, Dividends, Interest, or Royalties, Rental Income • Income is only counted: • From spouse to spouse and parent to child • Income & resources from step-parents, siblings, and grandparents are not counted www.dmas.virginia.gov 14

15. Medicaid – Long-term Care Department of Medical Assistance Services • Types of long-term care received by Medicaid eligible individuals: • Care in Nursing Facility (NF) • Care received under Community Based Care Waiver (including PACE and Hospice). www.dmas.virginia.gov 15

16. Long Term Care – Financial Requirements Department of Medical Assistance Services • Income limit is 300% of SSI • ABD Resource limits apply • Different income and resource rules for married individuals www.dmas.virginia.gov 16

17. Long Term Care – Financial Requirements Department of Medical Assistance Services • Once Medicaid eligibility determined for receipt of long-term care, must then determine individual’s patient pay (their share of the costs of the care) • All long-term care members must have a patient pay calculated • Not all members will have a patient pay www.dmas.virginia.gov 17

18. Medicaid Facts for Veterans Department of Medical Assistance Services Military Pensions to Retirees and Survivors • Considered Unearned Income; portions withheld as a contribution to participate in SBP is excluded from the income determination. • There is no unearned income disregard applied. • An application for this benefit is required as it a benefit to which an individual is entitled. • Failure to apply results in a denial of Medicaid eligibility. Veterans Educational Benefits • Some educational benefits count as unearned income; however, any portion of a grant, scholarship, or fellowship used for tuition, fees or other necessary educational expenses is excluded from income. An application for educational benefits is not an eligibility requirement for Medicaid. www.dmas.virginia.gov 18

19. Medicaid Facts for Veterans (cont.) Department of Medical Assistance Services Veterans Pension Based on Disability or Death • Needs Based Pensions resulting from Aid and Attendance, Household Allowances, or Unusual Medical Expenses are not treated as income. • Non-Needs Based Pensions resulting from a Medal of Honor or a special act of Congress are unearned income to which the $20 unearned income disregard applies. • An application needs based pensions is not required as it is not counted in the eligibility determination. • An application for non-needs based benefit to which an individual is entitled is an eligibility requirement. Failure to apply results in a denial of Medicaid eligibility. www.dmas.virginia.gov 19

20. Medicaid Facts for Veterans (cont.) Department of Medical Assistance Services Veterans Compensation Payments • Surviving Parent Compensation is treated as unearned income. • The unearned income disregard does not apply with the exception of payments resulting from Aid and Attendance, Housebound Allowances, or Unusual Medical Expenses, and then it is not treated as income. • All other compensation to a veteran spouse, child or widow(er) is unearned income to which the $20 unearned income disregard applies. • An application for any compensation that does not meet the exceptions is required as it is a benefit to which an individual is entitled. Failure to apply results in a denial of Medicaid eligibility. www.dmas.virginia.gov 20

21. Affordable Care Act Department of Medical Assistance Services • Coverage Pathways • Medicaid • Streamlines current eligibility groups • Exchange • Marketplace for individuals and small businesses to find and purchase health insurance, VA has opted for federal insurance • Will certify and sell qualified health plans (QHP) that provide essential health benefits and meet cost sharing requirements • Will offer subsidies and cost sharing reductions for eligible individuals www.dmas.virginia.gov 21

22. Helpful Medicaid Links Department of Medical Assistance Services To apply for Medicaid benefits online: https://commonhelp.virginia.gov/access/ Virginia Department of Social Services Public Site: http://www.dss.virginia.gov/ Medicaid Manual: http://www.dss.virginia.gov/benefit/medical_assistance/manual.cgi (Department of Veterans Affairs Payments can be found in Chapter S0830.300) Listing and contact information for local department of social services: http://www.dss.virginia.gov/localagency/ Medicaid Applications, Fact Sheets, FAQ’s, and Medicaid Manuals: http://www.dss.virginia.gov/benefit/medical_assistance/index.cgi www.dmas.virginia.gov 22

23. Department of Medical Assistance Services (DMAS) Department of Medical Assistance Services Contact Information: Eligibility and Enrollment Unit: Lois Brengel Sarah Samick Eligibility and Enrollment Manager Senior Enrollment Specialist (804) 371-6333 (804) 786-4537 lois.brengel@dmas.virginia.govsarah.samick@dmas.virginia.gov www.dmas.virginia.gov 23