Federal link: www.cms.gov/medicaid/
What is it: Medicaid is a state-federal partnership that pays for health and long-term care services to certain low-income individuals, including children, the elderly and people with disabilities. Each state administers its Medicaid program within the general requirements of federal law and regulations. States and the federal government share the cost of the program.
- Beneficiaries must meet various restrictions (income or medical need).
- Medicaid programs and eligibility varies from state to state.
Who qualifies: Most states determine whether a person meets the criteria for disability with the Medicaid program according to the standards used by the SSI program, and most states adopt the income and resource disregards used by the SSI program.
www.ssa.gov/notices/supplemental-security-income/
- Eligibility varies by state.
- In some cases, people who are disabled and work can maintain Medicaid coverage.
SSI & MEDICAID AUTOMATIC ELIGIBILITY - In 39 states, everyone receiving SSI (and a state supplemental payment in states that supplement SSI benefits) is eligible for full Medicaid coverage (Social Security Act § 1902(a)(10) and 42 CFR § 435.232). In many of these states, SSI beneficiaries automatically receive Medicaid and do not have to complete a separate Medicaid application.
SEPARATE MEDICAID APPLICATION - In 11 states (called 209(b) states),
SSI eligibility does not guarantee Medical eligibility. These states
use more restrictive eligibility criteria for Medicaid: Connecticut,
Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North
Dakota, Ohio, Oklahoma, and Virginia .
What it covers: There are certain federally mandated services specified in law, along with a list of optional services for which a Federal match is available. States dictate which other services they will provide and this varies from state to state.
- MANDATED SERVICES are: inpatient and outpatient hospital services; prenatal care; vaccines for children; physician services; nursing services for persons over 21; family planning; home health care for certain individuals; and early and periodic screening, diagnostic and treatment (EPSDT) services for children under 21.
- DURABLE MEDICAL EQUIPMENT (DME) ALL medically
necessary and non-experimental DME must be provided; there can
be no exclusive list of DME. While a State may have list of pre-approved
DME, such a list is only for administrative convenience to eliminate
a cumbersome application process for each DME request. www.cms.hhs.gov/manuals/06_cim/ci60.asp
- OPTIONAL SERVICES Currently they are about 34 approved services at the state level for which federal funding is available. States can provide as many or as few as they would like. Also, they can provide services to their categorically needy population that they do not provide to other groups. The most common include: diagnostic services; clinic services; rehabilitation and physical therapy services; optometrist services and eyeglasses; intermediate care services for the mentally retarded (ICFs/MR) and home and community based care to certain persons with chronic impairments.
- OPTIONAL MENTAL HEALTH SERVICES include: inpatient psychiatric services for patients age 21 and younger; services provided by licensed non-physician practitioners (e.g.. psychologists and social workers); case management, diagnostic, screening, preventive and rehabilitative services; and clinic services furnished under the direction of a physician.
MEDICAID PAYS FOR: prescription drugs, hearing aids, eyeglasses and other services not covered by Medicare. www.cms.gov/medicaid/mservice.asp
What it costs: States may
impose cost sharing (deductibles, coinsurance and co-payments),
provided the amount is nominal and that it is not applied to certain
populations and services. For example, no cost sharing may be applied
to pregnant women and children under 18. In addition, co-payments
cannot be applied to emergency medical services or family planning
services, regardless of a recipient's category.
- Premiums prohibited with some exceptions
- "Nominal" cost-sharing allowed with some exceptions
- No overall cap specified
At or below 150% Federal Poverty Level ($18,400 for family of 4 in 2003), current regulations on cost sharing for adults receiving Medicaid apply. States can impose the following:
- Premiums: $15-19 per family per month
- Deductibles: $2 per family per month
- Co-insurance: 5% of non-institutional costs
- Co-payments: range from $.50 to $3.00 per service
- Institutional care: 50% of the first day's costs.
Impact for Youth: Youth has access to health care insurance when certain criteria are met (income and disability).
How to Apply: Contact State Medicaid Office.
www.cms.hhs.gov/medicaid/consumer.asp
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
CMS-Aging and Disability Issues
www.cms.hhs.gov/medicaid/consumerag.asp
Highlights health-related issues of interest to people with disabilities and the elderly.
CMS-Medicaid Eligibility Policy
www.cms.hhs.gov/medicaid/eligibility/default.asp
CMS-State By State Medicaid Program Descriptions
www.cms.gov/medicaid/statemap.asp
Profile of each state. Provides information: location of state office, Waivers, eligibility and related resources.
KAISER FAMILY FOUNDATION
State Health Facts Online
www.stat ehealthfacts.kff.org/
(click on Medicaid and SCHIP). If the person's income is below the
threshold listed, the person is probably eligible for Medicaid and/or
SCHIP. Even some people whose incomes are above the thresholds will
be eligible because federal rules require states to disregard certain
types of income
Guides:
ALLIANCE FOR HEALTH REFORM
MEDICAID 101: The Basics of America's Biggest Health Program
www.allhealth.org/
Although less well known than Medicare, Medicaid covers even more people. In fact, about 47 million people were expected to have been covered by the program for at least part of last year, including more than one in four children across the country. This briefing will offer an opportunity for new staff to gain a foundation of knowledge on Medicaid, and for others to refresh their understanding of this key and complex public program. Fact sheet, related policy resources and links area provided.
AMERICAN ASSOCIATION FOR RETIRED PEOPLE-THE MAGAZINE
Understanding Medicare, Medigap and Medicaid
www.aarpmagazine.org/family/Articles/a2003
-01-21-understandingmed.html
AARP - Know how the system works so you can take advantage of what
it has to offer.
CMS- CENTERS FOR MEDICARE AND MEDICAID SERVICES
National Medicare Training Course
cms.hhs.gov/partnerships/tools/materials/medicaretraining/default.htm
The online course, designed for independent study, will enhance
your knowledge of the Medicare Program as it relates to beneficiaries.
The classroom materials used in the national Train-the-Trainer workshops
can be downloaded and/or printed from this site.
KAISER FOUNDATION - KAISER COMMISSION ON MEDICAID AND THE
UNINSURED (KCMU), AND NATIONAL CONFERENCE OF STATE LEGISLATURES
Medical Benefits: Services Covered, Limits, Co-Payments and Reimbursement
Methodologies for 50 States, the District of Columbia and the Territories
www.kff.org/medicaidbenefits/
www.kff.org/content/2003/20031027/
The searchable database is comprehensive, with information about
benefits covered by each state, for what populations the benefits
are available, and the limitations, co-payments and payment rules
that apply to the benefits. The database is searchable by Medicaid
benefit as well as by state.
NATIONAL ASSOCIATION OF STATE MEDICAID DIRECTORS
Aged, Blind, Disabled Medicaid Eligibility Survey-Interactive Tool
www.masterpiecepubl ishers.com/eligibility/default.asp
Data base of various eligibility choices for aged, blind, and disabled populations made by state Medicaid programs. Site contains an explanation of aged, blind, and disabled eligibility rules, - options on how to search for specific information on eligibility options chosen by all fifty states and the District of Columbia .
MAXIMUS
MEDICAID REIMBURSEMENT - School Based Administrative
Claiming
www.maximusschools.com/home.html
The SBAC program is consistent across districts and considerably
streamlines the entire claiming process. One of the more important
features of the program is the use of a statewide random moment
sample (RMS) time study methodology. This methodology replaces continuous
time logs that tend to be burdensome to participant staff. Utilizing
the statewide RMS methodology, each calendar quarter, selected staff
persons from each participating district are included in one large
sample pool. Instead of all staff filling out detailed time logs,
a randomly selected portion of the pool will be asked to complete
a short form at a designated date and time. All the forms will be
returned to us and compiled to determine how much time is being
spent statewide on reimbursable activities. That percentage and
your school district’s Medicaid eligibility percentage are
then applied to your school district's expenses to determine the
amount of your reimbursement.
NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS AND RELATED
INSTITUTIONS (NACHRI)
AMERICAN ACADEMY OF PEDIATRICS (AAP)
2003 State by State Medicaid Fact Sheets
www.childrenshospitals.net/
The National Association of Children's Hospitals and Related Institutions
(NACHRI) and the American Academy of Pediatrics (AAP) have made
available one-page, state-specific fact sheets about children and
Medicaid. The fact sheets are available for all 50 states, the District
of Columbia, and for the Nation. They are intended for use by policymakers,
researchers, educators, and others in their efforts to understand
the importance of the Medicaid program for children.
THE NATIONAL HEALTH LAW PROGRAM (NHELP)
THE ACCESS PROJECT
IMMIGRANT ACCESS TO HEALTH BENEFITS: A RESOURCE MANUAL.
www.nhelp.org
Released in Summer 2002 a revised publication This manual, originally published in 2000, has been revised and expanded. "Immigrant Access to Health Benefits: A Resource Manual" was written for use as a resource in conjunction with an intensive training program developed by The Access Project and the National Health Law Program. "Immigrant Access to Health Benefits: A Resource Manual" is essentially a primer on health access for immigrants. It details and explains basic eligibility requirements for key federal and state programs and identifies issues that can be significant barriers to access to health care for immigrants and their families. Available from either organization at a price of $25.
To order call 310-204-6010 or send an e-mail to nhelp@healthlaw.org.
PFIZER
A Short Guide to Understanding MEDICAID
www.viewsmakingnews.com/policy/medicaid.shtml
Easy to read and understand fact sheet about Medicaid.
Resources:
2003 SSI FBR, RESOURCE LIMITS, 300% CAP, BREAK-EVEN POINTS,
SPOUSAL IMPOVERISHMENT STANDARDS
www.cms.hhs.g ov/medicaid/eligibility/ssi0103.asp
HHS POVERTY GUIDELINES
(sometimes known as Federal Poverty Level)
aspe.hhs.gov/poverty/poverty.shtml
This site gives most current poverty levels by family size.
SSA - Title XIX of the Social Security Act establishes the Medicaid program.
www.ssa.gov/OP_Home/ssact/title19/1900.htm
Title XIX of the Social Security Act establishes the Medicaid program. Medicaid is the nation's major public financing program for providing health and long-term services and supports to low-income persons.
Centers for Medicaid & Medicare Services MEDICAID and DME
Coverage Issues Manual - Durable Medical Equipment
www.cms.hhs.gov/manuals/06_cim/ci60.asp
SUMMARY - The purpose of the July 14, 2003 State Medicaid Director letter (SMDL #03-006) was to make sure, if disabled people in an institution need DME, the DME is actually available BEFORE they move and is not a barrier to their moving into the community. The SMDL acknowledges and helps because CMS recognizes that States have set up barriers in the past and the CMS letter explains how to eliminate them.
The new CMS instruction, include:
- ALL "medically necessary" and non-experimental DME must be provided; there can be no exclusive list of DME.
- While a State may have list of pre-approved DME, such a list is only for administrative convenience to eliminate a cumbersome application process for each DME request. However, DME, like other MA services, must comply with "medical necessity" (whether the person resides in the community or an institution).
- A list of "covered" DME is only the first step. Even if a DME is not listed on a State's DME list, if the person can establish "medical necessity" (often at an administrative hearing), the services can be obtained. 4. While some DME is readily transferred from the institution to the community (e.g., wheelchairs), some DME may be necessary either only in the community (e.g., home modifications) or the DME is actually owned by the institution (e.g., commode).
SOURCE: Steve Gold SteveGoldADA@cs.com
Back issues of other Information Bulletins are available online at www.stevegoldada.com with a searchable Archive at this site.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
- State By State Medicaid Program Descriptions
www.cms.gov/medicaid/statemap.asp
Profile of each state. Provides information: location of state office, Waivers, eligibility and related resources.
HEALTH INSURANCE FLEXIBILITY AND ACCOUNTABILITY (HIFA)
DEMONSTRATION INITIATIVE
- Information on HIFA Demonstration
www.cms.hhs.gov/hifa/default.asp
Centers for Medicare and Medicaid Services - Purpose of the initiative is to expand health insurance coverage to the uninsured within currently available Medicaid and State Children's Health Insurance Program (SCHIP) resources. The initiative is targeted to people below 200 percent of poverty and offers states new flexibility in Medicaid and SCHIP. The waiver encourages statewide reforms to coordinate private and public health insurance coverage and provides for less restrictive rules regarding cost sharing and benefits design.
- NCSL - Health Insurance Flexibility and Accountability (HIFA) Demonstration Initiative
www.ncsl.org/programs/health/hifa.htm
The Centers for Medicare and Medicaid Services (CMS) demonstrations sites to reform Medicaid, SCHIP, or a combination of both programs that are consistent with the HIFA initiative goals. This initiative is an 1115 waiver of Medicaid and SCHIP, which allows states to waive certain requirements of the laws to experiment with new ideas for improving the programs. Unlike waiver applications in the past that may have involved daunting documentation and administrative time, HIFA is guaranteeing a simple application process and an expedited review for those states that meet the criteria.
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