The Medicaid Program and Eligibility Guidelines

THE MANY FACES OF THE MEDICAID PROGRAM

Todays Agenda Overview Medicaid Programs & Categories Medicaid Managed Care Medicaid Excess Income Program Chronic Care Medicaid Additional Medicaid Information Questions? 2

MEDICAID OVERVIEW 3

The Many Faces of Medicaid At least a dozen different programs fall under Medicaid (MA). It is the responsibility of the local Department of Social Services (DSS) or NYS Department of Health (DOH) to determine which programs the applicant is eligible for. Consumers can have other insurance (Medicare, Employer, etc.) but MA is the Payer of Last Resort . 4

Traditional Medicaid Type of Program - Health Insurance Fee for Service -or- Managed Care Model Applications Used: Access NY Medicare Savings Program Prenatal Care Assistance Program Standard DSS Online (for Health Exchange consumers) 5

Medicaid Covered Services Inpatient & Outpatient Hospital Care Physician Services Skilled Nursing Care Laboratory & X-Ray Services Prescription Drugs Prior Approved Services: Home Health Care Services Transportation Services Additional Services that may be available through a Waiver Program or Managed Long Term Care Plan 6

Eligibility Guidelines Income Guidelines adjusted annually Medicaid (MA) Standards by household size and category Resource Level for Individuals 65 and older, blind or disabled Must submit a Supplement A (DOH-5178A) No Resource Limits for other consumers 7

Documentation Needed For all applications: Citizenship/Identity Immigration Status Social Security Number (can attest) Residence Income Household Composition Other Health Insurance 8

Documentation Needed continued For some applications Health/Disability information Medical Bills Resources (only required for over 65, blind or disabled - in most cases can attest to amount) Attest: Community Coverage w/o Long Term Care Current Month: Community Coverage w/ Community-Based Long Term Care 60 Months: Full Coverage w/ Nursing Home Care 9

MEDICAID PROGRAMS & CATEGORIES 10

Prenatal Care Assistance Program (PCAP) Expanded Eligibility for pregnant women Pregnant consumer eligible from date of case opening through twelve months post-partum Applications taken at Qualified PCAP Provider sites Dolan Family Health Center Hudson River Health Care Planned Parenthood Southampton Hospital Suffolk County Health Dept. 11

Child Health Plus - (CHP) A program for children who: Do not have other health insurance Are under 19 years of age Are not eligible for Medicaid Premiums may apply based on income Children who are not citizens or eligible immigrants may receive CHP Must apply via the Health Exchange (NYSOH) 12

Continuous Coverage from Birth to Age Six Effective January 1, 2025, children from birth to the age of six will be continuously Medicaid eligible. Most children who are determined fully eligible for Medicaid, and subsequently lose Medicaid eligibility, will have guaranteed Medicaid coverage until the end of the month of their sixth birthday. Exceptions include: no longer being a resident of the state, being unable to locate, voluntary termination, agency error, fraud, and death. 13

Medicaid Buy-In For Working People With Disabilities Expanded eligibility levels for working persons with disabilities allows for Medicaid coverage despite increased income In order to qualify, an applicant must: Be a New York State resident; Be certified disabled by either Social Security or the State Disability Review Team; Be at least 16 but under 65 years of age; Work in a paid position for which all applicable income taxes are paid; Pay a premium if required (premium payment has not yet been implemented). 14

Medicare and Medicaid Medicaid may be able to help pay for Part A and or Part B premiums, coinsurance and deductibles. These programs are collectively called Medicare Savings Programs . QMB - Qualified Medicare beneficiary QI-1 - Qualified Individual-1 (QDWI) - Qualified Disabled and Working Individual 15

Medicare Savings Programs QMB QI-1 Pays For Premium ONLY (Part B) Premium, Coinsurance, Deductibles, Copayments (Part A & B) 138% FPL Income Limit 186% FPL Resource Test? NO NO Can have Medicaid? YES NO Earliest Effective Date Month after determination 3-month retroactive within calendar year 16

Medicare Part D Consumers who are eligible MUST sign up for Medicare, including Part D. Dual Eligibles (Medicaid/Medicare recipients) are automatically eligible for the Medicare Low Income Subsidy. There is no monthly premium if consumer is enrolled in a benchmark plan . up to $72.34/mo. in 2025 17

Other Programs Cobra Continuation Coverage- Medicaid can pay premiums for COBRA Continuation Beneficiaries AIDS Insurance Continuation- Medicaid to pay health insurance premiums for persons with AIDS or HIV-related illness Family Planning Benefit Program- Designed to increase access to family planning services and prevent or reduce the incidence of unintentional pregnancies 18

Other Programs - continued Medicaid Cancer Treatment Program-Need treatment for breast, cervical, prostate or colorectal cancer or pre-cancerous conditions Transportation-Medicaid recipients may receive transportation services to and from health care providers. Medical Answering Services (MAS) is the Medical Transportation Provider. Essential Plan-Health insurance program for NYS residents who don't qualify for Medicaid 19

Medicaid Update for Undocumented Non-Citizens Aged 65 and Over Undocumented Non-Citizens Aged 65 and Over can now have Mainstream Managed Care Health insurance coverage for undocumented non-citizens who are 65 and or older has been expanded So long as they are otherwise eligible, they can be provided health insurance coverage through a Medicaid Mainstream managed care plan Consumers eligible for the new health coverage are also entitled to nursing home benefits available within the mainstream managed care plan if determined financially eligible for nursing home care 20

MEDICAID MANAGED CARE 21

Mainstream Managed Care (MMC) & Managed Long Term Care (MLTC) Unless excluded or exempt from participating, Medicaid recipients must join a Managed Care Plan MLTC Plans provide Medicaid home care and other community long term care services. Some may also provide Medicare services, including Dr. office visits, hospital, Rx etc Health and Recovery Plans (HARP) are specialized MMC plans for people with significant behavioral health needs New York Medicaid Choice is responsible for all outreach and enrollment including information on exemptions and exclusions 22

MEDICAID EXCESS INCOME PROGRAM 23

Medicaid Excess Income Program If monthly income is over the Medicaid level, consumers may still be able receive Medicaid coverage. Any income above the Medicaid level is the consumer s excess income and works like a deductible. Medicaid excess income is sometimes referred to as a spenddown or overage . 24

CHRONIC CARE MEDICAID 25

What Is Chronic Care? Chronic care is the branch of Medicaid that provides coverage for a higher level of care than routine or emergency services. Chronic care MA provides coverage for people who are: receiving services in a nursing home, an intermediate care facility (ICF) or in a hospital at an alternate level of care. 26

Applying for Chronic Care A person must be in receipt of services and need coverage in order for eligibility to be determined. (must be documented) Recipients of community Medicaid can notify DSS of a change in need due to a nursing home admission that is expected to last 30 days or more. 27

General Eligibility Requirements Applicants for chronic care must document: marital status, as spouses are legally responsible for one another. Suffolk County residence or that Suffolk is otherwise fiscally responsible for them. third party health insurance they possess as MA is the payer of last resort. Resource documentation for the 60 months prior to the month of application must be reviewed in determining eligibility. 28

Income Eligibility The chronic care budgeting methodology does allow for deductions Institutionalized individuals in permanent absence status are subject to the chronic care budgeting methodology. Any income remaining after applying the allowable deductions is applied to the cost of care on a monthly basis. 29

Married MLTC Enrollees Married Medicaid recipients who are enrolled in a Managed Long Term Care (MLTC) Plan are considered institutionalized and are subject to the more beneficial of either spousal impoverishment or community budgeting methodology. These persons are not subject to transfer penalties and do not require a 60 month resource review unless they are admitted to a skilled nursing facility for 30 or more days. 30

ADDITIONAL MEDICAID INFORMATION 31

Keeping a Medicaid Case Active New York State allows transfers of Medicaid eligibility when an eligible recipient moves from one county to another. (Luberto) New York State allows suspension of Medicaid eligibility for incarcerated individuals. New York State allows suspension of Medicaid eligibility for individuals in a psychiatric center. 32

MA and SNAP for SSI Recipients Suffolk County DSS has a centralized unit (MANIT) that handles both Medicaid and SNAP cases for consumers in receipt of Supplemental Security Income (SSI) benefits. Only cases where all active individuals are in receipt of SSI are assigned to the MANIT Unit. Consumers can call: 631-854-9904 631-854-5823 33

What is MAGI? MAGI is a federal income tax term which stands for Modified Adjusted Gross Income . People in the MAGI category will have eligibility determined counting income using federal income tax rules. Undocumented Immigrants are able to obtain coverage for Emergency Services via NYSOH. MAGI Consumers with existing Medicaid coverage transition from the LDSS to the NYSOH as they come up for renewal. Consumers meeting certain criteria may remain at the LDSS, despite being MAGI. 34

MAGI vs. Non-MAGI MAGI Pregnant women Infants and Children < 19 NEW Adult group Not pregnant Age 19-64 (19 and 20 living alone) No Medicare* Parents/Caretaker relative (any age) 19 & 20 Year Olds (Living with Parents) Family Planning Benefit Program Child in Foster Care (Chaffee) Non-MAGI SSI cash recipients SSI-R and ADC-R medically needy Residents of nursing homes, institutions, congregate care, adult homes, residential treatment facilities Waiver children and adults Medicare Savings Program MBI-WPD (Working Disabled) MCTP (Cancer Treatment Program) Disabled Adult Children Aged 65, non-caretaker relative <Aged 65 w/Medicare non-caretakers 35

Who Is Responsible? Retained by DSS PCAP applicants SSI Recipients Consumers with a spenddown Aged 65 and over Non-parents/caretakers with Medicare Medicare Savings Program Adult Home/Assisted Living/Nursing Home Waiver/Specialized MA programs Handled by NYS Pregnant Women Infants and Children under 19 19-64 yr olds without Medicare Parents/Caretaker Relatives Family Planning Benefit Program 36

How to apply for Medicaid today Most consumers who are aged, blind, or disabled with Medicare must still complete an application and submit it to DSS. Under a NYS grant, Nassau Suffolk Hospital Council and Community Service Society of NY (using Health and Welfare Council of Long Island as a subcontractor) offer Application Assistance for the Aged, Blind and Disabled. MAGI consumers must apply for health insurance through the New York State of Health either by phone or online. NY Medicaid Choice staff have been designated as Certified Application Counselors provide application counseling services for in- person MAGI applicants at our 2 MA sites This includes answering questions, scanning documents, and, if necessary, completing the data entry on the NYSOH site. 37

Exchange Referrals to DSS Consumers who apply or renew through the NYSOH may trigger a referral to the local DSS MA office. Referrals can be for a number of reasons: Medicaid eligibility determination of spenddown; Blind, disabled or chronically ill; Aged 65 or older; Requests for home care or waiver services; Applications for nursing home care; No longer eligible via NYSOH (for any reason). 38

The Future of Medicaid DSS continues to be responsible for all active cases, regardless of category. DSS will continue to process new applications for the populations NOT included in the NYSOH (Non-MAGI). Future enhancements will expand the NYSOH to include additional populations. The next phase is currently developed and is expected for late 2025. 39

Public Health Emergency Unwind Phase As of 7/1/23, the Medicaid Program has returned to Pre-Public Health Emergency rules and operations, with a few exceptions. For renewals not seeking an increase in coverage from Community Coverage no Long term Care or Community Coverage with Long Term Care to Nursing Home Care, the resource test has been waived An automated renewal process was implemented for aged, blind and disabled consumers on Medicaid with active SNAP coverage Consumers who are discontinued for failing to renew have up to 90 days to submit their renewal 40

Communicating with LDSS Call Center Website Shared inboxes Fax Mobile Upload 41

Questions? 42