CLAIM Time Webinar

1. CLAIM Time Webinar Missouri HealthNet and Medicare Savings Programs

2. What is Medicaid? • Federal and state program • Medical assistance for people with limited income and resources • Covers about 74 million adults and children • Medicaid—67 million individuals enrolled • Supplements Medicare for more than 10 million people who are aged and/or disabled Medicaid and the Children's Health Insurance Program

3. Medicaid Administration • Jointly financed federal and state program • Federally established national guidelines • States get federal matching funds • Known as the Federal Medical Assistance Percentage (FMAP) • Used to calculate amount of federal share of state costs • Varies from state-to-state • Based on state per capita income Medicaid and the Children's Health Insurance Program

4. State Medicaid Administration • Within broad federal guidelines, each state • Develops its own programs • Develops and operates its own plan • Establishes its own eligibility standards • Determines the type, amount, duration, and scope of services • Sets the payment rate for services • Partners with the Centers for Medicare & Medicaid Services (CMS) to administer its program • Administers its own program once approved by the federal government • States may change eligibility, services, and reimbursement during the year Medicaid and the Children's Health Insurance Program

5. The Single State Medicaid Agency • Administers the Medicaid State Plan • May delegate some administrative functions • Local office names may vary • Social Services • Public Assistance • Human Services • Family Support Division Medicaid and the Children's Health Insurance Program

6. Medicaid Eligibility • States are required to cover certain population groups, like • Low income families • Qualified pregnant women and children • Individuals receiving Supplemental Security Income (SSI) • States have flexibility to cover other population groups, like • Individuals receiving home and community based services • Children in foster care who aren't otherwise eligible • Financial and non-financial requirements must be met to qualify for Medicaid Medicaid and the Children's Health Insurance Program

7. Medicaid Eligibility (continued) • In all states: • You can qualify for Medicaid based on income, household size, disability, family status, and other factors. • Eligibility rules differ between states. • In states that have expanded Medicaid coverage to the adult group: • You can qualify based on your income and non-financial eligibility factors. • If your household income is below 133% of the federal poverty level (FPL), you qualify. NOTE: Because of the way this is calculated, it turns out to be 138% of the FPL. A few states use a different income limit. Medicaid and the Children's Health Insurance Program

8. Modified Adjusted Gross Income (MAGI) Methodology • MAGI is a methodology for how income is counted and how household composition and family size are determined • MAGI-based rules are used to determine Medicaid and CHIP eligibility for most individuals Medicaid and the Children's Health Insurance Program

9. Verification • Primary reliance on electronic data sources • Supported by Federal Data Services Hub • Social Security • Internal Revenue Service (IRS) • U.S. Department of Homeland Security • Decreased reliance on documentation • Increased reliance on self-attestation Medicaid and the Children's Health Insurance Program

10. Coverage—Mandatory Medicaid State Plan Benefits • Inpatient hospital services • Outpatient hospital services • Early and Periodic Screening, Diagnostic, and Treatment services (assurance for children under 21) • Nursing facility services (except for Medically Needy) • Home health services (for individuals entitled to nursing facility care) • Physician services • Rural Health Clinic services • Federally Qualified Health Center services • Laboratory and X-ray services • Family planning services • Nurse Midwife services • Certified Pediatric and Family Nurse Practitioner services • Freestanding Birth Center services (when licensed or otherwise recognized by the state) • Transportation to medical care • Tobacco cessation counseling for pregnant women Medicaid and the Children's Health Insurance Program

11. Treatment of an Emergency Medical Condition Medicaid provides payment for emergency services for individuals who have an emergency medical condition and are otherwise eligible for Medicaid in the state (must meet Medicaid income and state residency standards), but don't meet the citizenship and immigration status requirements. Medicaid and the Children's Health Insurance Program

12. Medicaid Spend-down MO HealthNet Spend-Down is a public assistance program that pays for certain health care costs of qualified persons. • This program is for those with income above the MO HealthNet limits. It allows them to “spend down” or “pay down” their income to the Medicaid limit in order to receive benefits. • The spend-down amount is determined on a monthly basis. In order for MO HealthNet to pay for medical expenses a person must meet or exceed their spend-down amount for that month. • A person is not required to pay or meet that amount every month for general purposes of maintaining MO HealthNet. Enrollment for MO HealthNet Spend-Down is done through FSD. Medicaid and the Children's Health Insurance Program

13. Medicaid Spend-down To determine the spend-down amount, the FSD Eligibility Specialist first determines the total monthly gross income based on the following: • Earned income (e.g. wages) • Unearned income (e.g. Social Security, pension, bank interest) Then the FSD Eligibility Specialist subtracts the following: • $20 personal income exemption • Amount paid each month for Medicare and certain types of medical insurance (Medigap policy, EGHP premium) • 85% of the current federal poverty level (MO HealthNet ceiling) for 2019 which is $905/mo (single) and $1,218/mo (couple) The remainder is the spend-down amount. Medicaid and the Children's Health Insurance Program

14. Meeting a Spend-down How to meet a spend-down: • Provide receipts or bills for the month to give to the FSD Eligibility Specialist. They can be prescription drugs, hospitalization, doctor care, and other medical services. Do they have to be bills for the same month medical services are needed? • No. Bills that are currently owed to meet Spend Down in a different month than when they were incurred can be eligible expenses incurred in the three months prior to the current month. If the amount of expenses from prior months exceeds the current month’s Spend Down amount, the excess balance can be used towards Spend Down for the following three months. Medicaid and the Children's Health Insurance Program

15. Meeting a Spend-down • Another option is to pay the spend-down amount directly to the state. • If your spend-down is met at least once January to July, your Extra Help will continue for the rest of the calendar year. • If met after July through December, it will continue through the entire following calendar year. Spend-down Unit 1-855-600-4412. You may also go to https://dss.mo.gov and search for “spend down” for further detailed information. Medicaid and the Children's Health Insurance Program

16. How Are Medicare and Medicaid Different? Medicaid and the Children's Health Insurance Program

17. Medicare-Medicaid Enrollees—“Dual Eligibles” • 8.3 million nationally • Medicaid may provide full benefits and/or partial assistance with Medicare costs • Medicare Savings Programs (MSPs) are partial Medicaid benefits that help pay Medicare premiums and sometimes cost-sharing • You can qualify for full Medicaid only, full Medicaid with an MSP, or just a MSP • For those with full Medicaid, Medicare pays first and Medicaid pays second for covered services Medicaid and the Children's Health Insurance Program

18. Medicare Savings Programs (MSPs) • MSPs are categorized into groups: • Qualified Medicare Beneficiary* (QMB) • Specified Low-Income Medicare Beneficiary* (SLMB) • Qualified Individuals* (QI) • Qualified Disabled and Working Individuals (QDWI) *Automatically qualify for Extra Help for Part D NOTE: Federal law bars Medicare and Medicare Advantage (MA) providers from balance billing a QMB beneficiary under any circumstances. Medicaid and the Children's Health Insurance Program

19. CLAIM Money Tips Sheet Medicaid and the Children's Health Insurance Program

20. LIS – Limited Income Sources • Extra Help through Social Security Administration • May qualify for zero premium for Part D Drug Plan • Reduced co-payments/co-insurance • Qualify for continuous open enrollment to change plans • Eligibility and level of help determined by income and resources Application available through Social Security or CLAIM Online at www.socialsecurity.gov Medicaid and the Children's Health Insurance Program

21. LIS – Extra Help QMB, SLMB, QI-1, MO HealthNet, and LIS numbers also include the $20/mo income disregard. • In ALL states, the first $65 of monthly wages (earned income) and one-half of monthly wages (after the $65 is deducted) will never be countedfor the Medicare Savings Programs (QMB, SLMB & QI-1) or SSA Extra Help. Medicaid and the Children's Health Insurance Program

22. Medicare Savings Programs • Federal and State funding through MO HealthNet to assist with: • Medicare premiums • Deductibles and coinsurance (QMB only) • Auto enrolled in Part D Extra Help • Income and resources determines assistance- • QMB • SLMB • Qualifying Individual • Enrollment - Missouri Family Support Division

23. Missouri RX • Missouri’s State Pharmacy Assistance Program (SPAP) • Pays 50% of the beneficiary cost sharing at all coverage levels of Part D coverage • Does not pay Plan premiums • Federally accepted plan • Payments count toward Part D plan out of pocket maximums Medicaid and the Children's Health Insurance Program

24. Missouri RX • Be enrolled in a Medicare Part D Plan • Meet income and asset requirements (Dual eligible, or in a MSP) • Be a Missouri resident • Provide a copy of: • Medicare Card • Social Security Card Plan benefit requirements: • A Missouri Pharmacy • A 30/31 day supply • Medication must be formulary on the plan or have a coverage exception. MORX is not accepted at all pharmacies. Medicaid and the Children's Health Insurance Program

25. SNP Plans – Medicare Plan Finder Medicaid and the Children's Health Insurance Program

26. Questions??? Medicaid and the Children's Health Insurance Program

27. Acronyms BHPBasic Health Program CHIP Children’s Health Insurance Program CMS Centers for Medicare & Medicaid Services ESRD End-Stage Renal Disease FMAP Federal Medical Assistance Percentage FPL Federal Poverty Level HCBS Home and Community-Based Services MAGIModified Adjusted Gross Income MSPMedicare Savings Program NTP National Training Program QDWIQualified Disabled and Working Individual QHP Qualified Health Plans QI Qualified Individual QMB Qualified Medicare Beneficiary SLMB Specified Low-Income Medicare Beneficiary SSASocial Security Medicaid and the Children's Health Insurance Program