Indiana Health Coverage
Programs
Learning Objectives
I.
Outline the basics of Medicaid and Indiana Health
Coverage Programs (IHCP)
II. Identify and define eligibility, goals and specifics of IHCP
programs
III. Discuss the standard elements of Medicaid and IHCP
Eligibility
IV. Examine eligibility notices, appeals and redeterminations
for Medicaid and IHCP
What is Medicaid?
• Enacted in 1965 by Title XIX of the Social Security Act
• The federal government matches state spending on Medicaid
• In Indiana, Medicaid is called Indiana Health Coverage Programs which is
administered by the Office of Policy Planning (OMPP) and Family and
Social Services Administration (FSSA)
• Provides free or low-cost health insurance coverage to low-income:
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Children
Pregnant women
Parents and caretakers
Blind
Disabled
Aged
• Income limits are based on the Federal Poverty Level (FPL)
• Offers variety of programs with varying criteria
Indiana’s Medicaid
• The Office of Medicaid Policy and Planning (OMPP) is
responsible for:
– Administering Indiana Health Coverage Programs (IHCP) at the
State level, including the following functions:
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Medical policy development
Program and contract compliance
Contracting with MCEs
Addressing cost containment issues
Establishing IHCP policies
Program reimbursement
Program integrity, including claims analysis and recovery
Indiana’s Medicaid
• The Department of Family Resources (DFR) is the
division of FSSA responsible for processing applications
and making eligibility decisions.
• The County Offices of the DFR administer IHCP at the
local level
• Online applications for Medicaid are located on the
DFR’s Benefit Portal
New Eligibility Groups
• As of January 1, 2014, the states must
cover:
– Former foster children
• Under age 26
• Receiving Indiana Medicaid when aged
out of the system
• Not subject to income limits until age 26
– Children age 6-18
• Up to 133% FPL
– Pregnant Women:
• Verification of pregnancy no longer required for Medicaid application
• Counted as 2 people
• Coverage continues 60 days postpartum
What are the Indiana Health Coverage Programs?
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Hoosier Healthwise (HHW)
Healthy Indiana Plan (HIP)
Care Select
Traditional Medicaid
Medicaid for Employees with Disabilities (M.E.D. Works)
Home and Community-Based Service Waivers (HCBS
Waivers)
Medicare Savings Program
Family Planning Services
Spend-Down—Eliminated June 1, 2014
Breast and Cervical Cancer Programs
What are Federal Poverty Guidelines (FPL)?
• Also known as Federal Poverty Level (FPL)
– Issued each year by the Department of Health and Human Services
(HHS)
• Measure of pre-tax income used to determine what is
considered poverty in the United States
– It is also used to determine eligibility for IHCP and coverage through
the federal Marketplace
• Anyone living at 100% or below the FPL is considered living
in poverty
– In 2014, an individual with a pre-tax income of $11,670 or less is living
in poverty, and so is a family of 4 with pre-tax income at or below
$23,850.
What are Federal Poverty Guidelines (FPL)?
2014 FPL for the 48 Contiguous States and the District of Columbia
Household Size
100%
133%
150%
200%
1
$11,670
$15,521
$17,505
2
15,730
20,921
3
19,790
4
300%
400%
$23,340
250%
$29,175
$35,010
$46,680
23,595
31,460
39,325
47,190
62,920
26,321
29,685
39,580
49,475
59,370
79,160
23,850
31,721
35,775
47,700
59,625
71,550
95,400
5
27,910
37,120
41,865
55,820
69,775
83,730
111,640
6
31,970
42,520
47,955
63,940
79,925
95,910
127,880
7
36,030
47,920
54,045
72,060
90,075
108,090
144,120
8
40,090
53,320
60,135
80,180
120,270
160,360
100,225
Hoosier Healthwise
GOALS
ELIGIBILITY
SPECIFICS
 Provide health care
 Children up to age 19
 Offers different benefit
coverage for low-income  Pregnant women
packages
parents/caretakers,
 Low income
 State determines
pregnant women and
parents/caretakers of
eligibility and coverage
children at little or no
children under age of 18  Member selects MCE
cost
and PMP
Enrollees excluded from mandatory enrollment in Hoosier Healthwise
include:
• Individuals in nursing homes and other long-term care institutions
• Undocumented individuals who are eligible only for emergency services (Package
E)
• Individuals receiving hospice or home and community-based waiver services
• Individuals enrolled in Medicaid on the basis of age, blindness or disability
• Wards of the court and foster children
Hoosier Healthwise
HHW PACKAGE
DESCRIPTION
A—Standard
 Full-service plan for children, pregnant
women and families
 No premiums
C– Children’s Health Insurance
Program (CHIP)
 Full service plan for children only (under
age 19)
 Small monthly premium payment & co-pay
for some services based on income
P—Presumptive Eligibility
 Ambulatory prenatal coverage for pregnant
women who are determined “presumptively
eligible” while their Indiana Application for
Health Coverage is being processed
Services Available under Hoosier
Healthwise
Medicaid provides coverage for the following:
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Medical care
Hospital care
Physician office visits
Check-ups
Well-child visits
Clinic services
Prescription drugs
Over the counter drugs
Lab & X-Rays
Mental health care
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Substance abuse services
Home health care
Nursing facility services
Dental
Vision
Therapies
Hospice
Transportation
Family planning
Foot care
Chiropractors
Hoosier Healthwise
Monthly Income Limits
Family Parents & Caretaker
Size
Relatives
1
n/a
2
$247
3
$310
4
$373
5
$435
Children
$2,432
$3,278
$4,123
$4,969
$5,815
Pregnant
Women
n/a
$2,727
$3,431
$4,134
$4,838
Children’s Health Insurance Program (CHIP)
• Child cannot be covered by other comprehensive health
insurance
• Individuals in CHIP are responsible for monthly premiums and
must pay the first premium prior to coverage becoming
effectuated (There is a 60-day grace period)
• A child whose coverage was dropped voluntarily may not receive
CHIP coverage for 90 days following the month of termination
with some exceptions
Family FPL
158% up to 175%
175% up to 200%
200% up to 225%
225% up to 250%
Monthly Premium
for 1 Child
$22
$33
$42
$53
Monthly Premium
for 2 or More Children
$33
$50
$53
$70
Healthy Indiana Plan (HIP)
GOALS
ELIGIBILITY
 Reduce the number of
 Hoosier adults
uninsured, low-income
between the ages
Hoosiers
of 19-64
 Reduce barriers and improve
 Household income
statewide access to health care
at or less than the
services
FPL
 Promote value-based decision
 Not otherwise
making and personal health
eligible for Medicaid
responsibility
 Promote primary prevention
 Prevent chronic disease
progression with secondary
prevention
 Provide appropriate and qualitybased health care services
 Assure State fiscal
responsibility and efficient
management of the program
SPECIFICS
 Provides full health benefits
including free preventative
services ($500), hospital
services, mental health care,
physician services, prescriptions
and diagnostic exams
 Does not provide vision, dental or
maternity services
 No co-pays except for nonemergency use of a hospital ER
 Provides a Personal Wellness
and Responsibility (POWER)
Account valued at $1,100 per
adult to pay for medical costs
• Enrollee contributes 2-5% of
gross income
• Employers and non-profits
can contribute
Healthy Indiana Plan (HIP)
HIP provides a basic commercial benefits package. Covered
services include:
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Physician services
Prescriptions
Diagnostic exams
Home health services
Outpatient, inpatient hospital and hospice services
Preventive services
Family planning
Case & disease management
Mental health coverage
Vision, dental and maternity services are not currently
covered by HIP
Healthy Indiana Plan (HIP) Enrollment
Family Size
Monthly Income Threshold
1
2
3
4
5
6
7
8
$973
$1,311
$1,649
$1,988
$2,326
$2,665
$3,003
$3,441
• Individuals who fail to make their monthly POWER Account
contribution after a 60-day grace period are disenrolled for 12
months.
• If individuals fail to complete their annual redetermination,
then they will be disenrolled from the program.
Healthy Indiana Plan (HIP) Key Dates
• In September 2013, the State received authorization from CMS to
continue the HIP program for one year (through December 31,
2014).
• Due to problems with the roll-out of the federal marketplace, HIP
eligibility was extended to those over 100% FPL (including the 5%
disregard) through April 2014 to allow for transition to the
Marketplace.
• On May 15, 2014, Indiana Governor Mike Pence announced a plan
to expand HIP from 100% to 138% of the FPL.
– As of July 2014, Indiana has submitted the HIP 2.0 waiver application
to CMS for approval
Managed Care Entities (MCEs)
• MCEs provide the following services and functions to Hoosier
Healthwise & HIP enrollees:
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Case management and disease management
Member services helpline
Screening enrollees for special health care needs
24-hour Nurse Call Line
Managing grievances and appeals
Provide member handbooks
• Hoosier Healthwise & HIP enrollees select one of the three
MCEs (Anthem, MDWise, MHS), or they are auto-assigned 14
days after enrollment
Managed Care Entities (MCEs)
Some factors for beneficiaries to consider when selecting an
MCE include the following:
o Provider network
• Is the individual’s doctor available in the MCE network?
• Are the locations of network providers easily accessible
for the enrollee?
• Are the locations convenient to the individual’s work,
home or school?
o Special programs & enhanced services
• Is there a service or program offered by the MCE that is
particularly important or attractive to the enrollee?
Managed Care Entities (MCEs)
Hoosier Healthwise enrollees can change
MCE:
 Anytime during the first 90 days with a
health plan
 Annually during an open enrollment period
 Anytime when there is a “just cause”
 Lack of access to medically necessary
services covered under the MCE’s
contract with State
 The MCE does not, for moral or
religious objections, cover the service
the enrollee seeks
 Lack of access to experienced
providers
 Poor quality of care
 Enrollee needs related services
performed that are not all available
under the MCE network
HIP enrollees can change MCE:
 In the first 60 days or until they
make the first POWER Account
contribution
 Annually at eligibility
redetermination
 Anytime there is a “just cause” as
outlined for Hoosier Healthwise
enrollees
Managed Care Entities (MCEs)
MCE
MEMBER SERVICES
WEBSITE
1-866-408-6131
WWW.ANTHEM.COM
1-800-356-1204
WWW.MDWISE.ORG
1-800-647-4848
WWW.MHSINDIANA.COM
Primary Medical Providers
• Once a beneficiary is enrolled in an MCE, he or she also selects
a Primary Medical Provider (PMP).
• Enrollees must see their PMP for all medical care;
• If specialty services are required the PMP will provide a referral.
• Provider types eligible to serve as a PMP include Indiana Health
Coverage Program enrolled providers with the
following specialties:
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Family practice
General practice
Internal medicine
Obstetrics (OB)/Gynecology (GYN )
General pediatrics
Care Select
GOALS
Care Select will phase-out January 1, 2015
due to a new coordinated care program
ELIGIBLITY
 Promotion of
 Aged, blind, disabled, a ward of the
preventative care
court or foster child, or a child
 Promotion of
receiving adoptive services or
treatment
adoption assistance
regimens for
 MUST have one of the following:
chronic illnesses
Asthma, Diabetes, Congestive, Heart
to better conform
Failure Coronary Artery Disease,
evidence-based
Chronic Obstructive Pulmonary
practices
Disease, Hypertension, Severe
 Promotion of
Mental Illness, Serious Emotional
less fragmented
Disturbance (SED) Depression,
and more holistic
Chronic Kidney Disease w/o dialysis,
care
co-morbidity of diabetes and
hypertension or other combinations,
or other approved serious or chronic
conditions
SPECIFICS
Enrollees select or are
assigned to:
• Care Management
Organization (CMO)
(oversees &
coordinates care)
• Primary Medical
Provider (PMP)
(provides care &
referrals)
Care Select
• Individuals do not specifically apply for Care Select.
– Medicaid enrollees in an eligible aid category with one of the qualifying
conditions, as evidenced by claims history or their medical provider contacting
the Enrollment Broker at 1-866-963-7383, have the option to participate
• Care Select enrollees choose or are assigned to both a Care
Management Organization (CMO) and PMP (Primary Medical Provider).
– Member services contact information for the State’s two CMOs is as follows:
Care Management
Organization
Phone Number
Website
Advantage
1-800-784-3981
www.advantageplan.com
MDwise
1-800-356-1204
http://www.mdwise.org/formembers/indiana-care-select
Traditional Medicaid (Fee-for-Service)
The following individuals who meet income and resource requirements are
eligible:
• Blind, Disabled, and Aged persons
• Persons in nursing homes & other long-term care institutions
• Undocumented aliens who do not meet a specified qualified status; lawful
permanent residents who have lived in the USA less than five years; or those
whose alien status remains unverified receiving Emergency Services only
• Persons receiving home and community-based waiver or hospice services
• Dual eligibles (individuals receiving Medicaid & Medicare)
• Persons eligible on the basis of having breast or cervical cancer
• Refugees who do not qualify for another aid category
• Former Independent Foster Children up to age 18, IV-E Foster Care Children, IVE Adoption Assistance Children, and Former foster children under the age of 26
who were enrolled in Indiana Medicaid as of their 18th birthday
Traditional Medicaid (Fee-for-Service)
• In Traditional Medicaid, beneficiaries are not enrolled in a
Managed Care Entity (MCE) or Care Management Organization
(CMO) and can see any Indiana Health Coverage Program
enrolled provider.
• All provider claims are paid fee-for-service by the State’s Fiscal
Agent, Hewlett-Packard.
Traditional Medicaid (Fee-for-Service)
BENEFIT PACKAGE
Standard Plan
Medicare Savings Program
Package E
Family Planning
DESCRIPTION
 Full Medicaid coverage
QMB: Medicare Part A & B premiums, deductibles, &
coinsurance
SLMB/QI: Medicare Part B premiums
QDWI: Medicare Part A premiums
Emergency Services only– for certain immigrants who
do not qualify for full Medicaid coverage
Family planning services only
M.E.D. Works
GOALS
ELIGIBILITY
 Provide full Medicaid
 Ages 16-64
for working people with  Fall below 350% FPL
disabilities
 Disabled according to
Indiana’s definition of
disability
 Not exceed asset limit
(Single: $2,000 or
Couple: $3,000)
 Be working (there is no
minimum work effort for
program)
SPECIFICS
 Full Medicaid benefits
 Members pay small
monthly premium
based on income
 Individual only program
 Members can put up to
$20,000 in Savings for
Independence and SelfSufficiency Account
 Members can have
employer insurance
M.E.D. Works
• Enrollees are responsible for monthly premiums based on
income of the applicant and spouse
Single
Married
Monthly Income
Premium
$1,459 - $1,702
$1,703 – $1,945
$1,946 - $2,432
$2,433 - $2,918
$2,919 - $3,404
$3,405
$1,967 - $2,294
$2,295 - $2,622
$2,623 - $3,278
$3,279 - $3,933
$3,934 - $4,588
$4,589
$48
$69
$107
$134
$161
$187
$65
$93
$145
$182
$218
$254
590 Program
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Provides coverage for residents of state-owned facilities
Does not cover incarcerated individuals residing in
Department of Corrections (DOC) facilities
• Eligible for Package A benefits with the exception of
transportation
Home and Community Based Waivers (HCBS)
WAIVER
ELIGIBILITY
Aged and Disabled
 Income: Up to 300% Supplemental
Security Income (SSI) benefit
•
Traumatic Brain
Injury
Community
Integration &
Habilitation
Family Supports
Parental income & resources
disregarded for children under 18
 Meets “Level of Care”
 Would otherwise be place in
institution such as nursing home
without waiver or other homebased services
SPECIFICS
 Complex medical
condition which
required direct
assistance
 Diagnosis of Traumatic
Brain Injury
 Diagnosis of intellectual
disability which
originates before age
22
 Individual requires 24
hours supervision
Home and Community Based Waivers (HCBS)
• To apply for the Aged and Disabled waiver or the Traumatic Brain
Injury Waiver, individuals can go the local Area Agencies on Aging
(AAA) or call 1-800-986-3505 for more information.
• To apply for the Community Integration & Habilitation or Family
Supports waiver, individuals can go the local Bureau of
Developmental Disabilities Services (BDDS) office or call 1-800545-7763 for more information.
• There are currently waiting lists for the Family Supports
waiver and the Traumatic Brain Injury waiver.
Behavioral and Primary Healthcare Coordination
Program (BPHC)
– Assists individuals with serious mental illness (SMI) who
otherwise won’t qualify for Medicaid or other third party
reimbursement
– Individuals meet the following eligibility criteria:
• Age 19+
• MRO-eligible primary mental health diagnosis (e.g. schizophrenia, bipolar
disorder, major depressive disorder)
• Demonstrated need related to management of behavioral and physical
health and need for assistance in coordinating physical and behavioral
healthcare
• ANSA Level of Need 3+
• Income below 300% FPL
– Single: $2,918/month
– Married: $3,933/month
Behavioral and Primary Healthcare Coordination
Program (BPHC)
• Individuals may apply for the BPHC program through a
Community Mental Health Center (CMHC) approved by
the FSSA Division of Mental Health and Addiction (DMHA)
as a BPHC provider.
• A list of approved CMHCs can be found at
http://www.indianamedicaid.com/ihcp/ProviderServices/Pr
oviderSearch.aspx.
Medicare Savings Program
• Covers low-income Medicare beneficiaries
• Helps pay for out-of-pocket Medicare costs.
• Individuals must be eligible for Medicare Part A
Program
Income
Threshold
Resource Limit
Benefits
Qualified
Medicare
Beneficiary
(QMB)
100% FPL
Single: $7,080
Couple: $10,620
 Medicare Part A & B
Premiums
 Co-pays, deductibles,
coinsurance
(Specified Low
Income) SLMB
120% FPL
Single: $7,080
Couple: $10,620
 Part B Premiums
Qualified
Individual (QI)
135% FPL
Single: $7,080
Couple: $10,620
 Part B Premiums
Qualified
Disabled Worker
(QDW)
200% FPL
Single: $7,080
Couple: $10,620
 Part A Premiums
Family Planning Program
GOALS
 Prevent or
delay
pregnancy
 Provide family
planning
services and
supplies
ELIGIBILITY
SPECIFICS
 Does not qualify for any other
category of Medicaid
 Meets citizenship or
immigration status
requirements
 Not pregnant
 Have not had hysterectomy or
sterilization
 Have income at or below 141%
FPL
Includes, but not limited to:
 Annual family planning
visits
 Pap smears
 Tubal ligation
 Vasectomies
 Hysteroscopic sterilization
with an implant device
 Laboratory tests, if
medically indicated as
part of the decisionmaking process regarding
contraceptive methods
 FDA approved antiinfective agents for initial
treatment of STD/STI
Family Planning Program
Services not covered:
• Abortions
• Artificial insemination
• IVF, fertility counseling or fertility drugs
• Inpatient hospital stays
• Treatment for any chronic condition
Individuals must request to be considered for this
program on their Indiana Application for Health Coverage
if not eligible for full Medicaid benefits
Breast and Cervical Cancer Program (BCCP)
GOALS
ELIGIBILITY
 Provide Medicaid
coverage to
women diagnosed
with breast and
cervical cancer
diagnosed through
the Indiana State
Department of
Health (ISDH)
 ISDH diagnosis
OR
 Age 19-64
 Need treatment for breast or
cervical cancer
 Not eligible for Medicaid under
any other program
 No health insurance to cover
treatment
SPECIFICS
 Uninsured or
underinsured Indiana
residents below
200% FPL (age 40+)
may qualify for free
breast and cervical
cancer screenings
and tests
Age
Eligible Services
40-49
Free office visit & Pap test
50-64
Free office visit, Pap test, and mammogram
65 and older
Free office visit, Pap test, and mammogram only if not enrolled in
Medicare
Presumptive Eligibility (PE)
• Allows individuals meeting eligibility requirements access to
services covered and paid for by Medicaid as they wait for
their application determination for full Medicaid
• Entails a simplified application process:
– Applicant must know gross family income & citizenship status
– Verification documents not required—applicant attests to information
Presumptive Eligibility (PE)
• The PE period extends from the date
an individual is determined
presumptively eligible until…
– When an Indiana Application for
Health Coverage is filed:
• Day on which a decision is made on
that application
– When an Indiana Application for
Health Coverage is not filed:
• Last day of the month following the
month in which the PE determination
was made
Presumptive Eligibility for Pregnant Women
GOALS
 Temporary coverage of
prenatal care services
while Medicaid
applications are pending
 Ensure timely access to
critical prenatal care
ELIGIBILITY
 Not currently receiving
Medicaid
 Pregnant
 Indiana resident
 US citizen (or qualified
immigrant)
 Family income less
than 208% FPL
 One PE period per
pregnancy
SPECIFICS
 Includes doctor visits,
tests, lab work, dental
care, prescription drugs
and other care for
pregnancy
 Does not pay for
hospital stays, hospice,
long term care, abortion,
postpartum services,
labor and deliver, or
services unrelated to
pregnancy
Qualified Providers
• Qualified providers (QPs) make PE determinations in
accordance with Indiana eligibility policy and procedures.
• QPs must meet the following criteria:
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Be enrolled as an Indiana Health Coverage Program (IHCP) provider
Attend a provider training
Provide outpatient hospital, rural health clinic or clinic services
Be able to access HP Web interchange, internet, printer & fax machine
Allow PE applicants to use an office phone to facilitate the PE and Hoosier
Healthwise enrollment process
• May include hospitals, pediatricians, family/general practitioner,
internist, medical clinic, rural health clinic among others
Hospital Presumptive Eligibility
• All states are required to permit hospitals that meet state
requirements to make PE determinations.
• In Indiana, the eligibility groups or populations for which
hospitals will be permitted to determine eligibility
presumptively are:
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Low-income infants and children
Low-income parents or caretakers
Former foster care children up to the age of 26
Low-income pregnant women
Individuals seeking family planning services only
General Medicaid Eligibility and Requirements
• Each Medicaid assistance
category has specific eligibility
requirements such as:
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–
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Age
Income
Pregnancy status
Indiana Residency
Citizenship/Immigration
Provide Social Security Number
(SSN)
– Provide information on other insurance
coverage
– File for other benefits
Requirement: Residency
• Applicant must be resident of the state
• State of residency is:
– Where individual lives
– Including without a fixed address OR
– Has entered the state with a job commitment OR seeking
employment
• A homeless individual or residents of shelters in Indiana
meet this requirement
• There is no minimum time period for state residency to
be Medicaid eligible
• Individuals are permitted to be temporarily absent from
the state without losing eligibility
Requirement: Citizenship/Immigration Status
• Individual must be US citizen, a US non-citizen national or an
immigrant who is in a qualified immigration status
o Lawful permanent residents are eligible for full Medicaid after 5 years
• Electronic data sources through the Federal Hub verify status
o If not, paper documentation is required, and a “reasonable opportunity”
period is granted to otherwise Medicaid eligible individuals– this period
lasts 90 days from the date on the eligibility notice
• Those exempt from citizenship verification process:
o
o
o
o
Individuals receiving SSI or SSDI
Individuals enrolled in Medicare
Individuals in foster care & who are assisted under Title IV-B
Individuals who are beneficiaries of foster care maintenance or adoption
assistance payments under Title IV-E
o Newborns born to a Medicaid enrolled mother
Medicaid Eligible Immigration Status under Immigration & Naturalization
Act (INA)
STATUS
ELIGIBILITY
Lawful Permanent Resident
 Full Medicaid eligible if residing in US prior to 8/22/96
 If entered US on or after 8/22/96 eligible for Package E
for 5 years; full Medicaid after 5 years
Refugees under Section 207 & Iraqi &
Afghani Special Immigrants under Section
101(a)(27)
 Full Medicaid
Conditional entrants under Section 203(a)(7)
prior to April 1, 1980
 Full Medicaid
Parolees under Section 212(d)(5)
 Full Medicaid eligible if granted this status for at least 1
year & entered US prior to 8/22/96
 If entered US on or after 8/22/96 eligible for Package E
Asylees under Section 208
Full Medicaid
Persons whose deportation is withheld under
Section 243(h)
Full Medicaid
Amerasians admitted pursuant to Section
584 of P.L. 100-202 & amended by P.L. 100461
Full Medicaid
Cuban & Haitian entrants
Full Medicaid
Other immigrants, visitor and non-immigrants
Eligible for emergency Medicaid only
Requirement: Provide Social Security Number
• Each Medicaid applicant must supply social
security number (SSN) with the following
exceptions:
 Individual ineligible to receive SSN
 Individual does not have SSN and may only be
issued one for a valid non-work reasons
 Individual refuses to obtain one due to well-established
religious objections
 Individual is only eligible for emergency services due to
immigration status
 Individual is a deemed newborn
 Individual is receiving Refugee Cash Assistance and
is eligible for Medicaid
 Individual has already applied for SSN
Requirement: File for Other Benefits
• Individuals must apply for all other benefits for which they
may be eligible as a condition of eligibility unless good cause
can be show for not doing so; these include:
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Pensions from local, state or federal government
Retirement benefits
Disability
Social Security benefits
Veterans’ benefits
Unemployment compensation benefits
Military benefits
Railroad retirement benefits
Workers’ Compensation benefits
Health and accident insurance payments
Requirement: Report and Use Other Insurance
• Medicaid enrollees can have
access to other insurance (third
liability); however…
– Individuals cannot have other
insurance and enroll in CHIP or HIP
– Applicants must provide information
on other insurance they have or
change in insurance status
– Medicaid is the payer of last resort–
other insurance is the primary payer
Modified Adjusted Gross Income (MAGI)
• Methodology for income counting and determining household
size and composition
• Used to determine eligibility for Indiana Health Coverage
Programs (IHCP) and tax credits on the Marketplace
• Not counted toward income:
• Assets such as homes, stocks or retirement account
• Scholarships, awards or fellowships not used toward
living expenses
• Income disregards (except tax deductions) and nontaxable income
• Child support received, Worker’s compensation and
Veteran’s benefits
Modified Adjusted Gross Income (MAGI)
Adjusted Gross Income
Tax Excluded Foreign Earned Income
Tax Exempt Interest
Tax Exempt Title II Security Income
MAGI
Modified Adjusted Gross Income (MAGI)
MAGI impacts:
New applicants:
 Adults
 Parents and Caretaker
relatives
 Children
 Pregnant Women
MAGI does NOT impact:
Aged
Blind
Disabled
Those needing long-term
care
Former foster children
under age 26
Deemed newborns
Modified Adjusted Gross Income (MAGI)
2014 Household Composition Rules
 Household = tax filer and all tax dependents
 Married couples living together are included in the same household
 Stepparents, stepchildren & stepsiblings now included in the
household
 Income of children & siblings who are required to file a tax return
is counted
 Adult children claimed as a tax dependent are now included in
the household of the tax filer
 For a pregnant woman under MAGI rules, her unborn child(ren)
is counted in determining her household size
Modified Adjusted Gross Income (MAGI)
MAGI Conversion
• The goal is to establish a MAGI-based income standard that
is not less than the effective income eligibility according to
the ACA
• Income disregards are not allowed with the exception of a
general 5% FPL deduction in certain cases
Steps:
1. Calculate the average size of the disregards for individuals whose
net income falls within 25% of the FPL below the net income
standard
2. Add this average disregard amount to the net income eligibility
standard
3. Step 1 + Step 2 = MAGI eligibility standard for the
eligibility group
Indiana Application for Health Coverage
• The Indiana Application for Assistance includes:
– SNAP, cash assistance and Health Coverage
• Application methods:
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Online (Recommended)
Telephone
Fax
Mail, or
In Person at Division of Family Resources (DFR) office
• Medicaid eligibility determinations are made within 45 days or 90
days for determination based on disability
• Applicants can check status of online application using:
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Case number
Case name
Date of birth
Last four digits of SSN
Authorized Representatives
• Individual or organization which acts on a Medicaid applicant or
beneficiary’s behalf in assisting with the application,
redetermination process and ongoing communications with the
state
• Commonly a trusted family member, but can also be a third party
entity
• Designation must be in writing and signed by the applicant or
beneficiary and the authorized representative
– State Form 55366 can be used
Verifying Factors of Eligibility
• States only permitted to collect paper documentation from
Medicaid applicants when electronic data sources are not
available or reasonably compatible
• Data sources used to verify:
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Social Security Administration
Department of Homeland Security
TALX Work Number
State Wage Information Collection Agency
State Unemployment Compensation
Vital Statistics
Eligibility Notices
• DFR provides written notice, via mail, to applications and
beneficiaries regarding any decision affecting eligibility
• Types of notices include, but
not limited to:
o
o
o
o
o
Approvals
Denials
Terminations
Suspensions of eligibility
Changes in benefit package
or aid category
Eligibility Notices
What to expect with eligibility notices:
• State sends notice within 24 hours + mailing time
• Member ID card, referred to as the Hoosier Health Card, sent
within 5 business days + mailing time
– HIP enrollees receive member ID card from their MCE
– CHIP & M.E.D. Works receive premium invoices
– HIP eligible individuals receive POWER Account contribution
notices
• Individuals can be determined Medicaid eligible for up to 3 months
of retroactive eligibility from the date of application
– Does not apply to HIP or CHIP
Eligibility Appeals
• Individuals wishing to challenge disability eligibility decisions
appeal to the Social Security Administration (SSA) or Indiana
Medicaid depending on the reason for the denial.
– Regarding an SSA disability on file: appeal to SSA
– Indiana Medical Review Team (MRT) decision: Indiana Medicaid
Eligibility Redeterminations
• Conducted every 12 months for MAGI categories
– The State renews if there is sufficient information, effective
December 2014
– If there is not sufficient information, a pre-populated renewal form
will be sent beginning in 2015
• Eligibility is terminated if the form is not submitted in a timely manner
• If eligibility is terminated but the documents are submitted within 90
days of the original due date, the documents will be reviewed
without the need to submit a new application
• An individual enrolled in Medicaid on or before December 31,
2013 cannot be denied Medicaid eligibility solely because of
the implementation of MAGI rules before March 31, 2014
Reporting Changes
• Enrollees are required to report changes to the state
(FSSA)
• Examples of changes include:
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Change in address
Income
Family composition
Babies born to Medicaid enrollees receive coverage for the first
year of life without the need for a separate application
• They will be covered under Hoosier Healthwise and enrolled in the
mother’s Managed Care Entity (MCE)
IHCP Application Methods
Program
Application Process
Apply at Area Agencies on Aging (AAA) or call 1-800-9863505
Breast & Cervical Cancer Apply for Medicaid coverage, option 3; Family Helpline: 1Program (BCCP)
855-435-7178
Care Select
Contact Enrollment Broker: MAXIMUS:1-866-963-7383
Community Integration &
Apply at Bureau of Developmental Disabilities Services
Habilitation or Family
(BDDS) office or call 1-800-545-7763
Supports Waiver
Family Planning Eligibility Division of Family Resources (DFR) Toll-Free at 1-800-403Program
0864 OR online
Healthy Indiana Plan (HIP) Print or pick-up application at a DFR office
Apply though FSSA Benefits Portal, by phone (1-800-304Hoosier Healthwise (HHW)
0864), or in person at DFR office
Apply at DFR office, online/phone, Community Enrollment
Traditional Medicaid
Centers
Aged & Disabled Waiver
Helpful Resources
• Hoosier Healthwise Helpline
– 1-800-889-9949
• Healthy Indiana Plan (HIP) Helpline
– 1-877-GET-HIP-9
• FSSA Benefits Portal
– Apply for cash assistance, SNAP and health coverage
• Indiana Medicaid Website
– Eligibility Screening Tools
– Guide to programs