Medicaid; Answers that Matterc.ymcdn.com/sites/€¦ · · 2017-02-14•There is no resource...

Angie Hartman and Amanda Bryant

County Technical Assistance and Compliance

Bureau of Business Operational Support

February 28, 2017

Medicaid; Answers that Matter

M a k i n g O h i o B e t t e rO H I O D E PA R T M E N T O F M E D I C A I D

Your Questions

Medicaid’s Answers


» Changes in Medicaid – ACA Updates

» At this time there has been no changes made to Ohio’s Medicaid rules, eligibility or coverage

» Updates will be posted as they are available at:» http://www.healthtransformation.ohio.gov

» http://www.medicaid.ohio.gov

http://www.healthtransformation.ohio.gov/

http://www.medicaid.ohio.gov/


Specialized Recovery Services (SRS) Program

• Specialized Recovery Services (SRS) is a Medicaid program for individuals with severe and persistent mental illness (SPMI)

• Services available through SRS include:» Recovery management

» Individualized placement and support

» Peer support

• The following individuals are prioritized in the SRS assessment process:» Individuals who were previously on spenddown Medicaid and are at risk of losing

coverage due to the Disability Determination Redesign (1634) changes

» Individuals who do not qualify for a base Medicaid category

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OAC 5160:1-5-07


SRS Eligibility Criteria• Be at least 21 years old

• Meet the definition of disability as used by the SSA

• Be in receipt of SSI or SSDI benefits

• Meet the clinical diagnostic, needs assessment and risk criteria» Must have severe and persistent mental illness (SPMI)» Determined by Recovery Managers (RM)

• Reside in a home and community-based setting» Determined by Recovery Managers (RM)

• Meet the financial and nonfinancial eligibility requirements of Group One or Group Two

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OAC 5160:1-5-07


SRS Eligibility Groups

• Be in receipt of Medicaid» All Medicaid categories are acceptable

» MPAP only individuals would not be considered for Group One

• Have countable income at or below 150% FPL

» Countable income is calculated with the same rules used in the individual’s Medicaid eligibility

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• Must meet the conditions of eligibility

• Cannot be otherwise eligible for Medicaid » MPAP only individuals would be considered for

Group Two

• Must have countable income at or below 150% FPL, using ABD budgeting

» If countable income exceeds 150% FPL, Group Twoindividuals can receive additional disregards:

─ $20 personal needs ─ The difference between 150% FPL and 300%

FBR for an individual• $2205 (300% FBR) - $1485 (150% FPL) =

$720

• There is no resource limit

SRS Group One SRS Group Two


SRS – Recovery Management Entities

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Ashtabula

Geauga

Lorain

Cuyahoga

Medina

Wood

Lake

Washington

MorganPickaway

Fayette

Madison

Ross

Hamilton

Morrow

Highland

HenryDefiance

Columbiana

Scioto

Perry

Richland

AshlandVan Wert

Union

Tuscarawas

Vinton

Jefferson

Athens

Meigs

Auglaize

Lucas

Ottawa

Erie

Fulton

Williams

TrumbullSandusky

Summit PortageHuronSenecaPaulding

Putnam Hancock Mahoning

CrawfordWyandotWayne StarkAllen

Hardin

CarrollMercer Marion Holmes

KnoxLoganShelby CoshoctonDelaware Harrison

Darke

Licking

Champaign

GuernseyMiamiBelmont

MuskingumFranklinClark

NobleFairfield

Montgomery

Preble MonroeGreene

HockingButlerWarren Clinton

Clermont

Brown

JacksonPike

Adams Gallia

Lawrence

Cleveland Region –Available Recovery

Management:CareSource(877) 209-3154CareStar(800) 616-3718

Marietta Region –Available Recovery

Management: CareSource(855) 288-0003CareStar(800) 616-3718

Columbus Region –Available Recovery

ManagementCareSource(844) 832-0159CareStar(800) 616-3718

Cincinnati Region –Available Recovery

ManagementCouncil on Aging(855) 372-6176CareStar (800) 616-3718


EPSDT/Healthchek:What should our assisters

know?

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Healthchek

» What is Healthchek?

» Ohio’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service package

» Comprehensive and preventative services for babies, kids, and young adults younger than age 21 who are covered by Ohio Medicaid

» Physicals» Hearing, vision, and dental check» Nutritional screenings» Mental health screenings» Developmental screenings» Vaccinations (if needed)

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EPSDT/Healthchek

» Coordination of program information

» The County Job and Family Services (CDJFS)» Forms are generated through the system» Healthcheck Coordinators for every county

» Providers – any doctor that accepts Medicaid

» The Medicaid Hotline» 1-800-324-8680

» http://www.medicaid.ohio.gov for available resources

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QMB Plus/SLMB Plus:Is this an Ohio thing?

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QMB Plus/SLMB Plus

• QMB/SLMB Plus means a Medicare eligible individual that has full Medicaid + QMB or SLMB

• Individuals are assigned an aid code based on the category of assistance and whether or not they have Medicare coverage

• Counties must ensure that an individual is in the correct aid code

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QMB Plus/SLMB Plus

• Provider view through the MITS portal will show coverage for an individual but does not always show an aid category

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QMB Plus/SLMB Plus

• MITS shows the aid category and aid code

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Why do we see ‘Inpatient Hospital Services’ in MITS?

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Inpatient Hospital Services in MITS

» Policy was updated effective 08/01/16

» OAC 5160:1-1-03(D)(1) now states that Medicaid can pay for claims incurred while the individual is receiving inpatient treatment in a medical facility.

» ONLY inpatient claims are covered» Even though policy was effective 08/01/16 the new aid codes were not updated in

MITS until 10/01/16 which reflect the ‘inpatient hospital service’

» Eligibility will reflect in MITS as ‘Inpatient Hospital Services’ for those individuals considered ‘confined’ but receiving Medicaid for an inpatient service

» If an individual is receiving Medicaid as a preleased individual or DYS, MITS will reflect no different. It will only reflect the Medicaid category being received, e.g. MAGI Adult

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18

• Counties should work with their local jails to determine a process to receive and process applications for Medicaid

• There is no longer a prohibition of enrolling offenders into Medicaid

• Medicaid applications for offenders may be processed to pay for inpatient claims or to coordinate care upon release – ODMHAS and the Courts are typically involved with these individuals

• ODM Direct Enrollment Unit is not managing a county jail case load

• Sheriffs/jails should be instructed that Medicaid coverage would allow for Inpatient Hospital Services only

County Jails and The County Job and Family Services

For questions email: [email protected]


Can ODM or the Medicaid Hotline help with providing proof of Medicaid coverage (or lack of coverage) to the

Marketplace?

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Providing proof of Medicaid coverage or lack of coverage

» 1095-B forms for tax purposes – maybe the Market Place will accept

» The County Job and Family Services» Certificate of Health Insurance

» Medicaid.Ohio.gov ‘contact us’

» ODM can provide generalized letter of ‘last date of coverage’ on letterhead

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What might be a reason for a “no-touch denial”?

Is there any course of action a health center assister can take if this

happens and the consumer is definitely

eligible?

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No-touch denials

» If an individual self-declares their income and it is over the income standard in place, this can cause an automatic denial

» OAC 5160:1-2-10(B)(8)(a)(i) - When an individual's declared income exceeds the relevant federal poverty level (FPL) threshold, the individual's declared income will be accepted without further verification

» If applicant disagrees with results» Contact the county for a review

» Request a state hearing

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Southwest Ohio CDJFS has a form for consumers to self-declare circumstances. Is this a county-by-county form or can assisters use a

global form?

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Self-declaration of information form

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Self-declaration of information form

• This is not a state form, but a county created form to help them in their business process

• Self-declaration does not have to be written, it can be verbal for Medicaid purposes

• Form should be used as a way to help in the application process but is not mandatory to be completed or provided by individuals

» Applications cannot be denied because the individual did not provide this form back to the CDJFS office

• ODM has created some forms and desk aids to help counties with gathering the information needed to process the application

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Income sources from another country – does this get “translated” to US dollars?

The example is a LPR from Canada. She works in Ohio now and is a resident. She receives a pension from her former career in Canada. When you add the US + Canadian dollars

equally, she is over income for Medicaid, however if you were to “weight” the Canadian dollars to their worth in American dollars, she would be eligible.

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Income sources from another country

• Income received in another currency should be converted to U.S. dollars to determine eligibility

• Current conversion rates should be used at the time of the eligibility determination• This should be checked upon renewal and upon any reported income change

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Several consumers are being denied with‘Aided on Another System’, why?

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PE Denials with ‘Aided on Another System’• Known defect in Ohio Benefits

» Related to span details stored in the Master Client Index (MCI)» Plan in place with a solution coming, expectation of ‘when’ is unknown at this time

• What can be done in the meantime?» Applications completed as thoroughly as possible

─ Contact Information» Use appropriate enumerations (i.e. name/SSN/DOB)» Ensure ongoing Medicaid application is complete

» For system issues with PE or deemed newborn applications, please contact us at [email protected]

» For MITS access issues, please contact the provider call center at 1-800-686-1516

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I just heard that TANF and SNAP eligibility are slated to be included in Medicaid application

process beginning Feb 2018.

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TANF and SNAP Eligibility - Ohio Benefits

• SNAP and TANF eligibility will begin to be determined in Ohio Benefits in 2018

• This should not change the Medicaid application process» Medicaid operates under a no wrong door policy:

─ ODM 7216 Application for Health Coverage and Help Paying Costs

─ JFS 7200 Request for Cash, Food, and Medical Assistance

» Individuals can apply for Medicaid in many ways: www.benefits.ohio.gov Medicaid Hotline: 1-800-324-8680

www.Medicaid.ohio.gov In Person at local CDJFS

www.odjfsbenefits.ohio.gov Via mail or facsimile

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http://www.benefits.ohio.gov/


http://www.odjfsbenefits.ohio.gov/


Resources for Your Consumers

» Encourage registration through the Self-Service Portal (SSP)» Benefits.Ohio.gov» Case management – renewals, document uploading and benefits status

» Provide individuals with their county contact information» Phone/fax number and website

» Encourage the Medicaid hotline for questions» 1-800-324-8680» The hotline can answer questions related not only to eligibility but income guidelines,

Managed Care and billing services

» Medicaid.ohio.gov » Contact Us

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