I Spy Eligibility Spotting Potential Medicaid Coverage for
I Spy Eligibility: Spotting Potential Medicaid Coverage for the Uninsured in TN
Getting Started • Tennessee Justice Center: Resources for Advocates – https: //www. tnjustice. org/resources/toolkit/ • Continuing Education Credit for Navigators and CACs: email anickerson@tnjustice. org if you want CE credit. • Slides will be emailed out after this presentation. • Questions? Email anickerson@tnjustice. org
Rob Watkins, Staff Attorney Andy Hofer, Client Advocate/Intake Coordinator
Agenda • Tenn. Care Eligibility – MAGI Categories • Children • Pregnant Women • Parents and caretaker relatives – Disability Categories – Others • Other Affordable Healthcare Options – Health Coverage on the Marketplace – Medicare Savings Programs
What is Tenn. Care? • Tennessee’s Medicaid program • Federal-state partnership program: federal government pays in but states shape where the money goes • Must be financially and categorically eligible (TN did not expand Medicaid under ACA) – Income restrictions – Resource restrictions for some categories
Tenn. Care Categories • MAGI Categories • Children • Pregnant women • Parents and caretaker relatives • Disability Categories • Other Categories
MAGI Categories
Children Almost every child is eligible for something!
Children – Coverage Categories • Tenn. Care Medicaid • Cover. Kids / CHIP • Tenn. Care Standard
Children – Tenn. Care Medicaid Children up to age 19 can get Tenn. Care for Children Income Limits HH Size Child 6 -18: 138% FPL Child 1 -5: 147% FPL <1: 200% FPL 1 2 3 4 5 6 7 1387 1868 2348 2829 3310 3790 4271 1477 1989 2501 3014 3526 4038 4550 2010 2707 3403 4100 4797 5493 6190 Based on 2017 Federal Poverty Level. The income limits for Tenn. Care adjust in the spring each year. 2/20/2021 10
Cover. Kids • Kids under 19 can get coverage under the state’s CHIP program, called Cover. Kids. • Cannot be enrolled in another health plan. • Apply on the Marketplace (healthcare. gov) Cover. Kids Income Limits HH Size 255% FPL 1 2 3 4 5 6 7 2563 3451 4339 5228 6116 7004 7892 Based on 2017 Federal Poverty Level. The income limits for Cover. Kids adjust in the spring each year. 2/20/2021 11
Tenn. Care Standard • Children under 19 that are on Tenn. Care Medicaid but become ineligible can sometimes roll into Tenn. Care Standard. • No access to employee health insurance. • Eligible if they are either – Below 212% FPL, or – have a qualifying health condition
Newborns • Tenn. Care Deeming • Cover. Kids Deeming • Newborn Presumptive Eligibility (NPE)
Tenn. Care Deeming • For moms on Tenn. Care, the child is deemed eligible for Tenn. Care for 1 year. • The coverage starts on the date of birth. • Call Tennessee Health Connection to enroll the child (1 -855 -259 -0701).
Cover. Kids Deeming • For moms on Cover. Kids, the child is deemed eligible for Cover. Kids for 12 months. • Coverage starts from the date the mother enrolled in Cover. Kids. • Call Cover. Kids (1 -866 -620 -8864) to report the birth.
Newborn Presumptive Eligibility (NPE) • For babies (12 months and younger) born to mothers on private insurance or no insurance. • For babies born to mothers on private insurance or no insurance, the effective date of coverage is the date of application.
Review: Tenn. Care Categories • MAGI Categories • Children • Pregnant women • Parents and caretaker relatives • Disability Categories • Other Categories
Pregnant Women • Tenn. Care Medicaid • Presumptive Eligibility (PE) • Cover. Kids
Pregnant Women – Tenn. Care Medicaid Pregnant women can get Tenn. Care below 200% FPL. Pregnant Women Income Limits HH Size <1: 200% FPL 2 3 4 5 6 7 2707 3403 4100 4797 5493 6190 A pregnant woman’s household includes the expected child(ren), but the expected child(ren) do NOT count in the household of other members of the pregnant woman’s household. Based on 2017 Federal Poverty Level. The income limits for Tenn. Care adjust in the spring each year. 2/20/2021 19
Presumptive Eligibility • To get onto Tenn. Care immediately, women can go to their local health department to get “presumptive eligibility. ” • Must apply for Tenn. Care through the Marketplace before the end of the month following the month PE begins. • Coverage should continue until Tenn. Care eligibility determination.
Cover. Kids for Pregnant Women • Pregnant women can also get access to health insurance through Cover. Kids. • Cannot have other maternity coverage. Cover. Kids Income Limits HH Size 255% FPL 1 2 3 4 5 6 7 2563 3451 4228 5228 6116 7004 7892 Based on 2017 Federal Poverty Level. The income limits for Cover. Kids adjust in the spring each year. 2/20/2021 21
Review: Tenn. Care Categories • MAGI Categories • Children • Pregnant women • Parents and caretaker relatives • Disability Categories • Other Categories
Parents and Caretaker Relatives • Tenn. Care Medicaid • Transitional Tenn. Care
Parents & CRs: Tenn. Care Medicaid • Tenn. Care for parents or caretaker relatives of children under 18*. *Or 18 only if a full-time student and living with the parent/caretaker-relative • “Caretaker relative” is a relative within a 5 th degree of the child (Uncle, Grandmother, etc. ) who lives with and provides primary care for the child. • Apply on the Marketplace.
Parents and CRs: Income Parents and CR Eligibility Household Size Income Limit 1 2 3 4 5 6 7 1, 066 1, 394 1, 693 1, 966 2, 218 2, 453 2, 672 Not based on Federal Poverty Levels. 2/20/2021 25
Transitional Tenn. Care For low-income families who lose Tenn. Care due to earned income. • Categorical: Must have been covered in Tenn. Care for at least 3 of the last 6 months. • Income: Must have income below 185% FPL. • Transitional Tenn. Care available to family for up to 12 months.
Review: Tenn. Care Categories • MAGI Categories • Children • Pregnant women • Parents and caretaker relatives • Disability Categories • Other Categories
Disability Categories
SSI & SSDI Differences Supplemental Security Benefits (SSI) – low income people over 65 or disabled. • • • NOT subject to income tax; Income limits are $735 individual $1, 103 couples; Automatic enrollment into Tenn. Care. Social Security Disability Insurance (SSDI) – under 65 and based on someone’s work history. • • • May be subject to income tax; Can be based on the person’s, parent’s or spouse’s prior work history; Not automatically enrolled in Tenn. Care 2/20/2021
SSI & SSDI Benefits Which one is it? SSI benefits are paid on the first day of each month*. *If the first is on a Saturday, Sunday, or legal holiday, the benefits will be paid on the banking day before. 2/20/2021
SSI & SSDI Benefits Which one is it? SSDI benefits are paid on: • • 2/20/2021 After 1997 on the 2 nd, 3 rd or 4 th Wednesday of the month. Before 1997 on the 3 rd day of the month.
Key Questions to Ask How much is your check each month? If over $735 it is probably NOT SSI When do you receive your check? If on or before the 1 st of the month, it is probably SSI. 2/20/2021
Disability Category Red Flags • SSI – Very low income individual with disabilities – SSI recipients should be automatically enrolled in Tenn. Care • 1619(b) – Losing SSI due to work income • DAC – Lost SSI after turning 18 due to higher SS check based on parent’s work history
Disability Category Red Flags • DAW – Lost SSI after turning 50 due to entitlement to SS retirement benefits • Pickle – Received or eligible for SSI and Social Security benefits in same month • ECF CHOICES (formerly DIDD) - Individuals with intellectual and developmental disabilities
Review: Tenn. Care Categories • MAGI Categories • Children • Pregnant women • Parents and caretaker relatives • Disability Categories • Other Categories
Other Categories
Other Categories • • • Medically Needy Spend Down Breast and cervical cancer Former foster children Emergency Medicaid Institutionalized individual
Medically Needy Spend Down • Covers children up to age 21 and pregnant women with income too high for other categories and high medical expenses. • Non-MAGI category. • Apply on the Marketplace. • Follow-up with Tennessee Health Connection.
Medically Needy Spend Down • Monthly household income must be below the following limits after subtracting allowable medical expenses. Spend Down Income Standards Household Size Income 1 2 3 4 5 6 7 241 258 317 325 392 408 467
Medically Needy Spend Down Example Monthly income: $3500 Household size: 2 Spend Down Income Threshold: $258 You need around $3242 in medical bills.
Medically Needy Spend Down What Counts? • Bills incurred during month of application or three previous months. • Older medical bill(s) if paid during month of application. • Bills from the whole family. Coverage starts from the date of application or when the spend down amount is reached.
Medically Needy Spend Down What Counts? • Health insurance premiums (for 4 months). • Transportation to and from health services (47 cents/mile). • Over the counter meds. • Vision, dental, and hearing aid services. • Medical equipment, supplies.
Medically Needy Spend Down Resource Limits Spend Down Resource Standards Household Size 1 2 3 4 5 6 7 Resource Limit 2000 3100 3200 3300 3400 3500 Spend Down is a non-MAGI category (for now). Resource limits still apply.
Other Categories • • • Medically Needy Spend Down Breast and cervical cancer Former foster children Emergency Medicaid Institutionalized individual
Breast and Cervical Cancer • Covers un(der)insured women under 65 in active treatment for breast or cervical cancer. • Must not have access to other insurance that covers cancer treatment. • State uses the screening program’s income limit of 250% FPL. • No resource limit.
Other Categories • • • Medically Needy Spend Down Breast and cervical cancer Former foster children Emergency Medicaid Institutionalized individual
Former Foster Children • Kids aging out of foster care in Tennessee maintain eligibility for Tenn. Care until age 26. • Former foster children must apply through the Marketplace. • No income or resource limit. • Little outreach to let them know about eligibility.
Other Categories • • • Medically Needy Spend Down Breast and cervical cancer Former foster children Emergency Medicaid Institutionalized individual
Emergency Medicaid • Meant to cover undocumented immigrants AND immigrants in the 5 -year bar during emergencies • Tenn. Care recommends filing paper applications through the Marketplace with a special cover sheet. – For more information, visit http: //www. tenncaretopics. com/emsreimbursement/
Other Categories • • • Medically Needy Spend Down Breast and cervical cancer Former foster children Emergency Medicaid Institutionalized individual
Institutionalized Tenn. Care Covers some individuals who: • Have been institutionalized more than 30 days, – Institution = nursing home, residential treatment center, hospital (NOT psychiatric hospital), ICF/ID • Have income below $2, 205 per month (only applicant’s income counts), AND • Have resources below $2, 000.
Other Categories • • • Medically Needy Spend Down Breast and cervical cancer Former foster children Emergency Medicaid Institutionalized individual
CHOICES – Categorical • Must meet CHOICES medical criteria. • CHOICES medical eligibility is based on ability to do activities of daily living (ADLs). CHOICES 1: Nursing home care CHOICES 2: Full array of HCBS CHOICES 3: At-risk group, limited HCBS (SSI only)
Review: Tenn. Care Categories • MAGI Categories • Children • Pregnant women • Parents and caretaker relatives • Disability Categories • Other Categories
Pat Yourself On The Back You’ve made it through the eligibility categories!
Not eligible for Tenn. Care? • ACA Marketplace Plans • Medicare and Medicare Savings Plans
ACA Marketplace Plans • Apply to the Federally Facilitated Marketplace. • Anyone can purchase a plan if they are a legal American resident. • Premium Tax Credits (PTCs) and Cost Sharing Reductions (CSRs) available based on income. – Cannot get PTCs and CSRs if employer coverage is available, affordable and adequate.
Marketplace PTCs and CSRs • Help make health insurance more affordable to low- and lower middle-income Americans. • Gap : <100% FPL • PTCs & CSRs : 100 -250% FPL • PTCs only: 250 -400% FPL • Over income: > 400% FPL
Medicare • Medicare: federally-run health insurance program – 65 and older – Or disabled (receiving SSDI for 2+ yrs)
Medicare Savings Plans (MSPs) • State administered plans to help low-income people pay for Medicare (deductibles, premiums, etc. ) – QMB (Qualified Medicare Beneficiary): <100% FPL • • Pays premiums and deductibles for Parts A&B Full extra help for Part D 20% coinsurance Cost-share for Medicare Advantage
Medicare Savings Plans (MSPs) – SLMB (Special Low-Income Medicare Beneficiary): <120% FPL • Pays Part B premium • Full extra help for Part D – QI (Qualified Individual): <135% FPL • Pays Part B premium • Full extra help for Part D – QDWI (Qualified Disabled and Working Individual): <200% FPL • Pays Part A Premium
Other Affordable Health Insurance Programs • ACA Marketplace Plans • PTCs • CSRs Medicare Savings Plans – QMB – SLMB – QI – QDWI
What does TJC do? Provide trainings Help clients one-on-one Advocate for Tennesseans
Threats to Medicaid • Nation’s largest entitlement program. • Medicaid is more efficient and lower cost than other third party payers. But it is still growing due to health care inflation and is seen as a culprit fueling the federal deficit. • For that reason, and because it benefits the poor, there have efforts at the federal level to dismantle Medicaid since the Reagan era.
Threats to Medicaid • Radically restructuring Medicaid is Speaker Ryan’s top budget objective. • President Trump and Speaker Ryan’s goals are nearly $1 Trillion in Medicaid savings over next decade. • That would cut TN’s state budget by $500 M annually, with devastating consequences for 1. 5 M Tennesseans.
Join our next webinar “Threats to Health Care: What's Next? ” Tuesday, Apr 18, 2017, 11: 00 AM – 12: 00 PM CDT Register on our website: https: //www. tnjustice. org/help/trainings/
Take Action! Our House Representatives and Senators need to hear why Medicaid matters to you. Call your Representative: 1 -866 -426 -2631. Then enter your zip code to be connected to your House member.
Other Resources • TJC: 615 -255 -0331 • https: //www. tnjustice. org/resources/toolki t/ – See: TJC Toolkit, Applying for Tenn. Care Best Practices Guide – IRS Publication 17 • SS Administration: ssa. gov – 1 -800 -772 -1213
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