MaineCare: Who’s covered, Who’s not Recent Changes Opportunities to Improve Access Maine Equal Justice Partners Eight Annual Maine Advocacy Conference November 14, 2013 www.mejp.org 1
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MaineCare:
Who’s covered, Who’s not
Recent Changes
Opportunities to Improve Access
Maine Equal Justice Partners
Eight Annual Maine Advocacy Conference
November 14, 2013www.mejp.org
1
About Maine Equal Justice Partners (MEJP)
• We work to find solutions to poverty and improve the lives of people with low income in Maine.
• We accomplish our mission through:– Public policy advocacy in the legislature and with governmental agencies
– Legal representation and impact litigation on systemic issues
– Statewide outreach and training on issues affecting people with low income and the supports that can help them prevent or move out of poverty
• MEJP focuses its work on the issues that affect people’s daily lives -access to adequate health care, food and income security, supports for working families, and higher education and training opportunities.
• Our website contains much information about public benefit programs—www.mejp.org
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Medicaid (MaineCare)
Members: low income children, parents, pregnant women, elderly, disabled
Eligibility: Must be in a category, e.g., parents, child and meet financial
guidelines. Income restrictions vary.
Coverage: Covers a wide range of services: including hospitalization, x-rays, lab services, clinic treatment, pediatrics care, family planning, nursing services
residential care, nursing facilities, medical and surgical dental care.
Funding: In Maine the federal contribution is 67% and the state
pays 33%.
Medicare
Members: over the age of 65, end stage renal
disease, and disabled (2 year wait period after
determination)
Eligibility: Available to all U.S citizens above the age of 65
irrespective of income, providing that he or she paid taxes into the
Social Security fund.
Coverage: Divided in to Part A which covers in-patient hospital care and skilled nursing, Part B which covers outpatient care and Part D which
covers prescription drugs.
Funding: federal funding and beneficiary premiums
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MaineCare applicants/members deal with
2 separate DHHS offices
Department of Health and Human
Services (DHHS)
Office of Family Independence
(OFI)
Determines eligibility for MaineCare and other programs including the Food
Supplement Program and the TANF/ASPIRE program
Office of MaineCare
Services (OMS)
Oversees MaineCare, Drugs for the Elderly and MaineRx Plus
Determines benefits covered
Bill payment and other account activity
MaineCare Member Services at 1-800-977-6740
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Category Benefit Level Income Limit Asset Limit
Children age 0-18 Full-benefit MaineCare 200% FPL None
19- and 20-year olds Full-benefit MaineCare 150% FPL None
Parents or guardians Full-benefit MaineCare 133% FPL (100% as of 2014) None
Pregnant Women Full-benefit MaineCare 200% FPL None
Adults with disabilities and seniors
age 65 and olderFull-benefit MaineCare 100% FPL
$2,000
($3,000/couple)
(many are excluded)
Adults with disabilities and seniors
age 65 and older who have
Medicare
Limited-benefit MaineCare (Medicare
Savings Program)175% FPL $50,000/$75,000
“Non-Cats”: adults who do not fit
into one of the “categories”
coverage group ends January 2014
Partial-benefit MaineCare – coverage
for this group ends 1/1/14100% FPL
$2,000
($3,000/couple)
(many are excluded)
Adults medically eligible for nursing
careFull-benefit MaineCare 300% of SSI benefit level
$2,000
($3,000/couple)
(many are excluded)
Adults living in residential care
facilities other than nursing facilitiesFull-benefit MaineCare
Income must be below the
private pay rate for the
residential care facility
$2,000
($3,000/couple)
(many are excluded)
Women who have breast or cervical
cancer (or pre-cancerous condition)Full-benefit MaineCare 250% FPL None
HIV-positive adultsMaineCare drug coverage and other
limited benefits250% FPL None
“Medically Needy” or “spend
down”: persons whose income is
too high for full-benefit MaineCare
Full-benefit MaineCare, after a large
deductible is metNone
$2,000
($3,000/couple)
(many are excluded – see Asset Rules)
Adults with disabilities and seniors
age 62 and older
Low Cost Drugs for Elderly and
Disabled (DEL)
175% FPL (income limit is
increased by 25% if drug
costs are high)
None
MaineCare Coverage Categories effective 1/1/14
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Health care services covered by full-benefit MaineCare
Doctors’ Visits: Well-child check-ups, sick care, specialist care, including surgery, prenatal care
Dental Services:Full coverage for children (with limits for adults)
Hospital Care: In-patient, outpatient, and emergency room
Long-Term Care: Coverage for care in a nursing home, or other residential care. Services may also be provided in the home.
Therapies: Speech therapy, Physical therapy, Occupational therapy
Early and Periodic Screening, Diagnosis and Treatment:Federal Medicaid law requires States to cover Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children and adolescents under age 21.
And More…This is just a partial list of services covered by full-benefit MaineCare. For more information, call MaineCare Member Services at 1-800-977-6740 (if you are deaf or hard of hearing and have a TTY machine, call 1-800-977-6741).
Services:
o Shots to prevent illness (immunizations)
o Prescription drugs
o Mental health services
o Substance abuse services
o Lab tests and x-rays
o Medical equipment and supplies
o Ambulance services
o Chiropractic care
o Family planning
o Midwife services
o School-based health centers
o Interpreters
o Transportation to medical and counseling
appointments
o Eye exams and eye glasses (with limits for adults)
o Hearing tests (with limits for adults) and hearing
aids (for children age 20 and younger)
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MaineCare Medically Needy
(Spend Down)Program
"Medically Needy" or "Spend Down": persons whose
income is too high to qualify for MaineCare
• Helps people with catastrophic health care expenses
• Participants must be in a coverable group (65 or older,
disabled, 20 or younger, pregnant, or the parent of a minor
child)
• Deductible amount depends on income level; medical bills
and other costs associated with medical care must have been
incurred, but don’t need to have been paid; Old medical bills
still owed can go toward the deductible
• Certification is usually for 6 months.
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Katie Beckett for Disabled ChildrenKatie Beckett is a MaineCare category for children with severe health conditions which require a
high level of care but who are not in a medical facility. The costs of providing needed services
can’t be more than the annual cost of institutional care. Children qualifying for Katie Beckett are
given full benefit MaineCare coverage.
Financial guidelines: Parents’ income and assets do NOT count when applying for Katie Beckett. Only the
income and assets of the child are looked at. In most cases, this means there are no assets or income to look at.
A child may get Katie Beckett if the child is 18 years old or younger, and
• Is NOT eligible for MaineCare in another category;
• Does NOT live in a medical institution; and,
• Meets the Social Security definition for disability: You do NOT have to get a Social Security disability
decision in order to apply. MaineCare’s medical review team can look at a child’s medical history to see if
they meet the definition for disability.
Private Insurance: A child can get Katie Beckett MaineCare even if they have private insurance. In some cases
MaineCare will pay the premium for private insurance if the child is eligible for Katie Beckett.
Will I have to pay for Katie Beckett?
• There are low cost premiums for Katie Beckett coverage. The monthly premium will depend on household
income and if you have private insurance with the Katie Beckett, or just have Katie Beckett.
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Maine Breast and Cervical Cancer
Program
1-800-350-5180
• Helps uninsured women, age 40-64, pay for breast or cervical cancer screenings at a participating provider service location site.
• Uninsured women diagnosed with breast or cervical cancer or undergoing treatment for breast or cervical cancer may also qualify for MaineCare if their income is below 250% FPL ($28,725 for an individual).
9
Home and Community Benefit for the Elderly or Adults with
Disabilities: Nursing Home Benefit
• In order to receive MaineCare coverage for nursing home care or equivalent care at home, an individual must need the level of medical care given in a nursing home and meet income requirements and asset test.
• There are other MaineCare programs that offer different levels of care in the home, depending on an individual’s needs. – The applicant must also meet income and asset limits, although the
income limits are higher (300% of SSI benefit level – about $2100/mo.) than for full-benefit MaineCare.
• Also, if the individual has a spouse, much of the spouse’s income will be disregarded.
• To learn more about these benefits, call your local Area Agency on Aging at 1-877-ELDERS1 (1-877-353-3771).
10
MaineCare for ineligible spouse
• For seniors who are living with a spouse, the income limit can be higher if only one spouse signs up for MaineCare. As a general rule, if the couple is $356 or less over income, check with an Eligibility Specialist regarding MaineCare with an ineligible spouse.
• This eligibility option disregards $356 from the ineligible spouse’s income (this is in addition to the other deductions). It also may be possible for spouses to alternate eligibility, switching their eligibility status with one another as often as once per month.
• Governor LePage proposed to eliminate this income
disregard in the 2013-2014 budget but the proposal failed
to get the support of the Legislature so this option remains
for low-income seniors living with a spouse who would
otherwise be over income.
11
Ineligible Spouse Budget Calculation
For Couple Households with No Earned Income
Steps
1. Income of ‘ineligible spouse”
2. Subtract $356 from ineligible spouse’s income
3. Combine income of “eligible spouse” and the answer from
line #2.
4. Subtract $100
• Compare result to Federal Poverty Level (FPL) for 2 people. If the household is below the FPL for 2 people, then the “eligible spouse” is eligible.
• If children in home, need to do allocation
12
Ineligible Spouse: For Couple
Households with Earned IncomeStep A
1. Eligible Spouse’s Unearned Income
2. Subtract Federal Disregard ($20.00)
Step B
3. Ineligible Spouse’s Earned Income:
4. Subtract Ineligible Spouse Standard ($356 in 2013)
5. Subtract $65
6. Subtract 50% of total from line 5
7. Add Ineligible Spouse’s unearned income
8. Total net income of ineligible spouse
Step C
9. Add Eligible Spouse’s and Ineligible Spouse’s Net income (total of 2 & 8)
10. Subtract State Disregard ($80)
Compare answer result (step 10) to the FPL for 2
•If children are in the home, need to do allocation
13
The Medicare Savings Program (sometimes called the buy-in program or dual eligible benefits)
Medicare Medicaid (MaineCare)
The Medicare Savings Program
(MSP)
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Eligibility for MSP
In order to get the MSP benefit, you need to
meet two criteria:
– You must be enrolled in Medicare and have
Medicare Part A coverage.
– Your “countable” income, after subtracting all the
allowable disregards, must be at or below
175% FPL ($20,108 for an individual)
– Helps pay Medicare premiums and some
coinsurance, and copayments
15
2013 Medicare Savings Program
(MSP) BenefitsQMB SLMB or QI
< 140% < 175%
Part A
Premium Yes No
Deductible Yes No
Co-insurance & co-pay Yes No
Part B
Premium ($104.90 a month) Yes Yes
Deductible Yes No
Co-insurance & co-pay Yes No
Part D
Premium Yes Yes
Deductible Yes Yes
Donut hole Yes Yes
Co-insurance Yes Yes
Co-pay Partial Partial
16
Low Cost Drugs for the Elderly and
Disabled Program (DEL)
• provides low-income seniors (175% FPL -$20,108 for a single person) over the age of 62 and people with disabilities with a discount on generic drugs and on brand name drugs to treat certain serious health conditions like diabetes, heart disease, chronic lung disease and Multiple Sclerosis.
• provides co-payment assistance to make drugs more affordable for seniors and people with disabilities enrolled in the Medicare Savings Program.
17
Low Cost Drugs for the Elderly and
Disabled Program (DEL)
Basic Benefits:
• •80% minus $2.00 of the cost of all generic prescription drugs on MaineCare Preferred Drug List.
• •80% minus $2.00 of the cost of brand-namemedications on the Preferred Drug List for the treatment of diabetes, heart desease, high blood pressure, chronic lung disease (emphysema and asthma), arthritis, anticoagulation, Hyperlipidemia (high cholesterol), incontinence, thyroid disease, osteoporosis, Parkinson’s Disease, glaucoma, Multiple Sclerosis, and ALS (Lou Gehrig’s Disease).
18
Low Cost Drugs for the Elderly and
Disabled Program (DEL)Supplemental Benefits:
• includes other drugs not covered in basic benefit. Drugs must be medically
necessary and supplied from participating manufacturers. Actual savings vary
from drug to drug. DEL Members pay the State’s MaineCare rate minus $2.00
Catastrophic Spending Limit:
• After a Member spends $1,000 on eligible prescription drugs (tracked from August
1st each year to July 31st of the following year).
• DEL pays 80% of the cost of all eligible prescription drugs, regardless of any disease
or condition. Drugs must be medically necessary and supplied from companies
with agreements with the State. Eligible prescription drugs are only those drugs
that were covered by DEL on May 31, 2001.
• Some drugs require ‘prior approval’ for coverage. Members with Medicare Part D
coverage are eligible for DEL Wrap benefits only.
• The DEL PDL is posted at http://www.mainecarepdl.org/pdl
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Other Rx Resources
• Maine Rx Plus Program 1-866-796-2463 Provides discounts of 15% - 60% off retail prices for drugs on the MaineCare Preferred Drug List for people with income up to 350% FPL.
• MedAccess 877-275-1787Helps patients and providers evaluate options including low-cost generic programs, Medicare Part D, patient assistance programs and other state and local programs that can help save on prescription medication costs.
• AARP Drug Savings Tool
www//drugsavings.aarp.org/ Free on-line tool to help consumers compare the
medication they have been prescribed to other
effective, safe and less expensive products
• Consumer Reports Health Best Buy Drugs
www.CRBestBuyDrugs.orgReports• Consumer Reports Health Best Buy Drugs provides free, independent
reviews about what drugs work best, are safest, and often less expensive .
20
New Financial Eligibility Rules for Parents, Children
and Pregnant Women
MAGI (Modified Adjusted Gross Income) is based on Adjusted Gross Income
(line 37 of the 1040) + Social Security income. Starting January 1, 2014, under
MAGI:
• No asset test for children, parents or pregnant women; 10 & 20 year olds
• The income of parents who reside with their child(ren) will count in all
circumstances when determining MaineCare eligibility.
• Taxable income counted for Medicaid and CHIP purposes. Non-taxable
income not counted
• Step-parents will be treated the same as parents when determining
MaineCare eligibility for children. Step-parents can no longer opt-out.
• Elderly and disabled categories will continue to have an asset test.
21
MAGI Income Changes
Countable Income:
• Gross taxable income (wages, unemployment compensation, alimony
recieved) minus certain payroll deductions that are taken out as pre-taxed
(e.g.: most health insurance premiums, contributions to some retirements
plans such as deferred Compensation and 401K plans, and ME State
employees retirement contributions)
• Pre-tax deductions are usually marked in some way on the employee’s
check stub (ex: state employee pre-tax deductions are marked with a “P”)
• Child support will no longer be counted as income or an expanse
• VA Disability will not be counted
• Certain expenses (e.g. health savings account deductions, alimony paid)
will also be deducted from a person’s gross income
• All disregards will be replaced by a fixed amount determined by household
size
22
MAGI: Treatment of Certain
Income TypesScholarships, fellowship grants and awards used for education purposes and not for living expenses:
• Monies received for tuition and course related expense are not counted.
• Income associated with Room and Board expense is counted
American Indian/Alaskan Native income derived from distributions, payments, ownership interests, and real property usage rights
Lump sum – counted only in the month received
23
New Asset and Income Disregards Rules
Under MAGI - Modified Adjusted Gross Income
• Child support will no longer count as income in determining eligibility for MaineCare benefits.
• Income deductions that had been allowed for parents and children (cost of child care up to $200 per month and the working parent disregard of $90 per working parent) will no longer be allowed. Instead of these deductions or disregards, the effective eligibility limits will increase slightly:
• Children: 213% of Federal Poverty Level (FPL);
• Parents: 105% of FPL;
• 19 & 20 year olds: 161% of FPL;
• pregnant women: 214% of FPL.
24
A. Does the individual
expect to file taxes?
Yes No
No
END
C. The individual is a non
filer
Yes
No
END
Yes
Start
B. Does the individual
expect to be claimed as a
dependent?
The individual’s household
size is the individual PLUS all
of his/her tax dependents
The individual’s household
size consists of the individual
and (if living with the
individual):
(1) the individual’s spouse;
(2) the individual’s children
under age 19 ;
(3) if the individual is under
19, the individual’s parents
and siblings who are also
under age 19.
Is the individual:
•Other than a spouse,
biological, adopted or step
child
•Under age 19 & claimed by a
non-custodial parent
• Living with both parents who
will not file a joint tax return
Determining MAGI Household Size
No
NOTE: Married couples filing a joint
tax return are included in the
household of the spouse – even if
NOT living together
NOTE: Married couples filing a joint
tax return are included in the
household of the spouse – even if
NOT living together
NOTE: If a taxpayer cannot
prove that another individual
will be a tax dependent for the
year in which Medicaid
coverage is sought, non-filer
rules apply for the other
individual.
NOTE: If a taxpayer cannot
prove that another individual
will be a tax dependent for the
year in which Medicaid
coverage is sought, non-filer
rules apply for the other
individual.
NOTE: In Maine, unborn children are
included in the household size for the
pregnant woman only.
Also, married couples who live together
are ALWAYS included in each other’s
MAGI household regardless of filing
status or any other rule.
NOTE: In Maine, unborn children are
included in the household size for the
pregnant woman only.
Also, married couples who live together
are ALWAYS included in each other’s
MAGI household regardless of filing
status or any other rule.
Is the individual claimed as
a tax dependent by another?
YesNo
The individual’s household
size equals the household
size of the taxpayer who
claims the individual as a tax
dependent
END
The Legislature rolled back coverage for parents from 200% FPL
to 100% FPL – only some of this cut has taken effect
Parents 100-133% FPL: The Federal government rejected Maine’s request to eliminate MaineCare coverage for 14,500 parents until December 31, 2013. Parents with earned income or child support will get transitional MaineCare (3-12 months).
Parents 133-150% FPL: MaineCare benefits for these parents was terminated on March 1, 2013. However, many of these parents with income between 133% FPL ($2,164 per month for family of 3) and 150% FPL ($2,441 per month for a family of 3)were found eligible for “Transitional” MaineCare if they were working or receiving child support when they lost their regular MaineCare benefits.
This coverage transition should have happened automatically. Any family that thinks they should receive Transitional MaineCare, but did not, should check with their case worker. Transitional MaineCare lasts for 3, 6, or 12 months depending upon a family’s circumstances.
Parents 151-200% FPL: MaineCare benefits for these parents was terminated on March 1, 2013. These parents are not eligible for “Transitional” MaineCare.
Important Note: Any parent who lost coverage as a result of this cut who is pregnant should reapply for MaineCare. Pregnant women remain eligible for MaineCare if their income is 200% FPL or below. 26
An Opportunity to Expand Access to
Health Care in Maine • The Affordable Care Act (ACA) allows states to provide Medicaid coverage to all
adults with incomes up to 138% of the federal poverty level ($15,856/year for an individual; $26,951/year for a family of three) beginning January 1, 2014.
• For states that expand coverage, the federal government pays 100% of the cost for covering all “newly eligible” individuals for the first 3 years. After that, the State’s share would still be considerably smaller than under the current MaineCareprogram. 100% funding last until January 2017, and then over the next 7 years slowly drops to 90% federal funding.
• Unfortunately Governor LePage vetoed a bill –LD 1066—that would have required the State to take advantage of this unprecedented opportunity. The Legislature was just a few votes short of overriding that veto.
• Because Maine did not pass this legislation, 10,000 childless adults and 14,500 low income working parents currently receiving coverage will lose it on January 1, 2014.
27
Cover Maine Now!
IT IS NOT TOO LATE– the Legislature could still vote to
expand Medicaid during the next legislative session. Legislation
has been filed to accept federal funds to provide this coverage.
A broad-based coalition of nearly 90 organizations are
working together to help make this happen.
Please contact your legislator to urge him/her to support this legislation or write a letter to the editor in your local paper urging Maine to accept federal funds to expand access to health care for thousands of uninsured Maine people.
Accepting these funds will:
Provide 69,500 people with health insurance who will otherwise go uninsured;
Create more than 3,100 new jobs;
Bring $250 M new federal dollars to Maine and generate $16-18 M dollars in new state revenue;
Avert a significant portion of hospital charity care expense which is ultimately passed on to all other payers in the health care system.
28
Big Changes at DHHS
• Some DHHS offices are strained and case workers’ caseloads are way too big. DHHS is making some changes to address this issue. They are switching from a case worker model to a statewide call center model. Here are some of the ways it is going to work:
• Clients will no longer have a single case worker.* Instead, all DHHS caseworkers will be able to assist with each case.
• All mail sent to DHHS will be scanned into a statewide database that all workers will be able to access.
• When people call DHHS they may talk with a worker at their local office or they may talk with a worker in another part of the State.
• Clients will still be able to go to their local DHHS office but they will not necessarily meet with the same person every time.
• * People in the TANF program will continue to have an ASPIRE caseworker assigned to their case.
29
Kiosks – another way
to apply for benefits
• DHHS is setting up kiosks in all of their offices. People who go into a DHHS office will have the option of using a kiosk if they don’t want to wait to meet with a caseworker.
• DHHS staff should be available to assist people if you have any questions using the kiosk.
• The kiosks are optional. People do not need to use them. They can still opt to meet with someone in person.
30
Apply for Benefits Online: My Maine Connection
• DHHS launched a new online application and screening tool for public programs: www.maine.gov/mymaineconnection/
• People can fill out a screening tool anonymously to find out if they are eligible for TANF; Food Supplement; MaineCare; WIC; Child Care; and/or EITC OR they can go directly to an online application to apply for TANF; Food Supplement; MaineCare; and/or Child Care.
• People are not required to apply online. Everyone will still have the CHOICE of applying in person or requesting an application over the phone.
31
For More Information
Jack Comart, Litigation Director
Ann Woloson, Policy Analyst
Maine Equal Justice Partners
207-626-7058
www.mejp.org
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