Mission: Vision - IN.gov eligibility overview final.pdfprescription medicine, mental healthcare, dental care, hospitalizations, surgeries and family planning at little or no cost to

Mission: To develop, finance and

compassionately administer programs to provide

healthcare and other social services to Hoosiers in

need in order to enable them to achieve healthy,

self-sufficient and productive lives.

Vision: To become a high performance,

integrated and interdependent agency,

leveraging its resources across the continuum

of services we provide in order to reliably and

consistently serve our customers while acting

as astute stewards of the state and federal

money provided to us.

FSSA Leadership

FSSA Secretary

• Jennifer Walthall, MD, MPH

Deputy Secretary/Chief of Staff

• Michael Gargano

Divisions Within FSSA

• Division of Aging

• Division of Disability and Rehabilitative Services

• Office of Early Childhood and Out-of-School Learning

• Division of Mental Health and Addiction

• Office of Medicaid Policy and Planning

• Division of Family Resources

DFR Leadership

DFR Director

• Adrienne Shields

Deputy Director Operations

• Victoria Knowles

Director of Training

• Monique Prezzy

Health Coverage Overview

• The Office of Medicaid Policy and Planning (OMPP) administers the Medicaid programs for the State, which include traditional Medicaid (fee for service) and health insurance programs to low income individuals

• DFR determines eligibility for the medical coverage programs in alignment with the policies and procedures established by Centers for Medicare and Medicaid Services (CMS)

Health Coverage General Eligibility

Factors and Requirements

• Age

• Indiana Residency

• Citizenship/Immigration Status

• Social Security Number (SSN)

• Information about other insurance coverages

• Tax Information

• Each health coverage program has specific income

and resource guidelines

Effective May 2017

Effective May 2017

• Indiana's health coverage program for children and pregnant women with low income

• Based on family income, children up to age 19 may be eligible for coverage

• HHW covers medical care such as doctor visits, prescription medicine, mental healthcare, dental care, hospitalizations, surgeries and family planning at little or no cost to the member or the member's family

Hoosier Healthwise (HHW)

Healthy Indiana Plan

• Uninsured adults age 19-64

• Individual may contribute to a Personal Wellness and Responsibility (POWER) Account

• The contribution is approximately 2% of the member’s income

• Minimum contribution is $1 per month

• Maximum contribution is $100 per month

• Applicant must select a Managed Care Entity (MCE)• Anthem

• Managed Health Services

• Mdwise

• CareSource

• Individuals that are not eligible for Medicare

HIP 2.0 Covers:

HIP 2.0: Plan Options

• Initial plan selection for all members

• Benefits: Comprehensive, including vision and dental

• Cost sharing:

• Must pay affordable monthly POWER account contribution: Approximately 2% of member income, ranging from $1 to $100 per month

• No copayment for services*

HIP Plus

• Fall-back option for members with household income less than or equal to100% FPL only

• Benefits: Meets minimum coverage standards, no vision or dental coverage

• Cost sharing:

• Members are not required to pay a monthly POWER account contribution

• Must pay copayment for doctor visits, hospital stays, and prescriptions

HIP Basic

• Individuals who qualify for additional benefits

• Benefits: Comprehensive, with some additional benefits including vision and dental

• Cost sharing:

• HIP Plus OR HIP Basic cost sharing

HIP State Plan

*EXCEPTION: Using Emergency Room for routine medical care

HIP 2.0: Treatment of Unique Populations

Medically Frail

Individuals (Ryan White) with a disability determination, certain conditions impacting their physical or mental health or their ability to perform activities of daily living such as dressing or bathing will receive enhanced benefits

• HIP Basic or HIP Plus cost sharing will apply but access to vision, dental, and non-emergency transportation benefits is ensured regardless of cost sharing option

• Will not be locked out due to non payment of POWER account contribution

Native AmericansBy federal rule, Native Americans are exempt from cost sharing. Can receive HIP benefits without required contributions or emergency room copayments. May opt out of HIP in favor of fee-for-service benefits as of April 1, 2015

Transitional Medical Assistance (TMA)

Individuals who no longer qualify as low-income parents or caretakers due to an increase in pay are eligible for HIP State Plan benefits for a minimum of six months even if income is over 138% FPL

Low-income Parents, Caretakers, and 19-20 year

olds

Individuals eligible for HIP State Plan Plus or HIP State Plan Basic benefits

HIP Plus vs. HIP Basic for Members with

Income Less than or equal to 100% FPLH

IP P

lus • More affordable

• Predictable monthly contributions

• More benefits

• Option to earn reductions to future monthly contributions

• May reduce future contributions by up to 100%

HIP

Bas

ic • May be more expensive

• Unpredictable costs

• Fewer benefits

• Potential to reduce future monthly contributions for HIP Plus enrollment, but these reductions are capped at 50%

Essential Health Benefits

HIP Plus HIP Basic HIP State Plan

Ambulatory(Doctor Visits)

Covered – Includes coverage for Temporomandibular Joint

Disorders (TMJ)

100 visit limit for home health

Covered – No TMJ coverage

100 visit limit for home health

Covered - Includes TMJcoverage & chiropractic

services. Home health limit does not apply

Emergency* Covered Covered Covered

HospitalizationCovered - Includes Bariatric

SurgeryCovered - No Bariatric Surgery

Covered - Includes Bariatric Surgery

Maternity Covered Covered Covered

Mental Health Covered Covered Covered

Laboratory Covered Covered Covered

Pharmacy Covered Covered - Generic Preferred Covered

Rehab & Habilitation

Covered – 75 visits annually of physical, speech and

occupational therapies

100 day limit for skilled nursing facility

Covered – 60 visits annually of physical, speech and

occupational therapies

100 day limit for skilled nursing facility

Covered - Requires prior authorization but not limited

to 60/75 visits annually

Skilled nursing facility limit does not apply

Preventive Covered Covered Covered

Pediatric Early Periodic Screening Diagnosis and Testing (EPSDT) services covered for 19 & 20 year olds

HIP 2.0: Essential Health Benefits

HIP 2.0: Additional Benefits

Other Benefits HIP Plus HIP Basic HIP State Plan

Adult Vision Covered Not Covered Covered

Adult DentalCovered – Limited to 2

cleanings per year and 4 restorative procedures

Not Covered Covered

Transportation Not Covered Not Covered Covered

Medicaid Rehabilitation Option (MRO)

Not Covered Not Covered Covered

Pregnancy-Only

Additional benefits for pregnant women including

transportation and chiropractic services.

Additional benefits for pregnant women including

transportation, vision, dental and chiropractic

services.

Pregnant women receive access to all pregnancy-only benefits on HIP Plus or HIP Basic plan and full

State Plan benefits.

HIP Plus Contributions

Are Not Premiums

• Unlike premiums, members own their contributions

• If members leave the program early with an unused balance, the portion

of the unused balance they are entitled to is returned to them

– Members reporting a change in eligibility and leaving the program (e.g. move

out of state) will retain 100% of their unused portion

– Members leaving for non-payment of the POWER account will retain 75% of

their unused portion

• If members leave the program early but incurred expenses, they may

receive a bill from their health plan for their remaining portion of the

health expenses

• Members remaining in the program may be eligible to receive a rollover of

their remaining contributions

– Rollover is applied to the required contribution for the following year

Medicaid for the Blind, Aged, and Disabled

• MA A

– Covers aged individuals over the age of 64 years old

• MA B

– Covers blind individuals according the SSA definition

• MA D

– Covers disabled individuals based on criteria defined by the State and SSA

• MADW

– Covers disabled individuals who are able to work

• MADI

– Covers individuals that have medically improved and are no longer eligible for MA D

• MASI– Covers SSI recipients

All categories must meet all other eligibility criteria in addition to meeting income and resource guidelines

Home and Community Based Services

Home and Community-Based Services (HCBS)

• HCBS are available for eligible aged and disabled

population

• Applicant can remain at home as opposed to

institutionalization

• Waiver applications are handled through the Division of

Aging and the Division of Disability and Rehabilitative

Services and generally there is a waiting list

• Waiver applicants should submit a Health Coverage

application for an eligibility determination

• Specific guidelines are utilized when determining Health

Coverage eligibility

Applying for Health Coverage

• Now that you have received

information regarding the Health

Coverage Programs…

• How do you apply?

Application Information• Applications for Health Coverage can be completed on-line via the benefit

portal, or applicants can apply at any local office on a self-service kiosk. Staff are available to assist with application processing and questions

• Applications can be printed, completed and submitted at a later date and can be mailed

Mail completed application back to:

FSSA Document Center

P.O. Box 1810

Marion, In 46952

Fax completed application to 1-800-403-0864

• Health Coverage applications take approximately 45 minutes to complete on-line, and can be completed via phone 1-800-403-0864

• When completing applications the following information is recommended:– Names, Date of Birth and Social Security Numbers for everyone applying in the household

– Employer and Income information for household members

– Tax filing status and tax dependent information

– Current health insurance information including policy number for household members

Individuals can apply for assistance by accessing the link below:

https://www.fssabenefits.in.gov/CitizenPortal/application.do

After an account has been created and logged into,

additional information can be accessed by clinking on

this link

Click this link for an optional screening tool to determine potential

eligibility

Estimated time to complete screening:

15 minutes

A full application must be completed before

eligibility can be determined

A recipient can also manage their benefits, report a change and request

proof of benefits. In order to access this information they must sign into

their account. If they do not have an account one can be created. If an

Authorized Representative wishes to obtain information and/or create an

account this is completed on this screen.

https://fssabenefits.in.gov/benefitsportal/app/portalhome#/

Benefits Portal Case Information Page Example

When a topic is selected, the fields

will expand with additional options.

If you select Case Forms…

The Case Forms field expands

Agency Portal

• Agencies working with clients through the interview and application process often need to know the status of their applications. In order to find this information as well as other information, such as upcoming appointments, agencies are encouraged to register on the agency portal. The portal will provide 24 hour access to the registered agency

https://www.fssabenefits.in.gov/AgencyPortal/#/

http://www.in.gov/fssa/files/Agency_Portal_Instructions.pdf

Redeterminations/Renewals

Redeterminations/Auto Renewals

• A Health Coverage redetermination is a required annual

review of Medicaid assistance groups to determine

continuing eligibility

• Timeframes for the review varies dependent upon when

eligibility initially began

• Some eligibility redeterminations are automatically

determined by specific systematic criteria and others

require the return of a mailer which must be signed by

the client or the authorized representative

• If changes are reported verification must be returned

with the signed mailer

PROTECTING HEALTH INFORMATION

What is an Authorized Representative (AR)?

• The individual or organization may assist with

the application and/or renewal of benefits

process and receive copies of notices for

Healthcare coverage

• An applicant or recipient can appoint or

designate an individual or organization to serve

as an authorized representative on their behalf

Authorized Representative Responsibilities

• The individual or organization whom is serving as an AR

must be knowledgeable of an individual’s

circumstances including, but not limited to, knowledge

of income and resources, household composition and

tax relationships

• Assume responsibility for the accuracy of the

information provided and must maintain confidentiality

of all information provided

Authorized Representative Form…

• If printed from the application Benefits Portal the health coverage

form contains a bar code and is unique to a specific case. Copies

of the form should not be made to attach to other cases, and the

bar code should not be altered under any circumstances

• Generic Authorized Representative Forms can be found at the link below:

http://www.in.gov/fssa/dfr/2689.htm

• Both the AR and the individual must sign the form.

…Authorized Representative Form (Continued)

• During form completion the AR and the

applicant will determine their specific

functions

– Apply functions include:• Sign the application on behalf of the applicant and represent the

applicant during an interview

• Provide all required verifications to determine eligibility

• Speak on behalf of the applicant at appeal

– Ongoing Functions include:• Reporting Changes

• Attending redetermination/renewal interview if applicable, or completing

redetermination/renewal mailer

• Receiving notices

Authorization for Disclosure of Personal and Health

Information Form

• Client will need to indicate what personal and health

information they are authorizing DFR personnel to disclose

• What is the purpose of the requested disclosure (i.e.

assistance with obtaining or using FSSA benefits or services)

• Whom is DFR authorized to disclose personal information

(i.e., names of the individuals or organization including their

contact information)

• Right to revoke at any time by providing written notice

• Once disclosed the information may not be protected under

state or federal privacy laws

• Signature and date is required to provide authorization

http://www.in.gov/fssa/dfr/2689.htm

Authorization for Disclosure of Personal

and Health Information Form

This document is utilized to authorize an individual or agency to obtain information

for a specific amount of time which generally expires in 60 calendar days. Receipt of

this form does not translate into the same information that an AR would receive.

DFR CONTACT INFORMATION

Statewide Eligibility Structure

There are 10 regions each with a Regional Manager and Deputy

Regional Manager

Region 1: Lake ([email protected])

Region 2: St. Joseph ([email protected])

Region 3: Allen ([email protected])

Region 4: Grant ([email protected])

Region 5: Marion ([email protected])

Region 6: Vigo ([email protected])

Region 7: Vanderburgh (DFR.Region

[email protected])

Region 8: Clark ([email protected]

Region 9: Tippecanoe ([email protected])

Region 10: Wayne ([email protected])

Each region as mailbox where inquiries can be sent for questions. A response will be received within 3-5 business days

All regions have one local office within their respective counties

that will assist individuals whom wish to apply for

assistance

Exception:Lake, St. Joseph, and Marion Counties have multiple offices which assist individuals by the applicant’s and/or recipient’s zip code

Locating a Local DFR Office:

You can use http://www.in.gov/fssa/dfr to locate your local office:

Information & Resources Tab

Or click here for directions nearest DFR officehttps://secure.in.gov/apps/fssa/providersearch/#/map

Reporting Information

Statewide DFR Telephone/FAX:

1-800-403-0864

• Mail

• FSSA Document Center

P.O. Box 1630

Marion, IN 46952

State Local Offices Mon-Fri 8am to 4:30pm

Additional Information

Health Coverage has a specific policy manual and income and resource guidelines for the determination of eligibility

Program specific information and policy manuals are available at www.in.gov/fssa

Health Coverage policy manual: http://www.in.gov/fssa/ompp/4904.htm

Questions

How will Ruth be able to afford her

medications?

• Ruth gets $1450/mo in Social Security, no other

income.

• Her $109 Part B premium comes out of SS check.

• Additionally, rent, utilities, insurance, car expenses total $965 per

month.

• Without insurance, her medications are

$432/month.

• What can Ruth do?

Ruth can call HoosierRx!

HoosierRx:

• Is a program that helps low-income seniors pay their premium for Medicare Part D prescription drug coverage, or pay the

prescription drug portion of a Medicare Advantage plan premium.

• Is not a Medicare Part D insurance plan, and cannot assist with deductibles, co-pays, or paying for medication that insurance won’t

cover.

HoosierRx Eligibility

• Must be an Indiana resident, aged 65 or older;

• Must be on Medicare and have a Medicare Part D or Medicare Advantage plan that

works with HoosierRx;

• Cannot be eligible for Medicaid, nor receiving 100% Low-Income Subsidy (Full

“Extra Help”) through Social Security;

• Must meet all other income and eligibility requirements.

Income and Asset Requirements

• Currently, members’ GROSS income must be

no greater than 150% Federal Poverty Level

(FPL).

• In 2017, for one person, gross income limit is

$18,330 annually; for married couple, $24,600

annually.

• There are no asset limitations for HoosierRx

Which Medicare Part D Companies work

with HoosierRx?

Currently, there are seven companies that

have contracts with HoosierRx:

• Cigna-HealthSpring

• EnvisionRx

• First Health

• Indiana University Health Plan

• SilverScript

• UnitedHealthcare/

AARP

• WellCare

How much assistance can HoosierRx

provide?

• HoosierRx can provide premium

assistance up to $70 monthly for eligible

members.

• The premium assistance is paid

directly to the company on

member’s behalf.

• If the premium is over $70/month, the

member will be billed the remaining

premium portion from the company.

How can HoosierRx help Ruth?

• HoosierRx sends Ruth an application to

complete and refers her to SHIP.

• SHIP helps her to find Part D insurance where there is no deductible

and covers her current medications.

• Ruth chooses a plan with a $56/month

premium.

• Her application for HoosierRx is submitted

and approved.

• HoosierRx pays her premium of $56 per

month.

• Her monthly co-pays on her current medication

will be $82.

How do I apply?

• Call 866-267-4679 and

ask for an application.

• Go online and print an

application: http://at.in.gov/HoosierRx

• Mail completed

application to:

HoosierRx

MS07

402 W Washington St. W374

Indianapolis, IN 46204

• Or Fax application and

supporting papers to:

317-234-3709

THANK YOU!

• If you have any questions, please call

866-267-4679.

• Be sure to tell others about this program!