12/8/2015
Medicaid Alphabet Soup: What you Need to Know
Valerie Bogart, Director, NYLAG Evelyn Frank Legal Resources Program
December 2015
[email protected] [email protected] 212.613.7310
2
Topics covered
Changes under ACA – MAGI and NON-MAGI
1.
A.
B.
C.
D.
2.
What is MAGI and who is eligible? How is household size calculated
Who has a CHOICE of MAGI or NON-MAGI and how to choose?
Can a MAGI person get Long Term Care – Home care or Nursing Home?
Transitions Issues – When a MAGI person becomes eligible for
Medicare – What Happens? What if She was receiving Home Care?
Basics on MLTC – What is it, what are the Plan choices
©2013 New York Legal Assistance Group
1
12/8/2015
3
PART 1
THE NEW WORLD OF MAGI
And Transitions from MAGI When Become
Enrolled in Medicare
4
Medicaid Expansion - ACA
• March 2010: Patient Protection and Affordable Care Act enacted.
• January 2014: NYS opens Marketplace (Exchange) to accept applications for
expanded Medicaid coverage to new group that includes single adults & families
up to 138% of the federal poverty level (FPL).
• Increases income limit for everyone under age 65 who does not have Medicare to
138% of poverty. In NYS, this was not really an expansion because the same
population was covered under Family Health Plus, which was eliminated
12/31/14
• Childless adults had an income limit of 100% FPL -- ACA switches them to
Medicaid and expands income to 138% FPL.
• Parents living with children under 21 had an income limit of 150% FPL. Now • Those with incomes < 138% FPL were switched to Medicaid
• Those between 138 – 150% FPL- NYS fully subsidized Premium on the
Marketplace (Exchange) and they had federal cost-sharing subsidy.
©2013 New York Legal Assistance Group
2
12/8/2015
5
Five Eligibility Criteria for Medicaid – Which
Changed under ACA?
1.
2.
Residency – No change. Resident = intend to remain in New York
“permanently or indefinitely.”
Immigration Status - NO CHANGE. PRUCOL immigrants still eligible.
Undocumented immigrants still eligible only for emergency Medicaid,
pre-natal care services, and Child Health Plus for children under 19*
3. Category – Big change – MAGI vs. NON-MAGI
4. Income –
• Non-MAGI - NO Changes for people who have Medicare – 65+, disabled
• MAGI - Big changes for almost everyone else – IRS tax rules modified
5. Resources –
• MAGI - NO resource limit
• Non-MAGI - resources still count (65+, disabled)
*See http://www.empirejustice.org/issue-areas/immigrant-rights/access-to-public-benefits/access-tomedicaid/immigrant-eligibility.html
6
New Medicaid Eligibility Categories
MAGI = Modified Adjusted Gross Income from income tax return
MAGI
NonMAGI
•
•
•
•
Pregnant Women or Family Planning
Children under 19
Parents/Caretaker Relatives*
Childless Adults ages 19 to 64, including
disabled if not on Medicare
• On Medicare caring for dependent
child/relative <18* has CHOICE to be MAGI
• Aged 65+, Disabled, Blind “DAB”
• Spend-down
• On Medicare and no dependent relative
<18*
• See next slide for other non-MAGI groups
*Live with their own child, grandchild or another relative or step-relative, under age
18 or under 19 if a full-time student
©2013 New York Legal Assistance Group
3
12/8/2015
7
3 Medicaid Categories – 3 sets of rules
MAGI
“Obamacare” Affordable Care Act
Who
Asset limit
(exclusions
apply)
Income
limit
Monthly
• < 65 and not on
Medicare OR
• any age on Medicare
and caring for minor
child/ grand-child
Non-MAGI
(Disabled-AgedBlind)(“DAB”)
SSI
Supplemental
Security Income
Age 65+ OR
Disability – any age
NONE
(but interest, dividends
count as income)
$14,850-Single
$21,750 Couple
$2,000- Single
$3,000 - Couple
$1,354 – single
$1,852 – couple
138% FPL - Higher if
pregnant, young children
$ 845 –Single
$1,229-Couple
$ 840 – single
$1,224 - Coue
MAGI = Modified
Adjusted Gross Income
8
NON-MAGI Categories –
#1 - Disabled, Aged 65+ and Blind = DAB
All still use “SSI-related” budgetiong rules for income & resources
• SSI recipients –still use low SSI income/resource limits
• Certified disabled, age 65+ and blind
• still use old income and resource limits and budgeting rules, including
Spend-down, pooled trusts, and spousal refusal
• Medicaid Buy-In for Working People with Disabilities under age
65 (MBI-WPD)
• Medicare Savings Programs
• Disabled Adult Children
• receive SSD on retired or deceased parent’s earnings, based on becoming
disabled before age 22
• Medicaid continuation of Pickle, Widow/Widower’s benefits
©2013 New York Legal Assistance Group
4
12/8/2015
9
Non-MAGI Categories - #2
• Spend-down – (also known as “Medically Needy”)
• Children under 21 and Parents/caretaker relatives may still “spend down”
to the old Medicaid limits, using the old rules, if they do not qualify using
MAGI budgeting, and if they prefer to use Medicaid to using Premium
and Cost-sharing subsidies for a plan on the Exchange
• Disabled, aged, blind may also still use “spend-down” & pooled trusts
• COBRA continuation - Medicaid pays COBRA premium
• Cancer Treatment programs for breast, cervical, colorectal and
prostate cancer – only if not eligible using MAGI
• Residents in adult homes, OMH residences
• Old Medicaid income and asset rules are used for these Non-
MAGI categories. Aged, disabled still have $14,850 asset limit.
• Transfers of assets still have a penalty for nursing
home care.
10
Some People have a Choice –
May choose MAGI or non-MAGI
• If certified disabled < age 65 and not yet on Medicare (in
waiting period) --may choose MAGI or non-MAGI. Once
receive Medicare, may not use MAGI UNLESS they live with and
care for a child/other relative < 18 ( < 19 if fulltime student).
• On Medicare but are a parent/caretaker relative of a Child/
grandchild under 18 (19 if in school).
• Disabled children may choose MAGI or NON-MAGI, unless they
are in a waiver program (eg. Katie Beckett program).
©2013 New York Legal Assistance Group
5
12/8/2015
11
Which to Choose if One has a Choice
MAGI is BETTER
NON-MAGI is BETTER
Higher income limit - 138%
FPL ($1354/mo) vs.
$825/month
If disabled person is working, better income
disregards and higher income limits with nonMAGI–
• 50% of gross earned income “disregarded” –
better than 5% MAGI deduction
• Medicaid-Buy-In for People with Disabilities –
income limit 250% FPL
Workers comp, VA benefits,
child support, gifts not
counted as income
MAGI has NO spousal refusal, no spend-down,
no pooled trusts – so if you need those (income >
138%FPL), non-MAGI is better
No asset test!
WHICH TO CHOOSE?
MAGI can mean full Medicaid with no spend-down if MAGI income < 138% FPL.
If MAGI income > 138% FPL, then choose NON-MAGI Medicaid with spenddown
or buy policy on Marketplace with Premium & Cost-sharing subsidies (but no LTC
available)
12
More about MAGI
• 12 continuous months of coverage, regardless of whether
income increases in year BUT in 2016 – those turning age 65 will
receive notices from the Marketplace and their LDSS that
Coverage ends unless they do a renewal and recertify under the
non-MAGI rules (lower income limits & asset test). Similar to
Stenson procedures when lose SSI.
• Apply online – https://nystateofhealth.ny.gov/ or through
Navigator (locate on same site)
• Rules very complicated – refer to Navigator!
• Full Medicaid benefits including home care, and in some cases,
nursing home care.
• BUT requires transfer of administration of case from
Marketplace to DSS!
©2013 New York Legal Assistance Group
6
12/8/2015
13
DETERMINING COUNTABLE
INCOME - MAGI
• How much income is allowed?
• Which income?
• Whose income?
• What is “household size?”
14
What is Income Limit?
MAGI simplifies budgeting with just one 5% disregard of
gross income. Most people under age 65 have a MAGI
income limit of 138% FPL (5% is the income disregard)
with special categories.
Category
Federal Poverty Level
Limit – MAGI income
Pregnant women
223% FPL
Infants under age 1
223% FPL
Children age 1 – 18
154% FPL
19 and 20-year olds living with parents
155% FPL
Family Planning Benefit program
223% FPL
< 26 who were in foster care when age 18
NO INCOME LIMIT!
All other MAGI people – under age 65
138% FPL
©2013 New York Legal Assistance Group
7
12/8/2015
15
Which income? Modified AGI
16
Common Income counted toward Medicaid MAGI
Type of Income
Form 1040 NOTE
Line
Wages, salary, tips
(earned income)
Line 7
!!! Does not include retirement or
cafeteria plan deductions – flexible
spending account – for health care or
child care. See note re child care.
Interest & dividends
Lines 8-9
Tax exempt interest is counted
State income tax refunds
Line 10
Alimony received
Line 11
Profit or Loss from SelfEmployment
Line 12
Only net income after expenses – use
Schedule C -GIS 14 MA/07
Rental income
Line 17
Net income after expenses
Unemployment
Compensation
Line19
Social Security Benefit
Line 20a
©2013 New York Legal Assistance Group
ALL SS income is counted, even
part not taxable – but not child’s
see next slide
8
12/8/2015
17
Income NOT Counted toward MAGI
Type of income
Explanation
Child Support
Not counted as income by the family that receives the support.
Person paying the support may not take a deduction
Veteran’s benefits Don’t count as income – both disability and pension benefits.
(But note that this is only for MAGI budgeting. Aged 65+ must
still count VA benefits). Military retirement pay IS counted.
Certain scholarship IRS rules count some scholarships & grants as income, but if
income
used for educational purposes, not living expenses, Medicaid
will continue to exclude them.
American Indian
income
Some types counted as income by IRS, but not by Medicaid
Gift or
inheritance
Not counted. Taxed to the donor of the gift, or to the Estate,
not to the recipient or beneficiary.
Child/ dependent’s income
Income of a child or tax dependent who is not required to file a
tax return is not included in the household income. GIS 15-MA08 (includes child’s Social Security)
Workers Comp
Not Counted
18
Lump sums, Gifts & Inheritances
• MAGI MEDICAID RULE -- The lump sum is treated as income in
the month received, but with 12-month continuous eligibility
guarantee, Medicaid can’t be cut off. It becomes a resource in
subsequent months – but resources are not counted in MAGI
budgeting. So lump sums in effect do not hurt eligibility.
• EXAMPLE – Lottery winning, lawsuit settlement
• Gifts and inheritances are NOT counted as income under MAGI.
• NOTE that MAGI budgeting for the Premium Tax Credit and
Coinsurance subsidy is different. Those are based on annual
income, so a lump sum that would be taxable is counted as
income (e.g. lottery). Not all lump sums are taxable – such as
gifts and inheritances.
©2013 New York Legal Assistance Group
9
12/8/2015
19
Which Income – Past, Current or Future?
• MAGI Medicaid uses anticipated income for the remainder of
the calendar year (this is an option afforded by 42 C.F.R. §
435.603(h)(2)). Applicants must “attest” to estimated annual
income.
• Data-matching will be used to compare the estimated income.
If the applicant’s estimate and the data from the IRS and other
sources are very different, you will be given a chance to verify
the reason (for example, that you lost your job or are retiring).
• When data obtained is “reasonably compatible” with an
applicant’s attestation, the State agencies are prohibited from
requiring additional documentation.
20
Adjustments (deductions) from Gross Income
• Alimony paid,
• Contributions to a flex spending
• certain moving expenses,
plan – medical, child care
• self-employment tax
• student loan interest
• self-employed health insurance
contributions
• IRA deduction.
©2013 New York Legal Assistance Group
10
12/8/2015
21
Household Size - Whose income is counted?
• Generally count income of everyone in the Medicaid tax
“household” -- but there are exceptions.
• Rules are very complicated* -- Factors:
1.
2.
3.
4.
5.
6.
7.
Does the individual expect to file taxes? See next slide.
Does the individual expect to be claimed as a dependent?
Is the individual a US citizen, or lawfully present?
Is anyone married, including same-sex couples?
Is anyone under age 19? Or age 18 – 24 and a full time student?
Who lives in the household at least half the year, or year-round?
Is anyone pregnant? Pregnant women counted as self + number of
expected children
*See NYS DOH 13ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act
(ACA) of 2010 and Natl. Health Law Program Advocates Guide to MAGI
http://www.healthlaw.org/publications/agmagi#.VmD5Er_l_ox
22
Household size for MAGI con’d.
• Medicaid uses tax rules for who is expected to file a tax return, and who is
claimed as dependents
• Medicaid has some special rules for people who don’t file tax returns,
because many low-income people don’t file tax returns.
• Three general categories of people for household size rules:
1. TAX FILERS - Those who are expected to file taxes and are not
claimed as a dependent by someone else;
2. DEPENDENTS - Those who are claimed as a dependent; and
3. NON-FILERS who do not file taxes AND are not claimed as a
dependent by someone else.
• Pregnant women – always count woman + number of expected
children when including her in household
• Spouses – Spouses who live together are counted in each other’s
household, regardless of whether they expect to file jointly.
©2013 New York Legal Assistance Group
11
12/8/2015
23
Family size Rule 1 – TAX FILERS
1. ► TAX FILERS - Those who are
expected to file taxes and are not claimed
as a dependent by someone else;
2.
3.
Those who are claimed as a dependent; and
Non-filers who do not file taxes AND are not claimed as a dependent
by someone else
THIS PRESENTATION ONLY DISCUSSES
24
Family size rule 1: Tax Filers
• Rule for people who file taxes who do not expect to be claimed
as a dependent by another taxpayer.
• RULE: Household = Tax filer + all persons whom taxpayer
expects to claim as a tax dependent
• Spouse rule - Spouses who live together are counted in each
other’s household, regardless of whether they expect to file
jointly. NO SPOUSAL REFUSAL!!!!
• Example– Joe and Mary are married and live with 2 kids under age 19,
Aaron and Andrew, as well as Joe’s Uncle Matt, who does not file taxes. Joe
files a tax return, claiming the 2 children and Uncle Matt as dependents.
Joe’s household is FIVE – he and his wife under spouse rule, and 3
dependents. If Mary is pregnant with twins,
household is SEVEN.
• Bigger Household Size = Higher Income Limit!
©2013 New York Legal Assistance Group
12
12/8/2015
25
Basic concepts for HOUSEHOLD SIZE
To figure out household size, need to know:
(1) WHO IS expected to file taxes? See chart next slide
(2) Who IS expected to be claimed as a dependent – must include in HH size
• There are 2 types of dependents:
• Dependent child “qualifying child”(or stepchild, foster child, grandchild,
younger sibling, niece/nephew) - under 19 or under 24 if in school, or any age
if disabled, lived with you > one-half of year, child did not provide more than
half of his/her own support for the year.
• Dependent relatives –“qualifying relative” – see next slide
• For BOTH types – You can’t claim a dependent if someone can claim YOU
as a dependent.
• May be claimed as a dependent but still file her own tax return (teenager
with part time job if child’s income doesn’t provide her with more than
one-half of her support. Even if child files her own tax return for a
refund, she is still in her family’s MAGI household.
26
Tax filing requirements – MAGI categories
Filing Status:
At the end of the
year you were:
File Return if your
gross income was at
least:
Single
Under 65
$ 9,750 ($ 812/mo)
65 or older
$11,200
Both spouses < 65
$19,500 ($1,625/mo)
Married filing Jointly
1 spouse >65
$20,650 ($1,720/mo)
Married filing separately
Any Age
$ 3,800
Under 65
$12,500 ($1,040/mo)
Head of household
65 or older
$13,950
Qualifying widow(er) with
dependent child
Under 65
$15,700
65 or older
$16,850
2014 IRS figures
©2013 New York Legal Assistance Group
13
12/8/2015
27
Test to be a dependent or qualifying relative
• Can’t be your dependent “child” or a dependent child of another taxpayer
(can use this if your child is age 24 or over)
• Relationship – must EITHER:
• Live with you year-round as a member of your household
• OR be your or your spouse’s parent, grandparent, child, grandchild,
niece/nephew, aunt/uncle..
• Includes step-relatives and in-laws. (Does not include cousins).
• Support – You must provide more than half of the person’s support in a
calendar year.
• Total support includes amounts spent to provide food, lodging, clothing,
education, medical and dental care, recreation, transportation, and
similar necessities (NOT taxes, life insurance premiums)
• Person’s gross income < $3,900 for year (some exceptions)
• US citizen, US national, resident alien, resident of Canada or
Mexico
28
Family size Rule 2 – DEPENDENTS
1.
TAX FILERS - Those who are expected to file taxes and are
not claimed as a dependent by someone else;
Those who are claimed as a
dependent
2. ►
3.
Non-filers who do not file taxes AND are not claimed as a
dependent by someone else
©2013 New York Legal Assistance Group
14
12/8/2015
29
Family Size Rule 2: Tax Dependents
• Dependents usually use the same household size as the tax
filer claiming the dependent.
• In the preceding example, wife Mary and the two children are a
household of FIVE, using the same household as Joe. If Mary is pregnant
with twins, two children’s household size would be SEVEN – same as for
Joe and Mary.
• THREE exceptions to this Rule (We address just the 1st)
1. Multi-Generation Households – A grandparent or other person (like
Uncle Matt) lives with Tax Filer who claims the grandparent/other
person as a dependent.
2. Unmarried parents of minor children, who all live together
3. Split custody families – child claimed as dependent by non-custodial
parent
30
Rule 2 EXCEPTION 1 – Multi-Generation Household.
If the grandparent, uncle, other relative or friend living with a
taxpayer is:
• claimed as a dependent by the taxpayer but
• is not a child or spouse of the taxpayer
The dependent’s household is just HIM/HER, and if they are living
with him, his spouse and minor children < 19 or student < 21
• EXAMPLE Uncle Matt living with Joe and Mary and their kids. Even
though Joe claims him as a dependent, and he is counted in Joe’s
Medicaid household, MATT’s household is just him- Matt. If they are
living with him, it would also include his Spouse, and his Children < 19.
• This rule helps low-income families with multi-generations living
together. (Matt can count just his own income not his nephew’s).
• Joe counts Matt as a dependent & in his MAGI household even if
Matt is non-MAGI
©2013 New York Legal Assistance Group
15
12/8/2015
31
Family size Rule 3
TAX FILERS - Those who are expected to file taxes and are
not claimed as a dependent by someone else;
2. Those who are claimed as a dependent
3. ► Non-filers who do not file taxes AND
are not claimed as a dependent by someone
else
1.
• Same rule applies to Exceptions under Rule 2
32
Family Size Rule 3: Non-Filers, Those Not
Claimed as Dependents, and Some
Dependents
Rule 3 applies to people who:
• Do not expect to file a tax return (non-filers), and
• Do not expect to be claimed as a dependent,
• OR are claimed as a dependent but are either:
• Not the spouse or child of the taxpayer (i.e. Uncle Matt)
• Are under 19 (or student < 21), expect to be claimed as dependent by ONE
parent though live with BOTH parents, where parents don’t expect to file a
joint tax return, or
• Are under 19 (or student < 21), expect to be claimed as dependent by
NON-custodial parent.
Carol, in previous example, would be in this rule if
she doesn’t expect to file a tax return or be claimed as a dependent.
©2013 New York Legal Assistance Group
16
12/8/2015
33
Family Size Rule 3: Non-Tax Filers who do not
expect to be claimed as dependent
• For everyone on previous slide -• RULE - Household Size = Individual, and, if living with the individual, the following:
• Spouse,
• Individual’s Children < 19 (or student <21),
• If the individual is <19 (or student < 21), the individual’s parents and siblings if
they are also < 19 (or student < 21).
Uncle Matt Example:
Uncle Matt is his own Medicaid household, even though he is claimed as a
dependent by nephew Joe. If Matt’s son, Tom, age 10 was also living with them,
Matt’s household would be TWO – he and his son Tom, even if Joe counted Tom as
a dependent.
Carol Example:
If Carol does not expect to file taxes or be claimed as a dependent,
her household size would be 2 – she and daughter Marcia.
34
Household Case Example # 1 –
Intact multi-generation family, pregnant wife
James (the taxpayer) and Alexis (James’s wife) live together with two children, John
and Susan, both under 18, as well as James’s Aunt Patricia, age 62, who receives
Social Security but does not file taxes. Alexis is pregnant and is expecting one child.
James claims all of them as dependents.
• What is James’Medicaid household size?
• James’ household size is six. His household includes James plus his four
dependents + unborn child.
• What is the household size of the dependents?
• Alexis – Spouse rule always counts her in James’ household. So she is SIX.
• 2 children - Since they are dependents and children of James, the taxpayer,
their household size is the same as James = SIX.
• Aunt Patricia - household of ONE because she is not James’ or
Alexis’ child or spouse, and she has no parents, spouse
or siblings living in the same household.
©2013 New York Legal Assistance Group
17
12/8/2015
35
What if Over-Income for MAGI Medicaid?
Children under 19 – Can get Child Health Plus – up to 400%
FPL. Also uses MAGI budgeting.
2. Parents/ Caretaker relatives of children < 18 (students <19)
1.
• CHOICE – Medicaid with a spend-down, using OLD budgeting rules or
• Buy Insurance on Exchange and get Subsidies:
• Premium Tax Credit – up to 400% FPL and
• Cost-Sharing Assistance – up to 250% FPL
• Those with incomes 138% - 150% FPL are losing Family Health Plus. State will
subsidize premium even more than the federal Premium Tax Credit.
3. Singles/Childless Couples and people age 20-21 not living with
parents - No Medicaid option, can only buy Insurance on
Exchange with premium & cost-sharing subsidies.
•
36
MAGI for Premium Tax Credits & Coinsurance
• Rules mostly the same as MAGI for Medicaid but some
differences.
• The 5% FPL income disregard does not apply to Premium tax
credits or cost sharing, only to Medicaid.
• Rule for determining number of people in the household is
different for Medicaid than for Premium tax credits/costsharing. Both rules are based on income tax rules but there are
some differences.
• For complete explanation and worksheets, see National Health
Law Program, Advocates Guide to MAGI (updated 10/2015).
http://www.healthlaw.org/publications/agmagi#.VmD5Er_l_ox
©2013 New York Legal Assistance Group
18
12/8/2015
37
Pop Quiz
Bob and Brenda are married. They have two children, Arthur age 2 and Hank age 19. Bob claims Brenda, Arthur and
Hank as his dependents. Bob and Brenda’s income is 155% of FPL for a household of four. Arthur works and earns
$5,000 per year and isn’t required to file taxes. Brenda’s mother, Beatrice also lives with them. Beatrice is 75
years old. She received $500 per month Social Security Retirement and Medicare. Beatrice does not file taxes.
Household size?
Bob, Brenda, Arthur and Hank = Household of four
Beatrice = Household of one
Benefit?
Bob and Brenda are eligible for FHP wrap.
Arthur is eligible for CHIP.
Hank is eligible for full Medicaid.
Beatrice gets full Medicaid.
Category?
Bob and Brenda are MAGI as parents.
Arthur is MAGI as a child under 18.
Hank is MAGI as a 19 year old living with his parents.
Beatrice is non-MAGI.
38
LONG TERM CARE & MAGI
•
•
•
•
•
•
15 OHIP/INF-1 (10/2015) (Q&A -Long Term Care and MAGI)
GIS 14MA/016 (Long Term Care Eligibility Rules and Estate Recovery
Provisions for MAGI Individuals)
13 ADM-31
10 OHIP/ADM-1
Department Regulations: 360-2.3, 360-4.4,
MLTC Policy 14.01: Transfers from Medicaid Managed Care to Managed
Long Term Care – at MRT 90 page
http://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm
©2013 New York Legal Assistance Group
19
12/8/2015
39
What MAGI people need LTC?
• Most elder lawyers are helping people with Medicare or those
age 65+ get long term care. They are non-MAGI.
• There are exceptions:
• Healthy young people have strokes, heart attacks, or accidents.
• People on Social Security Disability during waiting period for Medicare –
they are MAGI and may need long term care at home or in a nursing
home.
• Eventually many of these people may become non-MAGI – they
turn 65, become enrolled in Medicare. But until then, they
may remain MAGI and access all Medicaid long term care
services.
40
MAGI & Home Care
• All Medicaid community-based Long Term Care services are
part of the MAGI benefit package –
• personal care (PCS), Consumer-Directed Personal Assistance (CDPAP),
certified home health agency (CHHA), & private duty nursing.
• Waiver services – OPWDD, OMH, Care at Home, NHTDW, TBI
• Assisted Living Program
• Most MAGI Medicaid recipients were required to enroll in a
mainstream Medicaid managed care plan (plan that serves 4.5
million Medicaid recipients without Medicare – families, kids,
singles, healthy, sick). These plans are required to provide
home care services (PCS, CDPAP, CHHA, private duty nursing)
• State doesn’t want members of mainstream plans to switch to
MLTC. State premium paid to MLTC plans (> $4,000/mo) more
than 10x rate paid to mainstream plans ($300/mo.)
©2013 New York Legal Assistance Group
20
12/8/2015
41
May MAGI enroll in MLTC?
• Under MLTC Policy 14.01 - Transfers from Managed Care to
MLTC* - a member of a mainstream managed care plan may
switch to MLTC only if s/he needs services unique to MLTC not
offered by mainstream managed care (social adult day care,
environmental modif’s, home delivered/ congregate meals).
• File request to transfer with NY Medicaid Choice or, in counties where NY
Medicaid Choice not handling managed care enrollment, with DSS
• But a new MAGI recipient not yet enrolled in a mainstream
plan MAY choose to enroll in MLTC initially. Id. Must act
quickly when apply for Medicaid on Marketplace!
*http://www.health.ny.gov/health_care/medicaid/redesign/mrt
_90.htm
42
Procedures: Must Transfer Case to LDSS from
Marketplace
• If someone found eligible for MAGI on the Marketplace wants
any long term care service not offered by their mainstream
Medicaid managed care plan, OR needs NH care even if in a
mainstream managed care plan, their Medicaid must be
transferred to the LDSS for input of needed eligibility codes.
• NYC HRA Alert “Consumers with Medicaid Coverage on the NYSOH
(Marketplace) whose Coverage Must be Transitioned to WMS” http://www.wnylc.com/health/download/486/ (6/11/14) – procedure
for transferring case to LDSS
• LDSS will still use “MAGI” rules (“MAGI-like”)
• Home Equity limit, however, applies for Long Term Care services. GIS
14/MA-016.
©2013 New York Legal Assistance Group
21
12/8/2015
43
MAGI & Nursing Home Care - Assets
• GIS 14 MA/16, "Long Term Care Eligibility Rules and Estate Recovery
Provisions for MAGI Individuals” and later Q& A 15 OHIP/INF-01
(10/29/2015) – implement CMS directive
• MAGI includes Nursing Home care if “medically frail.” Above GIS says that
need for NH care alone meets that definition. Does not require a disability
determination UNLESS income > 138% FPL so not MAGI 15 OHIP/INF-1 #20 22.
• Transfer of Assets – If need NH care > 29 days, must submit 5-year lookback
and normal transfer penalty/ exceptions apply. Makes little sense since there
is no RESOURCE test for MAGI.
• A MAGI individual is “otherwise eligible” if income < 138% FPL. 15 OHIP/I
NF-1.
• NO LIEN on homestead. GIS 14 MA/16. But home equity limit applies to
single individuals. 15 OHIP/INF-1 Q. #11.
• Must transfer case to LDSS just like home care – previous slide.
44
MAGI & Nursing Home Care – Income
• MAGI income limits apply in NH, counting only NH resident not
spouse’s income.
• If NH resident income alone < 138% FPL – eligible and no
NAMI. (Can keep $1,354/mo.!) Even though cannot use
spousal impoverishment, nothing precludes giving that income
to one’s spouse.
• If also “disabled” can opt to use non-MAGI budgeting instead,
with spousal impoverishment, if more advantageous.
If individual was in managed care plan, stays in plan when enters
NH and that plan pays for NH care.
©2013 New York Legal Assistance Group
22
12/8/2015
45
Estate Recovery and MAGI
Estate Recovery applies to a MAGI Medicaid recipient for cost of:
• any nursing home care or other home and community-based
services received on or after 55th birthday,
• related hospital and prescription drug services received on or
after the MAGI individual's 55th birthday
• Same exclusions apply for other Medicaid recipients wrt/
surviving spouse, disabled children, etc. SSL 369, GIS 14MA/016, 15 OHIP/MA-01 Q. 12
(For non-MAGI, estate recovery of ANY Medicaid expenses after
55th birthday)
46
TRANSITIONS: MARKETPLACE
TO LOCAL DSS
What happens when the MAGI recipient reaches
age 65, or becomes eligible for Medicare?
Or had Medicare with a dependent child who is
now over 18, so parent is no longer MAGI.
©2013 New York Legal Assistance Group
23
12/8/2015
47
Transitions when one loses MAGI
(1) Must switch from MAGI to old rules
1.
Must renew/requalify for Medicaid under the old budgeting
rules – lower income limits and an asset test
• Through 2015, anyone who turned 65 still kept MAGI Medicaid active
because they were guaranteed 12 months of continuous coverage.
• In 2016, this will end – anyone turning 65 will receive notice that they must
complete renewal with LDSS – document assets, income. Details of
procedures not yet available. Should be entitled to Aid Continuing if
determine not eligible under regular Medicaid rules…
• Client’s income could have been under MAGI limits ($1354) but now will
result in a spend-down. Must enroll in a trust, etc.
• ASSETS now count, though they didn’t before.
• For clients approaching 65 who were MAGI – help them do
Medicaid planning even if they already had Medicaid!
48
Transition (2) Leaving Medicaid Managed Care
If client is now eligible for Medicare, she will be automatically
disenrolled from “mainstream” Medicaid managed care plan.
• Must enroll in a Part D plan, and may buy a Medigap plan.
• May be marketed to by her mainstream Medicaid managed care plan to
enroll in their Medicaid Advantage product – this is a combo-plan which
combines a Medicare Advantage plan with a Medicaid managed care plan
- covers both Medicare and Medicaid.
• If client had doctors already in the Medicaid plan’s network it may be ok as
the network is likely to be the same. And obviates the need to buy a
Medigap plan.
• NOTE: If client needs home care, must join a FIDA or Medicaid Advantage
Plus plan, not a Medicaid Advantage plan if she wants to use this model!
Medicaid Advantage plans do not cover home care and do not allow
enrollment in MLTC.
• OR she may have Original Medicare with MLTC and Part D.
©2013 New York Legal Assistance Group
24
12/8/2015
49
Transition 3. What if client had MAGI home
care??
• Since 2011, people without Medicare had to access personal
care, CDPAP, and nursing services from the mainstream
managed care plan – not from their local DSS. They submitted
an M11q (physician’s order) for an assessment just as with DSS,
and the plan authorized and paid for home care.
• But.. When they get Medicare they are automatically
disenrolled from the managed care plan! That means their
home care STOPS.
• NYLAG and other groups advocated for this policy - MLTC Policy
15.02: Transition of Medicaid Managed Care to MLTC (June
2015). Explained on next slide - to prevent gaps in long term
care between MMC disenrollment and MLTC enrollment
50
(3) Transition to MLTC from MAGI/Managed
Care
State MLTC Policy 15.02 - plans must identify anyone reaching
65 who is receiving home care, and give the list to NY Medicaid
Choice – the enrollment broker contracted with the State.
• NY Medicaid Choice will send these individuals a letter telling
them to select an MLTC plan or they will be assigned.
• Before MMC disenrollment, there will be a chance to choose
an MLTC plan:
• If MMC has a “sister” MLTC  passive enrollment to sister MLTC
• If no “sister” plan  auto-assigned to an MLTC if don’t choose one
• BEWARE OF PROBLEMS! We have seen plans failing to identify
these cases, or failing to transfer them to their sister MLTC.
©2013 New York Legal Assistance Group
25
12/8/2015
Part 2- MANAGED LONG TERM
CARE (MLTC)
What is Managed Long Term Care
(MLTC)?
• Program for dual eligible adults who need more than
120 days of long term care
• Long term care (and other Medicaid services)
provided through health plans
– Medicaid pays the plans to provide services (monthly
capitation rate)
– Includes care management component
• Mandatory in all counties statewide
– Each county must have at least two MLTCs
52
icannys.org
©2013 New York Legal Assistance Group
26
12/8/2015
MLTC Benefit Package
Long Term Care
•
•
•
•
•
•
Nursing Services at home
Therapies in the home
Home Health Aides
Personal Care
Adult Day Health Care
Consumer Directed
Personal Assistance
• Nursing home
Additional Services
• Social Adult Day Care
• Home Modifications
• Medical Equipment &
Supplies
• Non-Emergency
Transportation
• Personal Emergency
Response System
• Home Delivered Meals
• Podiatry, Optometry,
Audiology, Dental
53
icannys.org
Who Must Join MLTC?
• Dual eligibles who are age 21 or older AND
• Receiving / need Medicaid Community-based long
term care services for >120 days in a calendar year
– Level II Personal Care
– Consumer Directed Personal Assistance
– Certified Home Health Agency services
– Adult Day Health Care (medical model)
– Private Duty Nursing
– Lombardi / Long Term Home Health Care Program
54
icannys.org
©2013 New York Legal Assistance Group
27
12/8/2015
Who May Join MLTC?
Voluntary enrollment for:
• Dual eligibles
1. 18 through 20 years old;
2. Need >120 days community long term care; AND
3. Assessed as nursing home eligible.
• Non-dual eligibles (Medicaid only)
1. 18 years and older;
2. Need >120 days community long term care; AND
3. Assessed as nursing home eligible.
55
icannys.org
Who Cannot Join MLTC?
• Only need Housekeeping services
(aka, Level I Personal Care services)
• Need <120 days Community Based Long Term
Care
• In receipt of Hospice services
– But if in MLTC and develop a need for hospice, stay in
MLTC
• Only need Social Adult Day Care
56
icannys.org
©2013 New York Legal Assistance Group
28
12/8/2015
Who is Currently Excluded from
MLTC?
Currently
Planned Carve in
Assisted Living Program
1/1/16
NHTD waiver
1/1/17
TBI waiver
1/1/17
OPWDD waiver
Late 2015 voluntary
2017-2019 mandatory
57
icannys.org
Steps to MLTC Enrollment
1
Assessment by Conflict Free Evaluation
and Enrollment Center (CFEEC)
2
Learn about Plan Types & Options
3
Obtain MLTC Plan Assessments and
Choose a Plan
4
Enroll in an MLTC Plan
58
icannys.org
©2013 New York Legal Assistance Group
29
12/8/2015
1
Conflict Free Evaluation and
Enrollment Center (CFEEC)
• CFEEC (Maximus)
• For people newly seeking MLTC
– No CFEEC assessment if transferring from plan to plan,
or from a previous Medicaid long term care service
• Evaluation Process
– CFEEC conducts initial evaluation of MLTC eligibility
(7 business days from call)
» Can obtain prior to Medicaid eligibility decision, but
assessment only good for 60 days
– CFEEC gives thumbs up or down for MLTC eligibility
59
icannys.org
2
Learn about Plan Types &
Options
Two Models of MLTC
• Partially Capitated MLTC (MLTC with only Medicaid
benefits)
• MLTC with Medicaid AND Medicare benefits
– Program for All-Inclusive Care for the Elderly (PACE)
– Medicaid Advantage Plus (MAP)
– Fully Integrated Dual Advantage (FIDA) (currently only
available in NYC & Nassau)
• http://www.health.ny.gov/health_care/managed_c
are/mltc/mltcplans.htm
60
icannys.org
©2013 New York Legal Assistance Group
30
12/8/2015
2
Learn about Plan Types &
Options
MLTC with only Medicaid benefits:
• Also known as Partially Capitated MLTC
• Provides Medicaid services only
• Does NOT provide Medicare-covered services
– For Medicare services use:
 Original Medicare
(or Medicare Advantage)
 Part D plan
(or Medicare Advantage/Prescription Drug Plan)
61
icannys.org
2
Learn about Plan Types &
Options
Medicaid Advantage Plus (MAP):
• Provides all Medicare and Medicaid services
• Additional eligibility requirement: Need Nursing
Home level of care
• Use plan’s provider network for all services
• CAUTION: Medicaid Advantage Plus (MAP) is not
the same as Medicaid Advantage (MA). Both include
all Medicare services, but:
– MA provides Medicaid without LTC
– MAP provides Medicaid with LTC
62
icannys.org
©2013 New York Legal Assistance Group
31
12/8/2015
2
Learn about Plan Types &
Options
Program for All-Inclusive Care for the Elderly
(PACE):
• Provides all Medicare and Medicaid services
• Provide services through a particular site – a medical
clinic or hospital. Because all providers are linked,
potentially more opportunity for coordinated care.
• Additional eligibility requirement(s):
– Need Nursing Home level of care, and
– Age 55+
63
icannys.org
2
Learn about Plan Types &
Options
Fully Integrated Dual Advantage (FIDA):
• Demonstration project to coordinate care for dual
eligible population
• Person-centered care model
• Currently only in NYC & Nassau (Suffolk &
Westchester rollouts delayed)
64
icannys.org
©2013 New York Legal Assistance Group
32
12/8/2015
2
Learn about Plan Types &
Options
Fully Integrated Dual Advantage (FIDA) cont’d:
• Provides most Medicare & Medicaid services
– But not: Methadone maintenance, out of network
family planning services, direct observation therapy for
tuberculosis, and hospice care (these are offered
through regular Medicare/Medicaid)
• Integrated Medicaid/Medicare appeals process
65
icannys.org
3
Obtain MLTC Plan Assessments
and Choose a Plan
• Find out which plans contract with preferred
providers
• Schedule plan assessment(s)
– Must be conducted within 30 days of request
– Obtain assessments from multiple plans
– Ask for proposed care plans
• Choose the MLTC that best meets needs
66
icannys.org
©2013 New York Legal Assistance Group
33
12/8/2015
4
Enroll in an MLTC Plan
• Partially Capitated MLTC (Medicaid only
MLTC):
–Must enroll through the plan
–Enrollment has no impact on Medicare
• MAP or PACE:
–Must enroll through the plan
–Automatically disenrolled from Medicare
Advantage, Stand-alone Part D and Mainstream
Medicaid Managed Care
67
icannys.org
4
Enroll in an MLTC Plan
• FIDA:
– Passive Enrollment
 Partially Capitated MLTC enrollees passively enrolled
(auto assigned) to a FIDA plan after 90 day’s notice
 Passive enrollment began April 1, 2015
 Individuals can affirmatively decline (“opt out of”) FIDA
enrollment by contacting NY Medicaid Choice
– Voluntary Enrollment
 Enroll through NY Medicaid Choice, not the plan
 Automatically disenrolled from Medicare Advantage,
Part D and Mainstream Medicaid Managed Care
68
icannys.org
©2013 New York Legal Assistance Group
34
12/8/2015
4
Enroll in an MLTC Plan
• Timing:
–Must enroll by noon on the 20th of month to be
effective by the first of the next month
• No lock-in!
–Can switch plans at any time
–But cannot return to fee-for-service Medicaid for
community based long term care
69
icannys.org
Independent Consumer
Advocacy Network (ICAN)
State-funded Ombudsprogram for:
Managed Long Term Care, Long Term services in
Managed Care Plans, FIDA
©2013 New York Legal Assistance Group
35
12/8/2015
What Is ICAN?
• Network includes a toll free helpline 1-844-614-8800
• Educates and advocates for people who want or get
Medicaid long-term care through managed care
plans – MLTC, managed care, FIDA
• Funded by a NYS Department of Health grant to the
Community Services Society, which subcontracts to
community-based organizations statewide
ICAN services are free, confidential and independent
from all health insurance companies
71
icannys.org
ICAN Can Help
• Answer questions about Medicaid programs for people
receiving long term care
• Provide Support and technical assistance to other
advocates
• Solve problems with plans and providers
• Help individuals understand their rights, file complaints
or appeal
• Assist with concerns about MLTC or long term care in
mainstream Medicaid Managed Care
• Act as a Sentinel to identify and report to DOH systemic
issues or problems with Medicaid long term care
72
icannys.org
©2013 New York Legal Assistance Group
36
12/8/2015
Get Help From ICAN!
Call
844-614-8800
TTY Relay Service 711
Email
[email protected]
Online
http://icannys.org/
73
icannys.org
Useful Contacts
• New York Medicaid Choice (888) 401-6582
• CFEEC (855) 222-8350
• DOH MLTC Complaints
– (866)712-7197
– [email protected]
• DOH Mainstream Managed Care Complaints
– (800) 206-8125
– [email protected]
74
icannys.org
©2013 New York Legal Assistance Group
37
12/8/2015
75
MORE INFO ON MAGI
• National Health Law Program, Advocate Guide to MAGI, October 2015, posted at
• http://www.healthlaw.org/publications/agmagi#.VmD5Er_l_ox
• Empire Justice Center, Health Coverage Crosswalk: Eligibility by Immigration Status
http://www.wnylc.com/health/entry/188/
• Empire Justice Center – Many other resources at http://www.wnylc.com/health/40/ and
http://www.empirejustice.org/issue-areas/health/
• Legal Aid Society – including http://www.wnylc.com/health/entry/194/
• Kaiser Family Foundation - http://kff.org/aca-consumer-resources/ - FAQs, graphics, tutorials,
etc.
• NYLAG - http://www.wnylc.com/health/entry/195/
KEY STATE REFERENCES – STATE POLICY –
• NYS DOH 13ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010
–download at http://www.health.ny.gov/health_care/medicaid/publications/pub2013adm.htm
• New York State Official Website on Exchange --- http://healthbenefitexchange.ny.gov/
©2013 New York Legal Assistance Group
38