facilitated enrollment for the aged, blind and disabled ... · by the end of this presentation...
TRANSCRIPT
Facilitated Enrollment for the Aged, Blind and Disabled Program
Presented By: Lizett De La Rosa Facilitated Enroller (Westchester, Putnam, Orange and Rockland Counties) Location: WDOMI Conference
Westchester Disabled On the Move Inc.
OBJECTIVES By the end of this presentation participants will be able to: – • Know the duties of a Facilitated Enroller • Describe what Medicaid is • Appropriately screen consumers and refer
them to the Facilitated Enroller • Understand some terminologies on Medicaid
Eligibilities • Know the necessary documentations needed
to complete Medicaid Applications
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Facilitated Enroller (FE) • The FE conducts interviews, screens and
assist eligible consumers for enrollment into Government Programs such MBI-WPD
I. Medicaid (LDSS Only)
II. Medicaid Savings Program (MSP)
III. Medicaid Buy In for Working People with Disability (MBI-WPD*
IV. Disability*
V. Pooled Trust*
* - Programs Provided by WDOMI but not funded by the CSS or the State
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What is Medicaid • Medicaid provides health
coverage to eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.
• The program is funded jointly by states and the federal government and administered by states based on federal requirements
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Who is Eligible for Medicaid Eligibility is categorized under 2 groups Modified Adjusted Gross
Income (MAGI) Non-MAGI
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MAGI Eligibility Group Eligibility based on solely based on household or individual income Pregnant Women Infants and Children under age 19 Childless Adults to include
individuals who are: not pregnant, age 19-64 not
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Non-MAGI Eligibility Group SSI recipients or
Individuals under the age of 65 who are certified disabled by the SSA, State Medicaid Disability Review Team, or local (NYC only) Medicaid Disability
Individuals who are age 65 and older
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Non-MAGI Eligibility Group Cont’d Residents of Adult Home run
by LDSS, OMH Residential Care Centers/Community Residences
Individuals who are certified as legally blind by the NYSCB providing they meet all other financial and eligibility requirements
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Income Eligibility for the Magi and Non Magi Group
2015-2016
Non-MAGI
Disabled, 65+
or Blind ("DAB" or SSI-
Related) and have
Medicare
MAGI
(< 65, Does not have Medicare)
138% FPL***
Family Size 1 2 1 2 3
Income $825 $1,209 $1,354 $1,832 $2,311
Resources $14,850 $21,750 NO LIMIT**
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Medicaid Buy In For Working People With Disabilities (MBI-WPD)
Provides Medicaid coverage for working individuals with disabilities who may be earning more than the allowable income limits for regular Medicaid
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Medicaid Excess Resource Program • Provides Medicaid coverage to certain
individuals with resources above the appropriate Medicaid level
• Individuals with “Excess Resources” can provide medical bills to meet the match up or meet the excess to get medical coverage under Medicaid
• Also referred to as the “Spend Down Program”
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Institutionalized Medicaid • Medicaid for persons in nursing homes is called
"institutionalized" Medicaid. • Rules for Community Medicaid differs from
Institutionalized Medicaid. • LDSS to review applicants resources to make
decision on Medicaid eligibility.
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Application Forms Review • Access NY Application Form • Access NY Supplement A Form • Medicare Savings Program Form • Disability Application Form* • Pooled Trust Application Form*
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Document Checklist • Proof of identity • Proof of citizenship • Proof of residency • Proof of current income • Proof of health insurance • Proof of resources • Medical bills for the past 3 or 60 Months • Other supplemental documents
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Case Study 1 • Jay, age 66, and Beyoncé, age
59. • Beyoncé cannot work and is
receiving Social Security Disability benefits.
• Beyoncé is in need of personal care services.
• They are both enrolled in Medicare but need additional coverage for Beyoncé.
Question: 1. Are Jay and Beyoncé FEABD?
Answer 1: Beyoncé is ABD because she qualifies as “certified disabled” due to her receipt of Social Security Disability benefits. Jay is ABD because he is 66
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Case Study 2 • Marcus, 69 years old, lives alone. – Receives
Medicare. – Does not have any significant health problems. – Would like help with his Medicare premium and additional coverage for services not covered by Medicare.
Question: What program could help Marcus with his Medicare expenses?
Answer: Medicare Savings Program (MSP)
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Case Study 3 • Bee Swift, age 66, and Tee Swift, age 59. – Tee cannot work
and is receiving Social Security Disability benefits. – Tee may need personal care services. – They are both enrolled in Medicare but need additional coverage for Susan. – Bee and Tee appear to be above the Medicaid income level. Question: What programs could Bee and Tee apply for?
Answer: Medicaid Excess Income Program or Medicare Savings Program
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Case Study 4 • Lee is 38 years old and has a disability. • Lee collects $1500 in Social Security Disability every
month. • He babysits his nephews afterschool and is paid $300 a
month cash by his sister. Question: What program should Lee apply for? Answer: Lee can apply for the MBI-WPD Program.
Answer: Lee can apply for the MBI-WPD Program.
Westchester Disabled On the Move Inc.
Westchester Disabled On the Move Inc.
Questions
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WHO WE ARE
We are New York State’s Ombudsprogram for Managed
Care
Who are our consumers
The program serves people on Medicaid Managed Care who need Long Term Care services.
WHAT IS LONG TERM CARE
Personal Services: dressing, bathing, feeding, toileting, transferring
Level 1 Services: cooking, meal preparation, cleaning, shopping
Adult Day Care Centers programs
WHAT WE DO
INFORMATION AND REFERRAL
NAVIGATION: securing services
ADVOCACY: Negotiate if services are insufficient or reduced
DISPUTE RESOLUTION: fair hearings
INFORMATION AND REFERRAL
Information about the process of securing Long Term Care, including timeline
Names/Contact Numbers for Conflict Free Evaluation and MLTCs
NAVIGATION
Expedite transfer of required forms to secure services
Make sure the process goes smoothly
Make sure services are in place in timely manner and consumers are satisfied
ADVOCACY
We negotiate on behalf of consumers:
Service hours
Supplies/Equipment
Home modifications
Timely manner of service delivery
Reimbursement
We communicate with Plan Liaisons
Complain to DOH
FAIR HEARINGS
Most disputes between MCOs and their members can be settled, but
If we are unable to negotiate an amicable settlement, we can bring the matter in front of a judge in an administrative proceeding known as a “fair hearing.”
This is essentially bringing a case to trial where a judge makes a decision based on the law and factual evidence presented at the hearing.
Thank you
IMPORTANT TO REMEMBER:
Consumer has the right to question the decision
Our agency can provide advocacy for FREE
ARE THERE ANY QUESTIONS?