OVERVIEW OF PROGRAMS

Indiana’s Medicaid and S-CHIP programs are part of the Indiana Health Coverage Programs (IHCP).  The Office of Medicaid Policy and Planning (OMPP), within the Family and Social Services Administration (FSSA), administers both programs.

Local offices of the Division of Family and Children (DFC) within the FSSA are responsible for determining eligibility for Medicaid and S-CHIP.  For a listing of county offices, go to www.in.gov/fssa/children/dfc/directory/index.html. Hoosier Healthwise outreach and education is performed by DFC offices, local enrollment centers, and the Hoosier Healthwise enrollment broker. Hoosier Healthwise is unique in that members choose a doctor and not a plan. Doctor choice is made through a Benefit Advocate available through the Hoosier Healthwise enrollment broker either in person or by phone through the Hoosier Healthwise Helpline at 1-800-889-9949.

Indiana’s S-CHIP program is a combination Medicaid expansion and stand-alone program.  It has been implemented in two phases.  Phase I of Indiana’s CHIP, which began July 1, 1998, expanded Medicaid to children below the age of the 19 with family incomes of no more than 150% of FPL (with other Hoosier Healthwise Package A members).  Phase II of Indiana’s CHIP, which Is a non-Medicaid premium-share program, was established beginning January 1, 2000 to provide coverage to children with incomes between 150% and 200% of FPL (in Hoosier Healthwise Package C).  The delivery system to children under both Package A and Package C is the State’s Hoosier Healthwise program.  [Note:  Hoosier Healthwise Package B is for women eligible for Medicaid pregnancy coverage only.]

Eligibility for Traditional Medicaid, Medicaid Select and Hoosier Healthwise Packages A and B members can be established retroactively up to three months prior to the member’s date of application.  Providers rendering services to members during a period of retroactive eligibility are bound by the State’s requirements.  Generally, Hoosier Healthwise Package C (S-CHIP) members do not have retroactive eligibility.

For Hoosier Healthwise children, generally $90 is deducted from gross monthly earnings (before taxes) and up to $200 in child care expenses before determining eligibility.

MEDICAID

Categories for Adults

Hooser Healthwise Package B (Pregnancy Coverage Only)

For pregnant women only.

Income cannot exceed 150% of FPL.

No resource limit.

Pregnancy coverage includes:

·         Delivery;

·         Family planning services;

·         Pharmacy;

·         Postpartum;

·         Prenatal care;

·         Transportation; and

·         Treatment of conditions that may complicate pregnancy.

Special care must be taken to use a diagnostic code that relates to the pregnancy or complications of the pregnancy or, when applicable, to check emergency on the claim form when billing for covered services.

Indiana Breast and Cervical Cancer Program

Must meet the following requirements:

·         Be younger than age 65;

·         Not be eligible for other Hoosier Healthwise packages or other insurance that covers breast or cervical cancer treatment;

·         Have a family income of less than 250% of FPL; and

·         Be screened and determined to need treatment through the Indiana Breast and Cervical Cancer Program.

These individuals are eligible for the full range of Medicaid benefits during the course of treatment. 

These individuals are in the FFS delivery system only.

Qualified and Unqualified Aliens

Must qualify through any eligibility category.

Unqualified aliens are eligible for emergency services only, including labor and delivery – the is referred to as Hoosier Healthwise Package E.

Categories for Families/Children

Hoosier Healthwise Package A – For children under age 19

Income cannot exceed 150% of FPL.

No resource limit.

Hoosier Healthwise Package A – For low income adults with children/families

Income cannot exceed 100% of FPL.

No resource limit.

These individuals/families are eligible for the full range of Medicaid benefits.

Adults enrolled in Hoosier Healthwise Package A are likely to qualify for, and therefore be classified in, a TANF aid category.

Women who qualify for Package A based on income and later become pregnant may remain in Package A, rather than changing to Package B.

TANF

Families with children under age 18 that are deprived of financial support from a parent by reason of death, absence from the home, unemployment, or physical or mental incapacity.

Automatically eligible for Medicaid based on eligibility for TANF (Income cannot exceed 100% of FPL).

Resources cannot exceed $1,000.

A family’s house is exempt from resource calculations.

Medically Needy/Spenddown

Members eligible for assistance under the spenddown provision are:

• Aged 65 and over;
• Blind; and
• Disabled
• QMB

An individual’s countable income exceeds the Medicaid need standard.  However, the individual is otherwise eligible for Medicaid by meeting all other eligibility requirements such as citizenship, residence, resources, etc.

“Spenddown” is similar to a deductible in that members must incur medical expenses in the amount of their excess income each month before becoming eligible for Medicaid. 

It is the member’s responsibility to provide verification of incurred medical expenses to the county Division of Family and Children (DFC) office.  When spenddown is met, the member becomes eligible for the remainder of the month.

Elderly/Disabled

Aged

Must be age 65 or older and meet the following financial criteria:

Be eligible for Supplemental Security Income (SSI)

OR

Have income that does not exceed $552/month (one person) or $829 (married couple).

Resources may not exceed $1,500 for an individual and $2,250 for a couple.

These individuals are eligible for Traditional Medicaid (FFS) or the new Medicaid Select managed care, which is currently available in selected counties and is being implemented statewide over a 10-month period.

Blind and Disabled

Must have a physical or mental impairment, disease or loss that has lasted or appears reasonably certain to last for a continuous period of 4 years that substantially impairs ability to perform labor or services or to engage in a useful occupation.

These individuals are eligible for Traditional Medicaid (FFS) or the new Medicaid Select managed care, which is currently available in selected counties and is being implemented statewide over a 10-month period.

Indiana does not adopt SSI for disability determination but has it’s own state-defined disability definition.

Medicaid for Employees with Disabilities (M.E.D. Works) Program

Income cannot exceed 350% of FPL ($2,620 as of 4/1/03).

Resource limits:  $2,000 for one person; $3,000 for a couple.

These individuals may be responsible for a premium payment, depending on their income level.

590 Program

For residents of state-owned facilities under the direction of the FSSA, Division of Mental Health (DMH), and the Indiana State Department of Health (ISDH)

Members enrolled in the 590 Program are eligible for the full array of Medicaid benefits, however, they do not receive a Hoosier Health Card.  The facility in which the member resides should contact the provider to schedule appointments for medical services.  All services provided on-site at the facility are the financial responsibility of the facility.

Services provided to members enrolled in the 590 Program are reimbursed per claim by the program when the claim total is greater than $150.   If the claim total is less $150, the 590 facility is responsible for the cost of services.  All services totaling $500 or more require prior authorization.

Incarcerated individuals are no longer enrolled in the 590 program.

HCBS Waiver Programs

The member must require institutionalization in the absence of the waiver or other home-based services.

Income limit is 300% of the SSI Maximum Benefit Rate (currently $1,635).

Resource limit:  $1,500 for an individual and $2,250 for a couple.

Members served under an HCBS Waiver are ineligible for services under any waiver.

The HCBS Waiver programs are not entitlement programs and can only service a limited number of members.

Qualified Medicare Beneficiary (QMB)

Income cannot exceed 100% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare deductibles, coinsurance and deductibles.

Only services covered by Medicare are reimbursable by Medicaid.

Specified Low-income Medicare Beneficiary (SLMB)

Income must be greater than 100% of FPL but cannot exceed 120% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part B premium.

Qualified Individual (QI-1)

Income must be greater than 120% of FPL but cannot exceed 135% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part B premium.

Qualified Disabled and Working (QDW)

Income cannot exceed 200% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

CHIP

Hoosier Healthwise Package C

To be eligible, a child must meet the following criteria:

·         The child must be younger than 19 years old;

·         The child’s family income must be greater than 150% of FPL but cannot exceed 200% of FPL;

·         The child must not have credible health insurance at any time during the three-month period prior to apply for the Hoosier Healthwise program;

·         The child’s family must satisfy all cost-sharing requirements.

There is no resource limit.

A child determined eligible for Package C is made conditionally eligible pending a monthly premium payment.  Only after the premium is paid is actual eligibility information transferred to IndianaAIM.

Monthly premiums are set according to income level.  For families at 150-175% of FPL, the premium is $11.00 per child or $16.50 for two or more children.  For families at 175%-200% of FPL, the premium is $16.50 per child or $24.75 for two or more children.

Package C has the same application process as the other Hoosier Healthwise benefit packages.

Members’ families are also required to make copayments for some services.

Package C members do NOT have up to three months of retroactive eligibility.  Package C members are eligible for coverage beginning on the first day of the month of application for Hoosier Healthwise.