Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation...

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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.

Transcript of Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation...

Page 1: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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.

Page 2: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 3: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 4: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 5: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

Who is Eligible for Medicaid Eligibility is categorized under 2 groups Modified Adjusted Gross

Income (MAGI) Non-MAGI

Westchester Disabled On the Move Inc.

Page 6: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 7: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 8: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 9: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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**

Westchester Disabled On the Move Inc.

Page 10: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 11: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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”

Westchester Disabled On the Move Inc.

Page 12: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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.

Westchester Disabled On the Move Inc.

Page 13: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

Application Forms Review • Access NY Application Form • Access NY Supplement A Form • Medicare Savings Program Form • Disability Application Form* • Pooled Trust Application Form*

Westchester Disabled On the Move Inc.

Page 14: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 15: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 16: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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)

Westchester Disabled On the Move Inc.

Page 17: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Westchester Disabled On the Move Inc.

Page 18: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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.

Page 19: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

Westchester Disabled On the Move Inc.

Page 20: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

Questions

Westchester Disabled On the Move Inc.

Page 21: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe
Page 22: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

WHO WE ARE

We are New York State’s Ombudsprogram for Managed

Care

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Who are our consumers

The program serves people on Medicaid Managed Care who need Long Term Care services.

Page 24: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Page 25: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

WHAT WE DO

INFORMATION AND REFERRAL

NAVIGATION: securing services

ADVOCACY: Negotiate if services are insufficient or reduced

DISPUTE RESOLUTION: fair hearings

Page 26: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

INFORMATION AND REFERRAL

Information about the process of securing Long Term Care, including timeline

Names/Contact Numbers for Conflict Free Evaluation and MLTCs

Page 27: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Page 28: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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

Page 29: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

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.

Page 30: Facilitated Enrollment for the Aged, Blind and Disabled ... · By the end of this presentation participants will be able to: – •Know the duties of a Facilitated Enroller •Describe

Thank you

IMPORTANT TO REMEMBER:

Consumer has the right to question the decision

Our agency can provide advocacy for FREE

ARE THERE ANY QUESTIONS?