MEDICAL ASSISTANCE FOR FAMILIES and CHILDREN HANDBOOK

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Transcript of MEDICAL ASSISTANCE FOR FAMILIES and CHILDREN HANDBOOK

  • MEDICAL ASSISTANCE FOR FAMILIES and CHILDREN HANDBOOK Commonwealth of Virginia Department of Medical Assistance Services

    www.dmas.virginia.gov

    Department of Medical Assistance Services 600 East Broad Street Richmond, Virginia 23219-1857

    Our mission is to provide a system of high quality comprehensive health services to qualifying Virginians and their families.

  • Department of Medical Assistance Services Effective 01/01/2014 www.dmas.virginia.gov Medical Assistance for Families & Children Handbook Page 1

    TABLE of CONTENTS

    GENERAL INFORMATION ................................................................................................... 4 Patient Protection and Affordable Care Act ......................................................................... 4 How do I apply? .................................................................................................................. 4 What will I be asked? .......................................................................................................... 5 Who makes the decision? .................................................................................................... 6 How long does it take? ........................................................................................................ 6

    COVERED GROUPS .............................................................................................. 8 Plan First ............................................................................................................................. 9

    MEDICAID AND OTHER INSURANCE .................................................................. 10

    VIRGINIA MEDICAID CARD ................................................................................ 11

    USING YOUR MEDICAID BENEFITS ..................................................................... 12 Medicaid ............................................................................................................................ 12 Managed Care .................................................................................................................... 12 Client Medical Management (CMM) .................................................................................. 13

    MEDICAL CARE THROUGH MEDICAID ............................................................... 13

    CO-PAYMENTS .................................................................................................. 16

    BENEFITS THROUGH MEDICAID ........................................................................ 17 What is not covered? ......................................................................................................... 22

    SERVICES FOR CHILDREN/EPSDT ....................................................................... 23

    LONG TERM CARE SERVICES ............................................................................. 25 Screening for LTC services .................................................................................................. 25 Home and community-based waivers ................................................................................ 25

    YOUR RIGHTS AND RESPONSIBILITIES ............................................................... 27

  • Department of Medical Assistance Services Effective 01/01/2014 www.dmas.virginia.gov Medical Assistance for Families & Children Handbook Page 2

    FRAUD AND OTHER RECOVERIES....................................................................... 28 Third party liability and personal injury claims ................................................................... 28

    WHEN AND HOW TO FILE AN APPEAL ............................................................... 30

    PRIVACY INFORMATION ................................................................................... 30

    DEFINITIONS ..................................................................................................... 35

    IMPORTANT ADDRESSES AND PHONE NUMBERS .............................................. 38

    OTHER RESOURCES ........................................................................................... 39

  • Department of Medical Assistance Services Effective 01/01/2014 www.dmas.virginia.gov Medical Assistance for Families & Children Handbook Page 3

  • Department of Medical Assistance Services Effective 01/01/2014 www.dmas.virginia.gov Medical Assistance for Families & Children Handbook Page 4

    General Information Medical Assistance Programs in Virginia Medical Assistance programs in Virginia are administered by the Department of Medical Assistance Services (DMAS). Eligibility for the programs is determined by the local Departments of Social Services (DSS). Patient Protection and Affordable Care Act Most individuals who do not receive Medicaid benefits must sign up for health insurance starting in 2014 or pay a penalty. If you currently receive Medicaid or FAMIS benefits and your situation does not change, you will probably still receive them. When your case is up for renewal, the local DSS will review it and let you know in writing of any changes. If you lose your Medicaid coverage a referral will automatically be sent to the Federal Health Insurance Marketplace. If you need help applying for medical assistance or insurance, go to the Cover Virginia website www.coverva.org or call Toll Free: 1-855-242-8282 TDD: 1-888-221-1590. To apply directly for health insurance, subsidies or the Advance Premium Tax Credit (APTC), go to the Federal Health Insurance Marketplace at www.healthcare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325). Medicaid Medicaid (also sometimes called FAMIS Plus) is a medical assistance program that helps pay for medical care. To be eligible for medical assistance you must have limited income (and resources for certain groups), and you must be in one of the groups of individuals covered by Medicaid. See section on Covered Groups on page 8. Medicaid is funded by the state and federal governments. Not everyone with high medical bills qualifies, but all individuals within a group are treated the same. Medicaid provides either full coverage or limited coverage.

    Full coverage provides the full range of benefits including doctor, hospital and

    pharmacy services.

    Individuals and families who meet a spenddown have time-limited coverage; limited

    coverage is also provided to men and women who may be eligible for family planning

    services through Plan First.

    FAMIS (Family Access to Medical Insurance Security) (similar medical programs for children, parents and pregnant women) and Medicaid for Aged, Blind and Disabled individuals have their own separate handbooks, also available from the DMAS website or your local DSS office. How do I apply for Medical Assistance? An application for Virginia medical assistance can be completed online at the CommonHelp website https://commonhelp.virginia.gov/access/. An application form can be printed from the Virginia DSS website www.dss.virginia.gov/form/. You can also contact the local DSS office in

    http://www.coverva.org/http://www.healthcare.gov/https://commonhelp.virginia.gov/access/http://www.dss.virginia.gov/form/

  • Department of Medical Assistance Services Effective 01/01/2014 www.dmas.virginia.gov Medical Assistance for Families & Children Handbook Page 5

    the city or county where you live to pick up an application or have one mailed. The phone numbers for local DSS offices (sometimes called human services or family services) are listed in the blue pages of the phone book and online at http://www.dss.virginia.gov/localagency/. Applications can be filed at some hospitals. Applications for medical assistance are also accepted through the Cover Virginia Customer Care Center by phone at 1-855-242-8282 or through the internet at www.coverva.org. An application must be signed by the person who needs assistance unless it is completed and signed by the applicants legal guardian, conservator, attorney-in-fact, or authorized representative. Electronic and telephonic signatures are acceptable. A parent, guardian, authorized adult representative, or caretaker relative with whom the child lives must sign the application for a child under the age of 18. Children under the age of 18 cannot apply for themselves, unless they are emancipated. However, if a child under the age of 18 has a child of his or her own, he or she as the parent can file an application for the child. A face-to-face interview is not required. You can designate an application counselor or navigator through CommonHelp to help you complete an application, but that person cannot sign the application for you.

    A screening tool is available on the Virginia Department of Social Services (VDSS) website to help determine whether you or someone in your family may be eligible for medical assistance. Screening tools and more information can be found on the VDSS website at https://commonhelp.virginia.gov and on the www.coverva.org website. The final decision regarding eligibility will be made by an eligibility worker at your local DSS. What Will I Be Asked? Applicants for medical assistance are asked to provide their Social Security number, declare Virginia residency, and may be asked to provide documentation of United States citizenship and identity. If you are not a U.S. Citizen you must provide information and documents about your immigration status. Some immigrants can be eligible for full Medicaid coverage; others can be eligible for Medicaid payment only for emergency services. If you are pregnant, you will be asked how many babies you are expecting and the estimated date of delivery.