Shownotes
We're diving back into the intricate world of Medicaid with the much-anticipated Part 2 of our series. Joining us again is Medicaid specialist extraordinaire, Michelle Rice, to guide us through the labyrinthine processes of Medicaid eligibility, applications, and renewals.
In this episode, we'll cover everything from the initial application steps to setting up a Qualified Income Trust (QIT) and maintaining Medicaid eligibility, which some say is like a full-time job in itself. We'll share key insights on how to avoid common pitfalls that can lead to application denials, the importance of timely paperwork, and how supportive teams and case managers work tirelessly to ensure every verification is meticulously handled.
Michelle will also recount a heartfelt story of assisting a man whose wife needed Medicaid for nursing home care, emphasizing the emotional and practical challenges families face.
So, settle in, and let's unravel the complexities of Medicaid together!
Top Takeaways
**Application Process**: Medicaid eligibility involves completing a thorough application, providing detailed income and household information, and submitting necessary verifications to county-level Job and Family Services (JFS).
**Verification Follow-up**: If initial verifications are incomplete, a secondary request for missing documents is sent within 10 days. Timely provision of these documents is crucial to avoid denial.
**Qualified Income Trust (QIT)**: A QIT, necessary for applicants exceeding certain income thresholds, must be set up separately from other accounts and regularly funded to maintain eligibility.
**Renewal Procedures**: Medicaid recipients must complete a 9-page renewal application sent three months before their renewal date, ensuring the most crucial page (page 9) is signed and dated to avoid cessation of services.
**Denial Reasons**: Common reasons for Medicaid denial include exceeding income limits, failure to establish a QIT, and not providing required verifications on time.
**Medicaid Maintenance**: Maintaining Medicaid eligibility can be equivalent to a full-time job, requiring detailed and timely documentation and communication with case managers.
**Support Systems**: Case managers and Medicaid specialists provide essential guidance, help gather necessary verifications, and collaborate with community agencies to support applicants.
**LTSS Medicaid**: Long-Term Services and Supports (LTSS) provided through Medicaid include medical, personal care, and social services for older adults and individuals with disabilities, with specific eligibility requirements different from Community Medicaid.
**Asset Considerations**: Applicants' assets, including ownership of homes or cars, affect eligibility. Improper transfer of assets can lead to restricted coverage periods.
**NOA Letters and Redeterminations**: Notices of Action (NOA) letters and annual redeterminations can be perplexing, but Medicaid specialists and county workers assist in resolving issues, particularly concerning QIT requirements and maintaining eligibility.
Let me know what you think of this podcast, as well as any ideas you have for an episode. Email me at kwhite@coaaa.org!
Copyright 2024 Central Ohio Area Agency On Aging
https://creativecommons.org/licenses/by-nd/4.0/
Transcripts
Welcome to Pretend I Know Nothing About. I'm Katie White, your host, Administrator of COAAA. We are back and talking about Medicaid again. And before we get into all the intricacies and details and complications, I wanted to start off by reading a little excerpt from an email that I received from the son of one of our consumers. My mom is almost 95 years old and lives on social security. No other forms of income and was approved for help through the Ohio Medicaid Long Term Care Assisted Living Program. Through a series of miscommunications and technicalities, my mom was notified that her benefit was going to end in August of this year. I put all effort and time into correcting this matter but was unsuccessful.
Katie White [:I ultimately reached out to my mom's case manager at COAAA for assistance. She was understanding, professional, and cared enough to go far above and beyond her regular duties. Although she and her team do not work for Medicaid or the state, you all were a crucial part in correcting an obvious mistake. I am pleased to say that because of this diligence and selflessness, my mom's case was resolved and corrected today, just 1 week before a state hearing. There are no words I can share that will adequately express how grateful my mom and I are for this assistance. In a world that often produces negative and hurtful environments, it is like a life giving breath of fresh air to know there are people and agencies such as yours that offer help in time of need. So today, we are focusing on Medicaid once again. There is so much to know that we thought we need to have another episode about this.
Katie White [:And so we are gonna focus on 3 primary points today, which are what is Medicaid eligibility? How do you apply and what's needed? A little bit about denials in that process. And then what in the world is the QIT and how important is it? So before Michelle Rice and I get back into the details, I read an article and just kinda wanted to share some of the, reasons why Medicaid is so important and why we're talking about it so much. So long term services and supports, l t s s, is what we provide a lot of here at c o triple a. So that's really the range of medical personal care social services that benefit an older adult or person with disabilities or someone with chronic health conditions. And the ACL, the Administration For Community Living, estimates that 69% of people will use LTSS services during their lifetime. So it's something that really affects most of us. And there's a couple of things that we need to know. These services can be delivered in institutions, nursing homes, hospitals, things like that, but they can also be delivered in home and community based care.
Katie White [:We also call that HCBS. And that, again, is really where the area agencies on aging in Ohio come into play. So we are delivering these long term services and supports in home and community based settings, which we know from surveys is where people really prefer to live. So what's all that got to do with Medicaid? Well, Medicaid, not Medicare, is the primary payer for long term services and supports And that and that accounts for 57% of the national spending on all home and community based services. So it's a wamper. It's a lot of money. It's the primary way we care for each other, our neighbors, our older adults, our family members, people with disabilities in our community. So just wanted to kinda lay that out because it is so important.
Katie White [:In addition to being extremely important, it's also extremely complicated. Right, Michelle?
Michelle Rice [:Yes. It
Katie White [:is. So all of that sort of framing to now bring us into the real meat and potatoes of what, I'm so glad you're here to talk to us about today. So as a reminder, Michelle Rice is a Medicaid specialist here. And so really the guru of helping individuals in the community and also staff members walk through these really complicated processes. So we are gonna start today just generally talking about Medicaid eligibility. Right? You wanna start there?
Michelle Rice [:Yes. That is a perfect place to start. Okay. Well, when you are have come up with the decision that you feel that your family member needs to have Medicaid, either it be because they're gonna go to a nursing home or because they are needing in home care. The first thing that they wanna do is call the county jobs and family services in the county in which they live. That way, they can mail them out an application. And this is really important because you wanna make sure you fill out the application completely. It is 16 pages long.
Katie White [:Oh my.
Michelle Rice [:Yes. And so you wanna make sure you answer all the questions because they're gonna wanna know who lives in your home with you. Is there nobody in the home with you? What is your income? What's your date of birth? What's your social security? Are you a US citizen? So there's a lot of things that come into play to be Medicaid eligible. Now just to touch a minute on, if you are wanting community Medicaid because you don't need in home care services, Just to let you know, when you go in to apply, if your income is over $943, you will not be eligible for Medicaid. For Community Medicaid. For Community Medicaid.
Katie White [:Yes. And the difference between Community Medicaid and LTSS Medicaid is what?
Michelle Rice [:Well, what the difference is is that they have just regular Medicaid to go to the doctors and to help pay with that When they have waiver services, that means that they're getting in home care and also they are in a nursing home.
Katie White [:Okay. So Community Medicaid is where it's your insurance plan, essentially. Your health care insurance. And then waiver Medicaid is where those wraparound services, like case management and care coordination that we provide come into play.
Michelle Rice [:Yes. That is true. Yes. Okay. So that's one thing. But then when they go in to apply and they provide their Medicaid application, they also have to provide all of the verifications for themselves. And what I mean by that is, like, they would have to provide their driver's license, their Social Security card, their Medicare card, if they have one. Because to be on passport, you don't have to have Medicare.
Michelle Rice [:Only if you are on the my care program, you have to have Medicaid and Medicare. Mhmm.
Katie White [:So, so you fill out this application. It's 16 pages, and it's all self reported, then you mail it back?
Michelle Rice [:Yes. You can mail it back, or you can take it to your jobs and family services that is closest to you.
Katie White [:And when at what point do you need to also bring in all of these verification points?
Michelle Rice [:The county will, call to set up an appointment.
Katie White [:Okay.
Michelle Rice [:And at that point in time, that's when you'll wanna take in all your verifications. Do not give them any of the originals. Okay. You will wanna have copies of everything. And what I mean by everything is if this is your first time ever applying for Medicaid, they are going to look back 5 years. And what that means is you'll have to have bank statements. And any information where you have given money away or you have opened up, stocks or whatever. They're just making sure that you don't have any
Katie White [:change every year with the financial requirement?
Michelle Rice [:No. It's been 5 years for quite some time.
Katie White [:I mean, the actual amount.
Michelle Rice [:Oh, the amount. The amount for Medicaid, like the SSI and stuff, it does go up every year.
Katie White [:Okay.
Michelle Rice [:It's when the cost of living goes up.
Katie White [:Up. Okay. That's what I thought. So this year, do you know what it is up to
Michelle Rice [:here? 943.
Katie White [:943. And then what about assets?
Michelle Rice [:And then it's still 2,000. Okay. That has never changed. That hasn't changed in probably over 15 years.
Katie White [:Okay. And what about a house, a car?
Michelle Rice [:A person can have their own home
Katie White [:Okay.
Michelle Rice [:As long as they are living in it. Okay. Now if they have a home here that they're living in, but let's say they have a condo out at Apple Valley in Mount Vernon, then that condo will be counted as a resource.
Katie White [:Okay.
Michelle Rice [:So then that means that they're gonna be over resources for the waiver program.
Katie White [:Okay.
Michelle Rice [:And, so they would have to sell one of the homes, and then there'll be a point of ineligibility because there are other resources, and they would have to spend down that money to the $2,000.
Katie White [:Okay. Got it.
Michelle Rice [:And anyone on the waiver program can have 1 car. The second car is counted as a resource. And when they provide verifications, they'll have to provide 5 years' worth of bank statements. And during that time, the county is really looking at what the income was, what your if you gave anything away or if you paid for your grandchild's college education or anything like that, you also have to provide, if you're married, your marriage certificate. Wow. And if you're married, you have to provide verifications for yourself and for your spouse.
Katie White [:So it's household Yes. Income and assets?
Michelle Rice [:Yes. But for waiver, they look at the people separately. And I know that sounds kinda confusing, but what it is is, like, the person that comes on to passport can have $2,000 in resources. And the person in the community can have as much as $154,000 So they get to keep their money, but the consumer can only have the $2,000 in resources. Interesting. Yes. So, like, if there's a life insurance policy, let's say because they look at the cash value, not the face value, but the cash value. And if that cash value is throwing them over the resource limit because remember, your bank accounts, your, cash value of that, any resources, if they add up to over 2,000, then you have to start spending down.
Michelle Rice [:And a lot of times, they recommend if someone hasn't set up their burial, that they can do an irrevocable burial with the funeral home and provide that verification to show that that life insurance policy isn't available anymore. Or if they just have too much cash, they can pay for their, you know, funeral and provide that verification to the county. The main thing is anything you spend money on, make sure you have proof of it because the county is gonna want it.
Katie White [:And so say they're in the 5 year look back period, and they find that you you gave away $10,000 or something to your grandson, what does that mean then? Are you not eligible for a while?
Michelle Rice [:That means that you would have a RMCP, which is a restricted period of coverage. K. And what they do is they take the amount of money that was part of the improper transfer and divide it by $7,787. And where that amount comes from is that is the average private pay nursing home rate.
Katie White [:Say that again. $7,787. And is that a constant, or does that No. And that that increases changed.
Michelle Rice [:That just changed, July 1st.
Katie White [:Okay.
Michelle Rice [:So, that was a new change that just took place. And this one doesn't change every year. It's maybe every couple of years. But what they do is they just add up everything that is improper, divided by that. And then that tells them how many months you are not eligible for Medicaid.
Katie White [:Because you would have had that money to pay for it yourself. Correct. So I'm looking at a piece of paper in front of you that has all kinds of specific numbers broken down. Tell me what this is and what's on there.
Michelle Rice [:We have what's called the Medicaid SSI standards. And anyone that wants to come on to Medicaid community wise. Remember that. It's your income can't be over 943. Mhmm. But when you come over to waiver, you can have more than that, for services, but then you also have to take into fact that we have a, special individual needs allowance of $1,839. And if your income is over that, what they do is take your income minus that, and that would tell them what your liability is gonna be for your waiver services.
Katie White [:And your liability is the kinda out of pocket expense.
Michelle Rice [:That's you're paying for services.
Katie White [:So we have this sheet that do we develop this every year to update all of the costs so that everybody working here knows those numbers?
Michelle Rice [:All this information comes from the state.
Katie White [:Oh, it's okay. So the information's from the state, but then we create that.
Michelle Rice [:Right. Then we type this up, and then it goes out to everyone. So everyone has this, what the community Medicaid is because sometimes you can be on community Medicaid and have and be Magi. Or sometimes you can be categorically needy. And what that is, if you're MAGI, your income can be up to $1,616, but you cannot have SSI as part of your income. And there's also no resource limit to be on that.
Katie White [:What is MAGI?
Michelle Rice [:MAGI stands for modified adjusted gross income. And what it is, it's children up to the age of 19, pregnant women, and adults from 19 to 64 years old. And they have to be below, a 138% of the federal poverty level. And the MAGI rules also apply to a time limited coverage for individuals who enrolled in Medicaid parents care category. And what that means is if a parent has a child still in the home, they can be eligible for MAGI waiver.
Katie White [:Okay.
Michelle Rice [:I'm I'm sorry.
Katie White [:It's
Michelle Rice [:not MAGI waiver. It's magi category for, community Medicaid. Anyone that comes on to our waiver, if they have this, that's why they have to do a resource assessment before applying because there's no resource limit. And for our waiver, they can only have $2,000.
Katie White [:Okay. So if you're anything like me and we're listening to all of these really specific numbers. It's a little overwhelming, but the good news is we exist. Yes. CO triple a exists. Michelle and her Medicaid colleagues exist because, like I said in the beginning, it's extremely complicated, but we sort of have the tools and the keys to help people navigate all of these. So you might not know or remember the exact numbers after listening to the podcast, but that's okay if you still know the general process and who you can call for help. Right.
Michelle Rice [:And when you're set up for, Medicaid, the county workers go over all this with you, and we'll tell you what category you're with, what is expected verification wise, for you to provide. And they're able to, and they send out what's called a NOA. It's a notice of action. And what it does is when someone gets these letters, they get kinda worried because it says, okay. You're you're eligible for this, but you're denied for all of this. And people are like, why am I denied? And it's like, just a second because we have access to see the NOAs that go out.
Katie White [:Okay.
Michelle Rice [:So we can tell, okay. Yes. You're eligible for a waiver, but you're not eligible for, like, magi or categorically needy.
Katie White [:Okay.
Michelle Rice [:And so those letters sometimes are intimidating to when people have to read them.
Katie White [:Sure. So okay. Just to kinda recap, eligibility. You're thinking that you wanna apply for Medicaid. There's an application from job and family services of the county in which you live that you have to complete, and then you have an appointment in person at JFS where you bring in all the documents to prove all of the things that you put in your application. Correct. Then you go home and you wait for the Noah?
Michelle Rice [:Well, you'll wait. The Noah won't be sent out until they make a determination. So a lot of times what will happen is the caseworker will send out another letter and it's called a 710 5. And what that is is that is just a list of what other verifications that they need because they can't make a determination on what was provided at the first visit.
Katie White [:Okay. So if you didn't bring any everything that you need in that first visit, you'll get this letter to get the rest of the documents in. So it's not like, oh, you missed a document. You have to start all over. They're really trying to work with folks to make sure they're making it out the other side.
Michelle Rice [:Yeah. But they only give them 10 days to get the verifications in. And if they don't get them in within that 10 days, a second letter will go out, and they give them another 10 days. And if they don't get them in by that date, then the county will go in and deny that Medicaid application.
Katie White [:Okay.
Michelle Rice [:And then at that point in time, then, yes, they would have to start all over again.
Katie White [:And so, again, that's where our team is a huge asset because if there are folks that we are working with and we know they're in this process, we are keeping up with them. Right? Did you find this? It's been 10 days. Make sure you get this in. Like, we are helping to move people along to that successful application.
Michelle Rice [:Yes. Because what we do is we work closely with our case managers, and we actually have a log that we, write notes in and everything to let us know, okay, the first letter went out. We'll send an email out to the case manager saying this is what they still need to do. And then we'll check back in in 10 days and see if they did it. And if not, then we let them know again. And we also, at that point in time, will send an email to the county saying, I see the first letter went out. Can you tell me if anything got provided? We don't see notes. And if they say no, then we just say, are you gonna be mailing out the second request?
Katie White [:Okay.
Michelle Rice [:And then at that point in time, we kinda watch it. And if it's not in by that date, we always wait a couple days after before we reach out to the county just to kinda give them time to get things uploaded and update it and everything. And we'll email back, and they'll say, yes. We got it. I've assigned it to someone to work on the case. So then we can let the case manager know, okay, they have the verifications. Someone's working on it. We'll know soon what the determination is if they're eligible or not eligible for Medicaid.
Katie White [:Okay. So all of that process goes according to plan. Right? We're talking about, like, the perfect scenario. The application's good. The verifications are good. So they get the determination and they're eligible For waiver? For waiver. Yes.
Michelle Rice [:Not for Medicaid? Well, for Medicaid, but it's meant yeah. I mean, if we're zoning in on waiver, then it'd be they're eligible for Medicaid for a community and then they would be eligible for Medicaid for waiver.
Katie White [:Okay. For those home and community based services. Yes. Okay. So then they are approved. They're eligible. We're good to go there. Now what if they are determined ineligible or denial? What are some of those denial reasons?
Michelle Rice [:The denial reasons would be that, one, if they were over income and they failed to do a QIT, and we are gonna touch base here in a few minutes on what a QIT is. Mhmm. If they're over resources or if the county asks for certain verifications and they fail to do so, they can deny him for that. So then they'll get a denial letter in the mail. And, unfortunately, they will have to start all over again if they're a new applicant to Medicaid. Okay. I know.
Katie White [:So when you're initially talking to someone, if they are telling you their income, you know right off the bat whether or not they're gonna be approved. And so I'd imagine if it's super obvious that someone isn't gonna meet those, we're not encouraging them
Michelle Rice [:to go through the process. Right? Well, you'd want them to go through the process because you'd wanna get that 5 year back look back period in place. So in case there are any issues, that date is already set. So then that way, they can start working forward.
Katie White [:On spending down
Michelle Rice [:to
Katie White [:then get to the point where they're eligible. Right. Okay. I'm glad I asked that question.
Michelle Rice [:Yeah. And go ahead and set up the QIT, and they will only need to set up the q I t if they're gonna apply for waiver or nursing home waiver.
Katie White [:Okay. Now let's go in q I t. We've teased it so much. Let's let's, let's fully define it and talk about it. QIT.
Michelle Rice [:Yeah. A lot a lot of people say, you always say QIT. What does that mean? It means qualified income trust, and it used to be known as the Miller's Trust. And this was created to help Medicaid applicants be eligible to receive waiver services. Because in the past, we had to do what was called a cost of care, and the case managers had to figure out what someone's cost of care would be. And then they would have to minus it from the special income level and to find out if their income that showed that their income came down to whatever the SSI standard was back then. So now if their income is over $2,889, that means that they have to have a QIT. And how they figure out the amount that goes into a QIT is they take their income and minus it against that.
Michelle Rice [:And then that will tell them how much each month that they have to put money into a QIT. Now you may ask, well, how do they even set up a QIT? What is, you know, involved in this, and what what do I have to do? This is where the county will mail out information on the QIT. They will mail out the form that that has to be filled out by the bank. By the bank? Yes. They have to go to a bank, and they always want them to try and use their bank where their Social Security check is being deposited to.
Katie White [:Okay.
Michelle Rice [:Only because it's easier to have it transferred from one account right to another. Sure. Sure. And the QAT cannot be included in with their checking account or savings account. It has to be its own individual account.
Katie White [:K.
Michelle Rice [:The State of Ohio is a beneficiary. And what happens is each month, let's say the county says you have to put in $1100 into the QIT. So every month, you have to put in that much money. And then let's say your liability is $1500. Well, what you're gonna do is draw out that QIT money, pay on your liability, and then add some to it of your other of your own money to pay the liability. Now at the end of the month, let's say your liability is really low because we have some people who have QATs, but they have to put $32 in. And so, you know, it's it's not that much, but it's an inconvenience because now they're like, okay. I can't even be eligible unless I go do this.
Michelle Rice [:And so once it's set up at the bank and they provide this information, the bank sets up the account, What they have to do is show that the first deposit was made into the account, and they have to provide that information plus the form back to jobs and family services so they will know, yes, the QIT is set up and the state is the beneficiary.
Katie White [:Okay. So I I'm gonna I need an example so that we can play this out. So the individual has an income of $3,000 a month from Social Security. Right. So that means q I t is needed because it's above the threshold.
Michelle Rice [:Correct.
Katie White [:So we take their $3,000 a month income and we subtract out $2,829. $2,829. Okay. So we subtract the $2,829 from their $3,000 a month of Social Security income, and we get a $171. Right. So every month, that $171 goes into their QIT, and that is right, whose beneficiary is the state of Ohio. That's gonna come back into play here in a little bit. And then say they have $100 a month liability, which is kind of that out of pocket cost.
Katie White [:So then every month, the $100 liability, they can pay out of that checking account. But then that means hit out of the QIT account. Oh, that's what I meant. Okay.
Michelle Rice [:Okay. Let
Katie White [:me say it again. So then every month, they pay that liability out of the QIT account. And if it's a $100, then every month, there's $71 left over. Right. So that can accumulate over time.
Michelle Rice [:Yes. Because they they can only withdraw that extra money to pay for any medical necessities for them.
Katie White [:Okay. So you could use that for other
Michelle Rice [:Right. You just can't. We had a client that went and bought candy bars for her spouse because she was trying to be nice while the county was like, no. And she used the QIT? Yes.
Katie White [:Oh, bummer.
Michelle Rice [:Yeah. Okay. I mean, just make sure when you withdraw that money that you are paying anything medical.
Katie White [:Okay. So any any additional money that is accumulating in there, you still have access to for any medical expenses? For only 30 days.
Michelle Rice [:And then at the end of the month, if it's still in there, you can't touch it the next month.
Katie White [:And you just have to know that amount personally and make sure you're not touching it or does it go away? No. It stays in
Michelle Rice [:the account and you just know that whatever is whatever you put in that new month, if you put in your next $171, know that you can withdraw a 171 to pay on something, but that 71 from the previous month has to stay there. Okay.
Katie White [:So you've got this all set up and you know what you can and can't do and when you can. And then you're on the waiver for 10 years. And when you die, there's $5,000 left in the account. What happens to that? QIT $5,000?
Michelle Rice [:Then what they have to do is they have to contact the AG's office. The attorney general's office. Yes. And let them know that this person was on Medicaid and has a QIT set up. And they will get with them to get the information of what's left in the QIT. And remember, Medicaid is the last to be paid when someone passes away. So all other bills will be paid, but that QIT does go back to the state because they're the beneficiary. And that's just a way of them to try and recoup some monies that are being spent out on different people receiving Medicaid services.
Katie White [:Okay. I think I got it, Michelle.
Michelle Rice [:I know. It's fun. I love QITs because a lot of times what happens is we get phone calls, and we just have to talk to the person through it because the banks, sometimes, will say, well, we don't do that. Well Really? Yes. So they do do them. Now there's a lot mandated?
Katie White [:Do they have to do them?
Michelle Rice [:No. They're not mandated. Okay. But your bigger banks are the ones that do it, like your PNCs and your Huntington's and your 5th thirds. Okay. There's only one credit union that will do QITS, and that's right, Pat.
Katie White [:Okay.
Michelle Rice [:They will set up a QIT because we have quite a few people that have, their QITs through them.
Katie White [:Okay.
Michelle Rice [:But it's just always helpful to remember if you're having troubles, really call into COAAA. We can, you know, they'll get you to someone that can talk you through this and just help with the little questions sometimes that the county doesn't help with. Because the county doesn't help set any of this up. They will mail you the information. But as far as helping you figure out the banking part or anything like that, they are hands off.
Katie White [:Okay. Because I guess it could be construed a conflict because then they ultimately benefit from that. So
Michelle Rice [:Right. And we can't tell you what bank to go use. Sure. We can, just tell you to start with your bank first and, and go from there because we're not allowed. And the one thing to kinda keep in mind is every year, everyone gets a raise, a cost of living raise. The county does not mail out a letter to tell you what your increase is for your QIT. Oh. So every January, when you get your raise and you have your Social Security.
Michelle Rice [:Right? Social Security. Yes. Or a pension or anything like that. Any income that you get, you'll want to add that up yourselves and call in to c o triple a to find out. Because January 1st, the special income level normally changes. So we can let you know what that is so you'll know what the new amount is to put in your QIT.
Katie White [:And then is there any documentation back to JFS that they're aware too? Or they're already aware?
Michelle Rice [:But Well, they'll be aware when they do the redep because for when they do the renewal, in which we call redep, they do one every year. If someone has a QIT account, they have to provide 12 months' worth of bank statements from that QIT account to show that each month, the money was put into the account. Because if they miss a month, then that could be a month of ineligibility because they didn't put that money in because they were over income.
Katie White [:Okay. So let me make sure I understand this. You go through this whole process to be eligible, and then you have to do a renewal redep, meaning redetermination every single year?
Michelle Rice [:Yes. Every year.
Katie White [:It's like a full time job.
Michelle Rice [:Yes. It is.
Katie White [:Just just maintaining your Medicaid eligibility.
Michelle Rice [:Right. And they get letters in the mail, just to touch base on renewals real quick. They they they will get a app a renewal application is what it's called in the mail 3 months prior to their renewal date. And, the state is who mails this out, and it comes in a white envelope. It looks like junk mail. Oh, jeez. And a lot of times, people just throw them away because they don't really know what they are. Okay.
Michelle Rice [:So if you do get a white envelope and you're not sure, open it up, especially if you're on Medicaid.
Katie White [:Who's it coming from? JFS?
Michelle Rice [:It's coming from the state.
Katie White [:So a big white envelope coming from the state. Open that open that baby up.
Michelle Rice [:Yeah. Open it up. And you'll wanna make sure now that application is only 9 pages long. And so you'll wanna fill that out. And the first page is pretty much already filled out with your name, your address, your phone number. And it will ask you, are there any changes? And that's when you'll want to make sure that you update any information if you haven't already provided that to the county. Okay. And, page 9 is the most important page to make sure you sign.
Michelle Rice [:So it has to be signed and dated. Even if they you don't draw anything else on it, just make sure you sign and date it and get that turned back into the county. Because once that's turned back in, the county will, upload that information, and they will either do what's called a passive renewal. And what that is is when they can check on your verifications through a system that's called AVS, and we don't have any access to that at all. That's something that the county can do to check what your bank statement, balances are, or they can get with Social Security for your income. The only thing you would have to provide, and they probably will ask, is if you have a pension. They want a copy of the award letter for the pension to see if there is any, Medicare premiums coming out. So that's a really important thing.
Michelle Rice [:So
Katie White [:Okay. A couple questions.
Michelle Rice [:Okay. So
Katie White [:is this done every January for everyone, or it's your own annual date of renewal?
Michelle Rice [:It's your own annual date of renewal. And what it is, it's usually the month when you applied for Medicaid.
Katie White [:The month that you applied.
Michelle Rice [:Mhmm.
Katie White [:I don't know why it's it's not funny to me. It's, like, it's outrageous because it literally you're just constantly working to to prove
Michelle Rice [:you're eligible.
Katie White [:Right. Once a year. Wow. Okay. So it's your own date. You get it 3 months prior. When do you have to have it in?
Michelle Rice [:They want it in within 10 days.
Katie White [:Within 10 days of receipt?
Michelle Rice [:Yes.
Katie White [:Okay. That's a big deal.
Michelle Rice [:And so once they send back in the renewal, what will happen is if the county needs verifications, they will mail out a 7105. It's a list of what they need, and it'll have a due date on it. Now let's say the person did not mail back in the renewal and they mailed out a second renewal and they still didn't do it. The county can deny that waiver for not providing that application to complete the renewal for that year. Wow. So what happens is, unfortunately, we don't get an alert.
Katie White [:We find out get any kind of alert?
Michelle Rice [:No. We find out when a case manager says, the provider isn't being able to be paid for this, or with my care, we get they're showing up inactive in our system. So then we get to go look and say, well, the county denied them because they didn't do the renewal. And then we have a template that we fill out to let the case manager know when the waiver and date is. If it for an example, let's say the RE debt is due, the month of August of this year, and they don't get everything in and the county denies them. Well, the county's end date will be 831. So that means that the if the consumer gets verifications in before 831, the waiver will be opened back up to the first. So there'll be everything will be great.
Michelle Rice [:But let's say they don't get the verifications in by 831, then we have to stop services.
Katie White [:What happens if we provided services because we didn't know that they weren't redetermined? Are we just out that money? We can't get reimbursed by our Medicaid contracts because they were technically not insured.
Michelle Rice [:Right. And the thing is and the thing is is the clients get letters saying that your Medicaid is denied. And sometimes they'll call into their case managers, sometimes they won't. And, so it's just, you know, it's just hit or miss. And but the minute we find out, we let everybody know. We had to put case notes in. And then from the time of the denial, let's say it's 831, the person has 90 days to get those verifications, and it's called retroactive coverage.
Katie White [:Okay. That's good.
Michelle Rice [:And then they can they can go back. If they get everything in, let's say, before that 90th day, then eligibility will go back to the 1st day of the next month, which would be September 1st. Okay. So then all that means is that everybody just has to rebill.
Katie White [:Okay. So Well, that's good. And, again, where we come in is this crucial piece because in theory, within that 90 days, we're gonna know and we're gonna reach out and help them get that.
Michelle Rice [:Yeah. Our case managers are wonderful. Yeah. Our case managers are wonderful. They'll go out and pick up verifications and bring them back and scan them to us, and then we forward them on to the county and then follow-up to make sure everything gets updated in the case.
Katie White [:How often or how many a month of of our of people that we case manage are are needing this redid this retroactive for
Michelle Rice [:this month? Just for the passport and and, traditional AL, there was 228 people that didn't have their redettes done.
Katie White [:228 in 1 month for Yes. For passport and a l, which
Michelle Rice [:are Yes.
Katie White [:Two programs of many that we do.
Michelle Rice [:Right.
Katie White [:That's a lot.
Michelle Rice [:Yeah. And so they get a they get a, a form from the state that shows them who needs a redep. The MiCare people, we don't get one. So ours is just we find out when we find out.
Katie White [:Say that again. We get a letter for Passport and AL?
Michelle Rice [:Passport and AL gets a spreadsheet from ODM each month saying this person you know, it gives them a list of what redoubts are due that month. And where the myCares, we, unfortunately, don't get any list.
Katie White [:And not to overcomplicate this, but in addition to the financial redetermination that occurs here, there's also a level of care reassessment that occurs every single year as well.
Michelle Rice [:Right. Because they do their reassessment after a year, and that's just where our assessors are going out and our case managers are going out to make sure that they are still eye lock. Because some people have gotten better, which is awesome. You know, it's great that they've gotten better, and they don't need the in home waiver services anymore. So if they're found not eye lock, then we have to stop services. And a lot of times, if they're in Franklin County, we can make a referral of senior options.
Katie White [:Yes. And Delaware's got source point and we've got some other Yes. Before we move on, I want you to define EyeLock, if you don't mind.
Michelle Rice [:It's intermediate level of care, and what that means is that, the person has to meet all their ADLs and IDLs. So that means assistance with their bathing, assistance with meal prep, getting up and down out of a chair.
Katie White [:So they're still eligible for Medicaid as that insurance payer that we talked about earlier, meaning community Medicaid if they're iLok?
Michelle Rice [:If they're iLok, yes. They'll still stay on waiver and everything. But if they're found not iLok and their income is over 943, then they're not eligible for Medicaid. So if someone's found not eye lock, what they do is, we have to stop services. But the person has 16 days to request a state hearing. Mhmm. So, especially if they don't agree with the assessor or the case manager, if they think that they are EyeLock and they think that they still do need the help, then they can ask for a state hearing. And if they do, the case managers here give them out all the information on the state hearings and how to apply for 1 and everything.
Michelle Rice [:But they have to do it within that first 16 days. So once they have that set up, if they have a hearing, and let's say they win the hearing, the hearing officer says, yes, they are eye lock. They do need waiver services. Then what we have to do is go back in and undo the closure that we did and get the Medicaid opened back up.
Katie White [:Okay.
Michelle Rice [:And so there's no loss. But let's say the state hearing officer said, you are not EyeLock, you know, and went on to say, then if their income is over 943, then they're not gonna be eligible for community Medicaid. But they could still be eligible to help with their Medicare premiums. It's not considered Medicaid, but their Medicare premiums. And that is like your q QMBs, your slim bs, and qi ones. I know. A lot of acronyms. I know.
Katie White [:Those are fun.
Michelle Rice [:I know. And what q and b stands for is qualified Medicaid beneficiary.
Katie White [:Okay.
Michelle Rice [:And this is all income based.
Katie White [:Okay.
Michelle Rice [:So if someone's income is over $1,215, if they're over that, then that means that they would jump down to the next level, which is your SLMB, which is specified low income Medicaid beneficiary. We just love these terms. It's just so much fun.
Katie White [:It really is so much fun. So individuals that are not eligible for Medicaid might be financially eligible for one of these other programs that helps pay for
Michelle Rice [:Their Medicare, premiums. Their Medicare premiums. Right.
Katie White [:Okay. And then their Medicare is what's paying for their Right. Whatever services that they might need or
Michelle Rice [:yeah, because the Medicare will help pay for the doctor visits, hospitalizations Okay. And everything.
Katie White [:And so just in general, individuals who are not eligible for Medicaid can also, of course, pay for long term care services out of pocket. Maybe they have a long term care insurance. Maybe their family member is providing the care for free. So these are just sort of all these different avenues to make sure that individuals are able to receive their long term services and supports via home and community based services. So in their homes, in these various capacities.
Michelle Rice [:Right. Because what the case managers do is whatever county that they are covering, they reach out to, like senior options here in Franklin County, Source Point, and Delaware County. Licking County has their own, and so does Madison and Union, you know, and Fayette and Fairfield. They just reach out to their outer counties to be able to maybe get meals delivered, get someone to come in and check on them and stuff like that.
Katie White [:And some case management. Yes. So if you aren't eligible for these Medicaid services, if you live in a county that has a levy, essentially, they're built to provide somewhat comparable services to individuals who have a little bit more income. So you can't financially qualify for the Medicaid programs, but you can still have access to a lot of those long term services and supports through the levy. And that's why those levy partners are so crucial to us. And there really is this hand in hand work of ensuring people get what they need and what they're qualified for.
Michelle Rice [:Right. That's the best part. Yes. So just remember, if you lose your Medicaid because you're not IILAC, but you can still receive help with your Medicare premiums. Yes.
Katie White [:So we have covered a lot. We talked about eligibility. We talked about how to apply. We talked about notices of action if within that application process, there are some forms you still need. We talked about denials. We also went over qualified income trust or QITS. And then we even got to redetermination redeterminations, redempts, or renewals. So really kind of the ins and outs of what the overall process looks like for an individual.
Katie White [:And even more so, I mean, I'm just always so thankful for the Medicaid specialist, but my goodness, Keeping track of all of these things and all for the ultimate goal of making sure people can get what they need in the community. It's incredible.
Michelle Rice [:Yeah. I feel like sometimes we're the voices that can get the information from the county, pass it on to the case managers, and then they help the client. So it's like a fixed it's like a circle of life where we just get to go in and help. And we do have spreadsheets galore, how we keep track of everything, but that's all behind the scenes that people don't really get to see. Mhmm. But the Medicaid system is really important to us and helping individuals, that's what we're here for. Yeah. And that's the best part.
Katie White [:Yeah. And I love when you talk about it and you say you love this. Right?
Michelle Rice [:Like I do. Yeah. It is. It's fun. It changes every every year. Medicaid is Medicaid. It changes without notice sometimes, or sometimes we'll get noticed about little changes. And so you just have to go with the flow, and you just make the best of it.
Michelle Rice [:And the case managers here are really wonderful with these guys and just they work with us really closely and we work with them. And we encourage clients to call us because a lot of the case managers will have them call us because they're like, I'm not explaining this correctly.
Katie White [:Yeah.
Michelle Rice [:And so it's just easier for them to hear it from us. Yeah. And then we can help them.
Katie White [:So this specialty, this is really what we're about. And we hear from people and from their family members just saying how thankful they are for our work in navigating this. Do you get feedback like that directly?
Michelle Rice [:Yes. Last week, for example, I got a call from a gentleman. His wife was in the hospital and getting ready to go to a nursing home, and they didn't have Medicaid. And so he was asking a whole bunch of questions, like, what the process is. So what we did is I went through and told him that there's a Medicaid application. And I actually mailed that out to him, along with the authorized rep form so he could be his wife's authorized rep. So the county will talk to him Mhmm. Because she is not able to speak right now.
Michelle Rice [:Okay. And so we did that, and I sent out a list of the verifications that he would need. And he just asked questions like, how does this process work? Where do I begin? And so we kind of went over, filling out the application, getting it sent in. And then he's he was talking a little bit about his resources and his income. And I did have to let him know that the county looks at them separately because he's not on Medicaid, but she's gonna be coming to Medicaid. So his income would not be affected at all. As far as the resources, I did tell him that she could only have 2,000, and he could have the 154 154,000. And he says, but everything is together.
Michelle Rice [:And I'm like, yeah. A lot of people come on, and they have all their accounts together. So what we did is we just kinda talked a little bit about having her have a separate checking account, which is her check going in and him having the other. But the problem was is they had so much resources.
Katie White [:Okay.
Michelle Rice [:And so what I did is I just told him it's a good idea if he gets a hold of an elder care attorney, talks to them. I told him that, you know, we I can't give any names of anybody, but just to kinda look and get with the social worker at the hospital and the social worker at the nursing home to have them kind of direct him in a way to speak to, elder law attorney. And, so he was gonna do that, and then he kept on he wanted to know, what happens if I just don't do anything? And I was like, well, then I'm not sure she'll get to stay in the nursing home. But you could always pay privately if you didn't wanna apply for Medicaid and lose and have to spend down all your money because he was worried that he was gonna be left with nothing. Nothing. Mhmm. And he still owned the home.
Katie White [:Sure. And, you
Michelle Rice [:know, there's house things that you have to pay for. There's upkeep, and he was really worried about that. And then he called me back a couple days later and said, remember I spoke to you? I'm like, yes. I do. And he, said, I have an appointment with the attorney. So I will figure out what we're going to do. And I said, that's great. So we'll wait and see if I see his name come through or anything or her name come through.
Michelle Rice [:But it it was just nice to be able to help explain some things. But just knowing that I can't give advice Mhmm. But we can give you, like, little suggestions and stuff and get a hold. I told him to go to the county and apply because they'll be the ones that can give the financial green light or red light.
Katie White [:Sure. But us giving the time, the empathy, the respect, the advice, the information that is huge. I mean, we had 2 episodes on Medicaid, and there's still so much more to talk about. But imagine going through it. A lot of times people are going through this during a crisis. And, again, we offer them that time and space and expertise and just, you know, a a helpful hand in navigating something extremely complicated.
Michelle Rice [:Yeah. I agree. I mean, because it's nice that our screening department can help filter some of those questions. Mhmm. And if they don't know, they always reach out to us. Yeah. And they'll forward the phone call to us. And that way, we can kinda talk to them and kinda ease their minds a little bit about this journey that they're gonna get ready to go on.
Michelle Rice [:Yeah.
Katie White [:And so screening is working with callers, generally external from the agency that we aren't case managing. And then our Medicaid specialists, like you, are working with people that were case managing internally. So
Michelle Rice [:And we get calls from people that aren't on Medicaid yet. Right. So yeah.
Katie White [:Well, thank you so much. Any last thoughts or anything that we didn't get to?
Michelle Rice [:I would just say if you're gonna apply for Medicaid, be thorough, provide all the verifications that they are requesting, and don't cross anything out on any bank statements or any paperwork. They wanna see everything, so don't block anything out. And,
Katie White [:hopefully, if you're approved and you're eligible when that renewal comes, sign page 9. That's right. Okay. Well, thank you so much. I appreciate it.
Michelle Rice [:You're welcome. Have a good day. You too.
Katie White [:I hope now you know a little bit more about Medicaid.
