I. WHY IS THIS
IMPORTANT?
Most people consider health insurance coverage to be
a necessity. Even individuals who are
not chronically ill or who do not have ongoing or special health care needs
desire the safety net that health insurance provides in the event of illness or
disability. However, health insurance
can be very costly. In addition,
individuals with disabilities or pre-existing medical conditions frequently are
unable to obtain private health insurance.
Our government system
recognizes the need for citizens to have access to quality medical care, as
well as the difficulties some individuals have in obtaining adequate health
care insurance coverage. Therefore,
several government health insurance programs have been established to assist
eligible individuals regarding medical coverage. One of these programs is Medicaid. Medicaid is a federal and state partnership program.
II. KEY POINTS
(NOTE: This Fact Sheet represents a very brief
summary of an extremely complex subject.
The information provided should only be used as an overview and general
guide to Medicaid. It is not intended
to fully explain all of the provisions or exclusions of the laws, regulations,
and rulings of the Medicaid program.
Please refer to the “Resources/Contacts” section for information on how
to obtain more detailed information about Medicaid.)
Medicaid is funded jointly by the federal and individual
state governments. As a result, the
Medicaid program differs from state to state, as well as changes within a state
from time to time. Within broad
national guidelines that the federal government provides regarding Medicaid
programs, each state is to establish the following:
·
eligibility
standards;
·
the
type, amount, duration, and scope of services;
·
the
rate of payment for services; and
·
the
administration of its own program.
Enrollment in Medicaid is
handled in two ways: 1) automatic enrollment (Individuals who are eligible for
and receive Supplemental Security Income (SSI) are automatically enrolled in
Medicaid. For children under the age of
18, including children with disabilities, the family's income and resources are
considered for eligibility determination purposes. However, it is important to note that once a child with a
disability reaches 18 years of age, only his/her personal income and resources
will be considered for eligibility determination purposes, not his/her
family’s. Another important area to
note is that recent changes in federal laws have made it possible for
individuals to retain their Medicaid coverage even if their income/wages
disqualify them from SSI.) or 2) by application (Individuals not receiving SSI
must apply under a separate eligibility determination process for
Medicaid. This process requires an
initial interview, either by telephone or in person, and subsequent completion
of several standardized forms. While
processing times may vary, federal regulations allow 90 days for eligibility
determination for applications requiring a disability decision and 45 days for
all others. Applicants have the right
to appeal if a timely decision is not made.)
Once an individual is found eligible, a Medicaid card is mailed and must
be presented to providers when medical and health-related services are
sought. Coverage is considered in
periods of 3, 6, or 12 months.
Continuing eligibility is reviewed at least once each year.
Each state’s Medicaid
program, through Title XIX of the Social Security Act, is to provide medical
and health-related services for certain individuals with low incomes and
limited resources. In addition to
Louisiana's Medicaid Program providing required medical services, it also
provides additional and special support services through optional and waiver
programs (i.e., Home and Community-Based Services) to eligible individuals.
Louisiana’s Medicaid Program
is administered by the Department of Health and Hospitals, Bureau of Health
Services Financing (BHSF). It provides
federal and state tax-supported medical coverage for eligible residents. It provides services to people in financial
need who are: children; pregnant; aged; blind; disabled; receiving SSI; and/or
receiving TANF (Temporary Aid to Needy Families), formerly known as AFDC (Aid
to Families with Dependent Children).
In Louisiana, Medicaid-covered persons, with certain restrictions, can choose their own doctors, hospitals, or other service providers. Recipients do not have to pay for Medicaid services, if the provider accepts Medicaid coverage as payment. It is important to always ask the doctor, hospital, pharmacy, or other provider if they accept Medicaid as payment for their services. Louisiana Medicaid is a vendor program and pays providers directly for covered services, after all other insurance coverages, including Medicare, have paid. Medicaid cannot reimburse certified recipients who pay for services themselves.
III. ROLES/NEXT STEPS
Students/Young
Adults:
Because individuals with disabilities may qualify
for both Medicaid and Medicare, it is important to learn about both programs,
including the differences between the two programs. Young adults who think that they may be eligible for SSI payments
and, as a result, Medicaid, should contact the SSA. Personnel in local or district offices can provide information
about eligibility and the application process, including the information and
documentation requirements. If support
or assistance is wanted or needed, young adults should contact the nearest
Social Security office or ask a family member or friend for help.
Young adults who are working or would like to work
should talk with family members and agency personnel and ask for information
about how working will affect SSI benefits.
They should learn about Work Incentives and ask adults supporting them
in their transition to help them access these programs. Young adults should consider having representatives
from SSA become members of their transition planning teams.
Families:
Because individuals with disabilities may qualify
for both Medicaid and Medicare, it is important to learn about both programs,
including the differences between the two programs. Families who think their sons or daughters may be eligible for
SSI payments and, as a result Medicaid, should provide needed assistance when
applying for benefits at the nearest Social Security office. Personnel in these offices can provide
information about eligibility and the application process, including the
information and documentation requirements.
When discussing the
transition to employment with agency personnel, families should ask about
various Work Incentives for which their sons/daughters may be eligible. If incentives are identified, they should
help their sons/daughters apply so that wages and salaries received from
employment do not interfere with their sons’/daughters’ SSI eligibility.
Agencies:
Transition personnel in Local Education Agencies
(LEAs) and adult service agencies should become familiar with the SSI program,
including Medicaid, so that information and assistance can be provided to
adolescents and young adults with disabilities and their families. In addition,
Social Security offices have brochures and other printed materials about
programs that can be shared with young adults and their families. These materials can also be accessed through
the SSA’s website. Finally,
representatives from SSA should be invited to participate as members of
transition planning teams as appropriate.
Agency representatives can
offer informational workshops on SSI, Medicaid, and other Social Security
topics for young adults and families.
Personnel in local or district Social Security offices can be contacted
to provide information about programs.
As requested, personnel from
the SSA should attend meetings at which transition to employment, financial
needs, and health insurance coverage are discussed. They can also serve on local or regional interagency transition
teams. By providing information to
LEAs, families, and young adults, SSA personnel can help young adults with
disabilities plan for employment, financial needs, and health insurance
coverage without the fear of losing needed benefits prematurely.
IV. RESOURCES/CONTACTS
Bureau of Health Services Financing (BHSF)
– Medicaid
Department
of Health and Hospitals, Box 91030
Baton
Rouge, LA 70821-9030
Phone
(225) 342-5774; Fax (225) 342-3893
http://www.dhh.state.la.us/medicaid/index.htm
Health Care Financing Administration (HCFA)
Families Helping Families Resource Centers
1-800-766-7736
Social Security Administration
1-800-772-1213 (voice) or
1-800-325-0778 (TTY)
(Persons calling these
numbers can get information about Supplemental Security Income and Medicaid and
can request that an appointment be made at a SSA office near them.)
Social Security and You Teacher’s Kit
This is a set of materials can be obtained by mail or downloaded from the SSA’s website. (See previous contact information.) Mailing information: Social Security, 4-J-8 WHR, Baltimore, MD 21235.
V. REFERENCES
Louisiana’s Medicaid Program, BHSF flier - “Medical
Programs”, issued February, 1994.
Louisiana’s Medicaid Program, BHSF flier LTC - “Nursing
Facility and Waiver Services Programs”, issued April, 1997.
Louisiana’s Medicaid Program, BHSF flier – “Medical Programs:
“Good Health Care - An Apple a Day Isn’t Enough!”, revised October, 1997.
Social Security
Administration Office of Disability. (January, 1996). Graduating to Independence. [available via Internet: http://www.ssa.gov]
Social Security
Administration. (January, 1999). Social
Security Update 1999. [available via Internet: http://www.ssa.gov]
