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Montana Medicaid and the HELP Act

Authored By: Montana Legal Services Association (MLSA) LSC Funded

Montana Medicaid and the HELP Act

 

What is Medicaid and what is the HELP Act?

 

Medicaid is public health coverage for qualifying low income individuals. It provides access to important health care services with limited out-of-pocket costs. There are several different Medicaid programs that have varying eligibility requirements. General Medicaid under the HELP Act provides coverage to low-income individuals and families for a wide range of medical services.

The HELP Act is Montana’s Medicaid expansion, which is part of the federal Affordable Care Act, aka the ACA or “Obamacare”. The HELP Act expanded Medicaid coverage for individuals and families by increasing the income limits to 138% of the Federal Poverty Level, which for a single individual would be a yearly income of around $16,105 or less and for a family of four it would be roughly $32,913 a year or less (per 2016 income guidelines). The HELP Act also expanded Medicaid’s coverage of services and care.

The majority of Medicaid recipients under the HELP Act will have their coverage administered by a Third Party Administrator, Blue Cross Blue Shield. Certain groups of recipients (such as medically needy, disabled, very low-income, Native Americans, etc.) will still have their benefits administered by the State under the Alternative Benefits Plan, some individuals are subject to different eligibility requirements. All Medicaid programs allow you to choose your own doctors and providers, as long as they accept the Medicaid insurance you have; this includes most hospitals, IHS, and many private doctors’ offices and clinics.

 

Who is eligible for HELP Act Medicaid?

 

To qualify for general Medicaid via the HELP Act you must:

- be at or below 138% of the Federal Poverty Level (FPL), which for a single individual in 2016 would be a yearly income of around $16,100 or less and for a family of four it would be roughly $32,900 a year or less.

- be between the ages of 19 and 64 (kids are covered by HMK Plus or HMK/CHIP)

- not be pregnant at time of enrollment (there is a Medicaid program to cover pregnant women, which has “easier” eligibility, aka a higher income limit of 157% FPL = income for one of up to $18,478/year, and coverage extends through pregnancy and 60 days post-birth, after which if at or below 138% FPL can have coverage converted to standard Medicaid)

- not be entitled or enrolled in Medicare

- not be considered disabled by Social Security

- not be eligible for the other Medicaid programs.

Other Medicaid programs exist with different eligibility standards for children, pregnant women, disabled individuals, former foster youth, individuals and/or families with a yearly at or below 50% of the FPL (which in 2016 would be about $5,885/year for an individual and $12,125/year for a family of four), those with exceptional health needs, Native Americans, individuals and families living in areas with limited resources/isolated areas, and other special circumstances.

If you aren’t sure if you qualify, you can still apply! When you apply for one type of Medicaid, you apply for all of them – the OPA will review your eligibility for all programs with one app!

There are no asset limits for HELP Act Medicaid. This means the money in your savings account, or an extra car or RV, for example, will not be considered in determining eligibility.

 

Work Requirement?

 

There is no work requirement for Medicaid.

However, there is additional funding and support for Medicaid recipients who want to participate in a work program, such as via the HELP-Link program (contact local Job Services for more info) or an Apprenticeship Program. You may receive information about some of these programs in the mail, but they are not requirements.

 

Apply!

 

If you aren’t sure if you qualify, you can still apply! When you apply for one type of Medicaid, you apply for all of them – the OPA will review your eligibility for all programs with one app!

You can apply for any of these Medicaid programs, including general/HELP Act Medicaid, by speaking with a Certified Enrollment Specialist, by visiting your local OPA, online at www.apply.mt.gov, or by calling the OPA Helpline at 1-888-706-1535.

For more information on Montana’s Medicaid programs, please look at Department of Health and Human Services website at http://dphhs.mt.gov/MontanaHealthcarePrograms.aspx.

 

What kinds of services are provided/covered with Medicaid?

 

Medicaid covers a wide variety of services, including:

-dental and vision care                                                                       -home and community based long-term care and nursing homes

-emergency room visits and hospital stays and procedures        -prenatal, maternity, newborn, and pediatric care

-lab work and x-rays                                                                            -prescription drugs

-mental health and substance abuse services                                -rehabilitative and habilitative care and devices

-preventative services                                                                        -ambulatory services

-diabetes prevention care                                                                 -hearing aid and audiology services

-Indian/tribal health services                                                             - reimbursement for transportation to services

-rural health services                                                                          -referrals to federally qualified health clinic services.

 

 

What are the cost shares/premiums and co-payments with HELP Act Medicaid?

 

Generally, recipients will pay a premium equal to 2% of their yearly income, which will be billed monthly. But, premiums/cost shares and co-payments when combined cannot exceed more than 5% of a recipients’ yearly income.

 

Paying Premiums

 

Overdue premium payments will be collected and failure to pay will result in notification to the Department of Revenue, and overdue payments may be collected via income taxes. However, if recipients are under 100% of the FPL (about $11,770 for an individual and $24,250 for a family of four per 2016 guidelines) their Medicaid coverage will not be cut-off due to failure to pay for premiums, but overdue payments may still be collected from tax returns. Recipients who are over 100% of the FPL and behind on premium payments will not be cut-off from coverage if they meet two of the following criteria:

- discharged from the military within 12 months prior

- enrolled in any Montana University system, tribal college, or accredited Montana college offering at least an associate’s degree

- participates in workforce program, such as through Job Servicesor an Apprenticeship Program

- participates in certain health behavior activities. For a list of what qualifies click here.

 

Co-payments

 

With the HELP Act, Medicaid does not have copayments for preventative health care services, regular immunizations, ordered medically necessary health screenings, generic pharmaceutical drugs, eyeglasses purchased through Medicaid program, or other services considered exempt by federal law. Additionally if a recipient is pregnant, 20 years old or younger, Native American, and/or terminally ill, then they are exempt from any co-payments. (see ARM 37.84.108 for details)

There is a quarterly (3 month period) limit to a recipient’s co-payments – it one-quarter of 3% of annual income. For example, say an individual makes $10,000/year, then 3% of their income is $300 and so the quarterly/three month cap on copayments is $75 – if they have reached that $75 limit within 3 months, they will not have any additional copayments for further services and care until the next 3 month period begins (see ARM 37.84.108, section (6) for rules).

Copayments for general services are as follows:

 

100% FPL and Under

Procedure

*copayments look same for aligned plan*

 

Above 100% FPL

$75/discharge

Inpatient Hospital

10% provider reimbursed amount

$8

nonemergency services provided in an emergency room

$8

$4

pharmacy-preferred brand drugs

$4

$8

pharmacy-non-preferred brand drugs, including specialty drugs

$8

$4

professional services

10% provider reimbursed amount

$4

outpatient facility services

10% provider reimbursed amount

$4

Durable Medical Equipment

10% provider reimbursed amount

$4

Lab and Radiology

10% provider reimbursed amount

 

Are there any special rules for Native Americans?

 

Yes. Native Americans are exempt from co-payments and cost shares/premiums if they receive, have received, or are eligible for services by IHS, a Tribal 638 provider, IHS Tribal or Urban Indian Health provider, or through referral under contract services. They participate in what is called the Aligned Medicaid Alternative Benefits Program and it means they do not need to make additional payments like premiums and co-pays and they will have the same level of coverage, if not more, as HELP Act Medicaid. They can continue to use their local, IHS, or Tribal providers and Medicaid will reimburse those providers for services given.

 

Anything else?

 

If you were already on “traditional” Medicaid your services are now expanded to meet those covered through the HELP Act.

Did you know Medicaid reimburses transportation expenses for medical visits? Transportation costs of $5 or more incurred from visits to the closest available medical provider (i.e. if you live in Laurel and there is a doctor in Billings that provides the kind of care you need, you cannot be reimbursed for travel to see a doctor in Red Lodge for the same kind of appointment you could have seen a doctor for in Billings) can be reimbursed if requested.

 

What if I was denied from Medicaid or disagree with something that was done?

 

If you feel you are denied services or coverage unfairly, have a problem with billing or reimbursement, or encounter any other program problems, you have a right to request a Fair Hearing. For more information on Fair Hearings, click here.

If you need advice or assistance resolving an issue with Medicaid, you can apply for assistance from Montana Legal Services Association (MLSA). You can apply by calling our HelpLine at 1-800-666-6899, visiting our website at www.mtlsa.org, or by stopping by one of our offices located in Billings, Helena, and Missoula.

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