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Overview

Medicaid is a partnership between the states and the federal government to provide health insurance and long term care services to certain groups of people who are low income and have few assets. States are not required to offer Medicaid. States choose to participate in the program. At this time, all states offer a Medicaid program, but not all state Medicaid programs are alike. The states may offer a wide range of health care programs under Medicaid. If a Medicaid program is offered in a state, it is an entitlement for those found eligible.

If a state chooses to partner with the federal government and offer Medicaid, the state is required to pay a portion of the program costs. The federal government provides an incentive for states to take part in Medicaid by matching the money the state pays. The federal matching money is important for the Medicaid program to operate.

Who is eligible for Medicaid coverage?

A state must follow the federal government?s rules for Medicaid programs. The rules say that a state must provide benefits to three mandatory populations: children and their parents, the elderly, and people with disabilities. In order to qualify an individual must be a US citizen or meet immigration and residency requirements. An individual must also have a low income and have few assets. A state, however, can choose to provide coverage to other populations (know as optional populations) beyond the Federal government?s mandatory groups.

Utah?s Medicaid programs provide coverage for 49 different eligibility groups of which 28 are mandatory and 21 are optional. Each eligibility group has separate income and asset level requirements. The groups break down into the following categories:

Mandatory populations

? Pregnant women whose incomes are less than 133% of the federal poverty level (FPL)

? Children birth to age 6 at 133% of FPL

? Low income parents up to 54 to 60% of FPL

? Senior citizens 65 or older up to 100% of FPL

? Persons who are blind up to 100%

? People with disabilities up to 100% of FPL

Optional populations

? Children age 6 ? 18 up to 100% of FPL

? Children age birth ? 18 with family incomes up to 200% of FPL through the Children?s Health Insurance Program (CHIP)

? Adults 19- 65 without dependent children to 150% through the Primary Care Network (PCN a waiver program)

? People with disabilities who are employed up to 250% of FPL

? Coverage for people with tuberculosis up to 200% of FPL

? Coverage for people with breast or cervical cancer up to 250% of FPL

? Medically needy up to 50% of FPL or spenddown to 50% of FPL

? Senior citizens 65 or older with incomes above 100% of FPL who spenddown to 100% of FPL

? Persons who are blind with incomes above 100% of FPL who spenddown to 100% of FPL

? People with disabilities up with incomes above 100% of FPL who spenddown to 100% of FPL

Poverty level guidlines

The Federal Poverty Levels that determine income eligibility are 2005 Poverty Guidelines 100% FPL Persons in Family Unit 48 Contiguous States and D.C. Alaska Hawaii 1 $ 9,570 $11,950 $11,010

1. 12,830 16,030 14,760
2. 16,090 20,110 18,510
3. 19,350 24,190 22,260
4. 22,610 28,270 26,010
5. 25,870 32,350 29,760
6. 29,130 36,430 33,510
7. 32,390 40,510 37,260

For each additional person, add 3,260 4,080 3,750 SOURCE: Federal Register, Vol. 70, No. 33, February 18, 2005, pp. 8373-8375.

Financial eligibility is reexamined each month someone is on the program.

Federal guidelines for assets vary depending on the type of Medicaid eligibility but generally limit an individual to $2,000. A family has a more generous limit that starts at $3,000.

What services are available through Utah Medicaid?

The Federal government requires states to pay for certain mandatory health care services. States may also include additional (optional) services. Utah must submit a plan to the Federal government describing the health care services the state will offer. The Federal government must approve the plan. Once a person is determined eligible for Utah Medicaid, he or she is entitled to any medically necessary service offered in the state plan. Utah?s State Medicaid Plan can be found at http://health.utah.gov/medicaid/st_plan

Utah?s State Medicaid Plan

- Mandatory services:

• Hospital Services
• Inpatient hospital services except for services provided in an institution for mental illness
• Outpatient hospital
• Outpatient surgical centers
• Free-standing birth centers
• Rural health clinic services
• Laboratory and X-ray services
• Nursing home care
• Child Health Evaluation and Care (CHEC) program providing early periodic screening diagnosis and treatment for children under 21 (the Federal EPSDT program)
• Family planning services
• Nurse midwife and nurse practitioner services
• Physician services
• Home health services
• Transportation services for health care appointments

Utah?s State Medicaid Plan

- Optional Services:

• Podiatric services
• Optometry services (including eyeglasses)
• Psychological services
• Private duty nursing services for children under age 21
• Clinic services
• Dental services (including dentures)
• Physical therapy
• Speech therapy
• Occupational therapy
• Prosthetic devices
• Prescription medications and prescribed over-the-counter medications
• Inpatient hospital services for mental illness
• Intermediate care facilities for the mentally retarded (ICFs/MR)
• Hospice care
• Case management
• Enhanced services for pregnant women
• Translators for medical services for clients with limited English or disability
• Medicare premiums for Part A and/or Part B for individuals who are dually eligible for Medicaid and Medicare

How do I apply for the Utah Medicaid Program?

You can apply for Medicaid at the Utah Department of Health Office or at Medicaid outreach offices found in major hospitals and public health clinics. You can find the location closest to you at: http://www.health.utah.gov/medicaid/provhtml/How%20and%20Where%20to%20Apply%20for%20Utah%20Medicaid.htm Follow the instructions and click on your zip code. You can apply on-line using this link. You can also call 801-538-6155 or toll free in Utah at 1-800-662-9651.

What documents do you need when applying for Medicaid?

? Proof of alien status if you are not a U.S. citizen

? Your social security number

? Proof of income

? Current bank statements

? Proof of the value of any certificates of deposit (bank CDs), savings certificates, any real estate you own other than your personal home

? Proof of the value of any stocks and bonds

? Trust account papers

? Copies of medical bills you owe or have recently paid

? The name, address and policy number of your medical insurance company and the cost of your premiums

What can you do if you are denied eligibility?

If you are denied Medicaid, you have the right to appeal the decision. You may contact the local Medicaid office supervisor for a conference. You may also call the Constituent Services Representative for Medicaid, or file for a Fair Hearing.

For more information about Utah Medicaid see: http://www.health.utah.gov/medicaid/provhtml/general_info.html

Medicaid Waivers

Utah Medicaid also offers additional services for special populations. These special services are available through waivers. A waiver allows a state to set aside some of the federal rules that apply to the regular Medicaid program. Waivers differ from regular Medicaid in that the state is able to design a program that meets the needs of a particular group of people. The state defines the group of people who are eligible for benefits, the geographic area that the waiver will cover, the services to be offered, the amount of services provided, and the total number of people who can receive the services. The state must get approval from the Centers for Medicare and Medicaid Services (CMS) for any waiver. Unlike regular Medicaid, waivered services are not considered an entitlement. The number of people served under a waiver is dependent upon money received from the state legislature. This means that a person may qualify for the services, but is not made eligible to receive services until there is funding available to give him/her services. Once the person is given funding under the waiver, all services within that waiver and all regular Medicaid services (see above) are available if medically necessary. Utah Medicaid operates five Home and Community Based Services (HCBS) Waiver programs for people with severe disabilities. These waivers provide services to individuals who are Medicaid eligible and who would require care in a Nursing Facility (NF) or Intermediate Care Facility for the Mentally Retarded (ICF/MR). The waivers allow Medicaid to pay for services that help people live in their own home or in the community. Each of the waivers has different income and asset limits, and additional standards that an individual must meet.

Technology Dependent Children (Travis C.) Waiver

This Utah Medicaid Home and Community Based Services Waiver serves medically fragile children who are dependent upon medical equipment for either breathing or eating. The Department of Health, Bureau of Children with Special Health Care Needs administers this waiver. To be eligible for this waiver the child must:

? Be a Utah resident

? Be less than 21 years of age when entering the program. A recipient may continue to receive services after age 21.

? Need the medical services provided in a Nursing Facility

? Qualify for Medicaid based on his/her own income and resources at or below 100 % of the Federal Poverty Level after allowable deductions (spenddown is an option). Parents? income and assets are not counted.

? Have at least one caregiver trained (or be able to be trained) and available to provide care in the home. The home must have enough space for the medical equipment and care staff to safely take care of the child.

? Require skilled nursing or rehabilitation services (or a combination of both) at least five days per week.

What services are available through this waiver?

In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

? Respite care

? In-home respiratory care

? Family support services

? Nutritional evaluation and in-home treatment

Only a limited number of children may receive help through this waiver. A child may qualify, but may need to be placed on a waiting list until funding is available.

Where do I get more information about the Travis C. Waiver?

More detailed information about the waiver can be found at: http://health.utah.gov/cshcn/Travis/index.htm

Or call the Division of Community and Family Health Services, Community Based Services case manager at 801-584-8240 or outside the Salt Lake area at 1-800-829-8200.

Individuals with Mental Retardation and Other Related Conditions Waiver

This Utah Medicaid Home and Community Based Services Waiver provides services to children and adults with intellectual and related developmental disabilities (e.g. cerebral palsy, autism and severe epilepsy). The Department of Human Services, Division of Services for People with Disabilities (DSPD) runs this waiver. To be eligible for this waiver the individual must display symptoms of the condition before age 22 and:

• Be a Utah resident
• Have significant life long functional limitation in three of the following:
  1. Self care (eating, toileting, bathing, dressing or grooming)
  2. Receptive and expressive language (unable to communicate and understand simple requests)
  3. Learning (a functional IQ measured at 70 or below)
  4. Mobility (may require a wheelchair, scooter, or other assistive devices and requires assistance to exist an area during an emergency)
  5. Self direction (not able to make appropriate decisions about safety, legal, financial or residential issues)
  6. Incapable of independent living (does not have the necessary skills to live in the community, or is a danger to oneself or others)
  7. Unable to become economically independent (receives disability benefits, or works part time, or requires assistance on the job and is paid less than minimum wage)
• Needs the services provided in an Intermediate Care Facility for the people with mental retardation (ICF/MR)
• Qualifies for Medicaid based on his/her own income and resources at or below 100 % of the Federal Poverty Level after allowable deductions (spenddown is an option). Parents? income and assets are not counted.

What services are available through this waiver?

In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

• Behavior consultation

• Chore services (heavy duty housekeeping)
• Companion services
• Day supports
• Environmental adaptations including home modifications, vehicle modifications and assistance dogs
• Extended living supports (for someone who is not able to attend a daytime activity due to illness, or who is transitioning to another provider)
• Family training and preparation services (training for the primary giver or family)

-Family and individual training and preparation services (a more intensive training when the family has numerous challenges)

-Financial management services

• Homemaker services (meal preparation and routine household care)
• Living start-up costs for basic household items required by an individual moving from an institutional setting into the community
• Massage therapy
• Personal assistance
• Personal budget assistance
• Personal Emergency Response System (purchase, on-going fees, and testing)
• Professional medication monitoring (supervision by a nurse)
• Residential placements with appropriate supports
• Respite care
• Specialized medical equipment (rental or purchase)
• Supported employment
• Supported living
• Transportation for non-medical needs
• Waiver support coordination

While the list of available services is extensive, the services received are dependent on an individual?s needs and assigned budget. No service may duplicate a similar service offered through the Medicaid State Plan. A service is made available through the waiver only if there is no other means of obtaining it. However, once someone is brought into this waiver, he or she is eligible for all services that are necessary for his or her health and safety.

A person may qualify to receive services through DSPD, however, he or she is not made eligible to receive services through the Individuals with Mental Retardation and Other Related Conditions Waiver until funding is available. Only a limited number of people can receive services through this waiver. DSPD maintains a waiting list of individuals who qualify for services and who are waiting to receive services through this waiver. Individuals are brought into services from the waiting list based on available funding and on their level of critical need. Utah State law requires DSPD to serve the most critical first. This often means that a person can be on the waiting list for many years before being brought into services.

How do I apply for services?

To apply for the Individuals with Mental Retardation and Other Related Conditions Waiver, call the DSPD State Office at (801) 538-4200 in Salt Lake County or (800) 837-6811 statewide to be referred to your regional DSPD office for an eligibility evaluation. You can also find the office nearest you at http://www.dspd.utah.gov/locationsmap.htm.

? You will be asked to provide a psychological assessment

? You will be asked to provide a developmental assessment for children under age 6

? You will also need to be interviewed to complete a Social History. (See http://www.hspolicy.utah.gov/dspd/pdf/forms/f824L.pdf )

? You may also need to provide school evaluations, medical records, or other documents as requested

? A local committee from the DSPD regional office will participate in evaluating your need for DSPD services. This evaluation is called a Needs Assessment and will establish your critical needs score. The Needs Assessment not only measures the severity of someone?s disability, but also looks at the family?s ability to safely care for the individual with disabilities. The critical needs score is used to establish your ranking on the waiting list. This score is also used to bring you into services when funding is available. You can ask to have a Needs Assessment redone at any time if there is a change in the health/behavior of the individual with disability or if there is a change in the ability of your family to care for the person with disabilities. To learn more about the services offered through DSPD click on http://www.dspd.utah.gov/

Individuals With Acquired Brain Injuries (ABI) Waiver

This Utah Home and Community Based Services Waiver provides services to individuals 18 years of age and older who have traumatic or acquired brain injury as a result of an accident or organic change in the brain?s neurological activities (e.g. stroke, near drowning, infectious disease). This waiver is not meant for individuals whose primary diagnosis is mental illness or substance abuse. The waiver does not cover brain injuries that are a result of a degenerative disease (e.g. Multiple Sclerosis, Muscular Dystrophy, Huntington?s Chorea, Ataxia, or Cancer). The Department of Human Services, Division of Services for People with Disabilities (DSPD, operates this waiver. To be eligible for this waiver an individual must have a brain injury and:

? Be a Utah resident

? Be 18 years of age or older

? Score between 40 and 120 on the Brain Injury Waiver Comprehensive Assessment Form

? Have difficulty with self-care and activities of daily living

? Require a level of care provided in a Nursing Facility

? Qualify for Medicaid based on his/her own income and resources at or below 100 % of the Federal Poverty Level after allowable deductions (spenddown is an option).

What services are available through this waiver?

In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

? ABI support coordination

? Chores services

? Community living supports

? Companion services

? Family assistance and support (enabling the person with disabilities to remain in the family home)

? Homemaker services

? Personal Emergency Response System (purchase, installation, on-going fees, and testing)

? Respite care services

? Specialized medical equipment and supplies

? Structured day program

? Supported employment services

? Transportation for non-medical needs

The services received are dependent on an individual?s needs and assigned budget. No service may duplicate a similar service offered through the Medicaid State Plan. A service is made available through the waiver only if there is no other means of obtaining it. However, once someone is brought into this waiver, he or she is eligible for all services that are necessary for his or her health and safety.

A person may qualify to receive services through DSPD, however, he or she is not made eligible to receive services through the Individuals With Acquired Brain Injuries Waiver until funding is available. Only a very limited number of people can receive services through this waiver. DSPD maintains a waiting list of individuals who qualify for services and who are waiting to receive services through this waiver. Individuals are brought into services from the waiting list based on available funding and on their Critical Needs Assessment score. Utah State law requires DSPD to serve the most critical first. This often means that a person can be on the waiting list for many years before being brought into services.

How do I apply for services?

To apply for the Individuals With Acquired Brain Injuries (ABI) Waiver, call the DSPD State Office at (801) 538-4200 in Salt Lake County or (800) 837-6811 statewide to be referred to your regional DSPD office for an eligibility evaluation. You can also find the office nearest you at http://www.dspd.utah.gov/locationsmap.htm. You can also call the ABI Program Manager at (801) 538-8244 for Salt Lake County, or (801) 374-7894 for Utah County

? You will be asked to provide documentation of your acquired neurological brain injury from a licensed physician

? You will need to prove that you are a Utah resident.

? You will need to participate in a Brain Injury Waiver Comprehensive Assessment to determine your eligibility for state funded services

? Once your Brain Injury Waiver Comprehensive Assessment is reviewed, a DSPD Intake Worker will administer a Critical Needs Assessment and complete a Brain Injury Social Summary (See http://www.hspolicy.utah.gov/dspd/pdf/forms/f824bi.pdf)

? A local committee will review your assessments and you will be given a critical needs score that will be used for ranking on the waiting list and to bring you into services.

? You may need to provide additional information as requested To learn more about the services offered through DSPD click on http://www.dspd.utah.gov/

Physical Disabilities Waiver (PWD)

This Utah Medicaid Home and Community Based Services Waiver serves adults with severe physical disabilities (cannot use 2 or more limbs) who require assistance from another person for personal care. The Department of Human Services, Division of Services for People with Disabilities (DSPD) operates this waiver.

To be eligible for this waiver the individual must:

? Be a Utah resident

? Be 18 years of age or older

? Have the functional loss of two or more limbs requiring assistance from a trained person for activities of daily living (bathing, dressing, transferring from bed to chair, walking, eating, toileting, grooming) and instrumental activities of daily living (use of the telephone, shopping, food preparation, housekeeping, laundry, transportation, medication use, ability to handle finances)

? Physical disability is expected to last for a continuous period of not less than 12 months

? Meet the admissions criteria for a Nursing Facility

? Be medically stable

? Capable of hiring, training, and supervising personal attendants

? Capable of managing his or her own financial and legal affairs

? Require at 14 hours a week of personal assistance

? Have at least one personal attendant trained (or willing to be trained) and available to provide needed services

? Qualifiy for Medicaid based on his/her own income and resources at or below 300 % of the Federal Poverty Level after allowable deductions (spenddown is an option). What services are available through this waiver? In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

? Local area support coordination liaison providing assistance in identifying local service providers, community resources, and natural supports

? Personal Emergency Response Systems

? Personal assistance services hands-on medical and non-medical care

? Consumer preparation services including effectively communicating your needs, management of personal attendants, instruction in problem solving

? Nurse case management

The services received are dependent on an individual?s needs and assigned budget. No service may duplicate a similar service offered through the Medicaid State Plan. A service is made available through the waiver only if there is no other means of obtaining it. However, once someone is brought into this waiver, he or she is eligible for all services that are necessary for his or her health and safety. A person may qualify to receive services through DSPD, however, he or she is not made eligible to receive services through the Physical Disabilities Waiver until funding is available. Only a very limited number of people can receive services through this waiver. DSPD maintains a waiting list of individuals who qualify for services and who are waiting to receive services through this waiver. Individuals are brought into services from the waiting list based on available funding and on their Minimum Data Set-Home and Community (MDS-HC) and Personal Assistance Critical Needs assessment score. Utah State law requires DSPD to serve the most critical first. This often means that a person can be on the waiting list for many years before being brought into services.

How do I apply for services?

To apply for the Physical Disabilities Waiver, call the DSPD State Office at (801) 538-4200 in Salt Lake County or (800) 837-6811 statewide to obtain a Physical Disabilities Application form.

? You and your physician will need to complete the Physical Disabilities Application form. The nurse coordinator will review the form.

? The nurse coordinator will use the MDS-HC and Personal Assistance Critical Needs assessment tools to evaluate your need for services.

? You will be given a needs assessment score for placement on the wait list or into services.

? Every 6 months you will receive a survey that you must complete to update your need for services. To learn more about the services offered through DSPD click on http://www.dspd.utah.gov/

Individuals Aged 65 and Older (Aging) Waiver

This Utah Medicaid Home and Community Based Waiver program serves people age 65 and older. The services provided through this waive allow the individual to remain in his or her own home or other community living arrangement instead of a Nursing Facility. The Department of Human Services, Division of Aging and Adult Services (DAAS), operates this waiver.

To be eligible for this waiver the individual must:

? Be age 65 or older

? Meet the admissions criteria for a Nursing Facility

? Qualify for Medicaid based on his/her own income and resources at or below 100 % of the Federal Poverty Level after allowable deductions (spenddown is an option). What services are available through this waiver? In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

? Adult day care

? Assistance with caregiver training

? Case management

? Chore services

? Companion services

? Home delivered meals

? Homemaking services

? Home modifications for physical accessibility

? In-home caregiver respite

? Non-medical transportation

? Nursing home overnight caregiver respite

? Personal care services (Home Health Aid or Personal Care Attendant)

? Personal Emergency Response Systems

? Specialized medical equipment, supplies, and assistive technology

A limited number of individuals can be served through this waiver. Services provided are dependent on an individuals needs and assigned budget. No service may duplicate a similar service available through the Medicaid State Plan. People are brought into waivered services based on their needs and available funding.

How do I apply for this waiver?

Contact your local Area Agency on Aging http://www.utahagingservices.org or call the Division of Aging and Adult Services at 1-801-538-3910 for more information.

? An Intake Worker from your local Area Agency on Aging will do a phone interview and give you a risk score

? The county nurse and or case manager will follow-up using the Minimum Date Set-Home and Community (MDS-HC) to evaluate your needs

? You will be placed on an application list

? When funding is available, your level of care will be determined and you will be brought into services. At this time there is no waiting list. Eligible individuals are brought into services immediately.

To learn more about programs offered through DAAS click http://daas.utah.gov

How to be successful getting the services you need through the Medicaid programs

? Have required documentation available for eligibility determination

? Ask for help from your Intake Worker if you are not able to complete the applications on your own

? Complete all required paperwork in the timeframe specified

? Request a reevaluation of your needs assessment if there is a change in the health or behavior of the person with disabilities, or in the ability of the family to care for this individual

? Contact your support coordinator/case manager/nurse coordinator frequently

? Document all your communications with state agency personnel

? If you have a problem, try to resolve it at the lowest level

1. Contact your support coordinator/case manager/nurse coordinator
2. Contact the agency?s ombudsman. The ombudsman cannot change your ranking on a waiver waiting list. S/he can make sure that you are treated courteously throughout the process.
3. File for an appeal

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