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MEDICAL ASSISTANCEMEDICAL ASSISTANCE(MEDICAID)(MEDICAID)
ininininMARYLANDMARYLAND
Workshop for Parents and Providers
A Partnership between The Parents’ Place of Maryland
and
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and Georgetown University Center for Child
and Human Development
About About Th M l d F il A I i i iTh M l d F il A I i i iThe Maryland Family Access InitiativeThe Maryland Family Access Initiative
A project funded by the federal Maternal A project funded by the federal Maternal and Child Health Bureau to: and Child Health Bureau to: assist families to access comprehensive services assist families to access comprehensive services
from managed care organizations which meet all from managed care organizations which meet all needs of their children with SHCN andneeds of their children with SHCN andneeds of their children with SHCN, andneeds of their children with SHCN, and
to ensure their enrollment in the plan best suited to ensure their enrollment in the plan best suited to their individual needs.to their individual needs.
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About Parents’ Place of MarylandAbout Parents’ Place of MarylandAbout Parents Place of MarylandAbout Parents Place of Maryland
How do we help?How do we help? How do we help?How do we help? Education Education Information Information Technical assistance Technical assistance Supportive activitiesSupportive activities
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About Georgetown University Center About Georgetown University Center for Child and Human Developmentfor Child and Human Developmentfor Child and Human Developmentfor Child and Human Development
The Center providesThe Center provides research research training training policy analysis and development policy analysis and development p y y pp y y p technical assistancetechnical assistance
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MedicaidMedicaid: The PuzzleThe Puzzle
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Medical Medical AssistanceAssistance
is veryis veryis very is very important for important for children withchildren withchildren with children with special health special health
care needs care needs and their and their
66familiesfamilies
Why is Medicaid Important?Why is Medicaid Important?y py p
Able to meet all or most of the needs of Able to meet all or most of the needs of children who are enrolledchildren who are enrolled
Free or very low outFree or very low out--ofof--pocket costspocket costsRecognizes children with special needsRecognizes children with special needsRecognizes children with special needsRecognizes children with special needsWaivers for special populationsWaivers for special populations Several options in MarylandSeveral options in Maryland Several options in MarylandSeveral options in Maryland
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Medicaid in MarylandMedicaid in MarylandMedicaid in MarylandMedicaid in Maryland
Complicated systemComplicated systemComplicated systemComplicated system Administered through the Department of Administered through the Department of
Health and Mental HygieneHealth and Mental HygieneHealth and Mental HygieneHealth and Mental Hygiene Provides services through Provides services through managed care managed care
i tii ti ff ff ii ttorganizationsorganizations, , feefee--forfor--serviceservice, , carvecarve--outsoutsMultiple ways to become eligibleMultiple ways to become eligibleHealthChoice is the managed care part of HealthChoice is the managed care part of
the systemthe system
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yy
Eligibility & EntryEligibility & EntryEligibility & EntryEligibility & Entry
MCHPMCHP
SSI
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Income BasedIncome BasedIncome BasedIncome Based
Low Income familiesLow Income families Eligible for Temporary Cash Assistance Eligible for Temporary Cash Assistance g p yg p y
(TCA) (TCA) Medically needy but greater than TCA Medically needy but greater than TCA
standardsstandards EntryEntry: Local Department of Social Services : Local Department of Social Services
(DSS)(DSS)
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Foster Care/AdoptionFoster Care/AdoptionFoster Care/AdoptionFoster Care/Adoption
Foster CareFoster Care Foster CareFoster Care Subsidized Adoption servicesSubsidized Adoption services Entry:Entry: Local Department of Social ServicesLocal Department of Social Services Entry:Entry: Local Department of Social Services Local Department of Social Services
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SSISSISSI SSI
Children with DisabilityChildren with Disability Disability Determination Disability Determination yy Income and Resources EligibilityIncome and Resources Eligibility Recipients of SSI Recipients of SSI pp Age 18Age 18 Entry:Entry: Social Security AdministrationSocial Security Administration Entry:Entry: Social Security AdministrationSocial Security Administration
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MCHPMCHPMCHP MCHP
Age: children up to 19 yearsAge: children up to 19 years Pregnant women of any agePregnant women of any age Based on income Based on income Enroll in HealthChoice MCOEnroll in HealthChoice MCO Entry:Entry: Local Health DepartmentLocal Health Department
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MCHP PremiumMCHP PremiumMCHP PremiumMCHP Premium
Age: children up to 19 yearsAge: children up to 19 yearsg p yg p y Based on income Based on income Pay monthly family contributionPay monthly family contributiony y yy y y Enroll in HealthChoice MCOEnroll in HealthChoice MCO Entry:Entry: Local Health DepartmentLocal Health Department Entry:Entry: Local Health DepartmentLocal Health Department
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RefugeesRefugeesRefugees Refugees Qualified immigrants or refugeesQualified immigrants or refugees Qualified immigrants or refugeesQualified immigrants or refugees Strict guidelines for qualifyingStrict guidelines for qualifying Residency requirements for immigrantsResidency requirements for immigrants Residency requirements for immigrantsResidency requirements for immigrants Entry:Entry: Local Department of Social ServicesLocal Department of Social Services
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WaiversWaiversWaivers Waivers
Medically qualifiedMedically qualified Need institutional level of careNeed institutional level of care Rehabilitative hospital level of careRehabilitative hospital level of care Alternative to InstitutionalizationAlternative to Institutionalization Limited number of recipients Limited number of recipients Entry:Entry: Different entry pointsDifferent entry points
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How does my child get care How does my child get care from MA?from MA?
Medicaid inin
Maryland
HealthChoice Fee-for-service/carve-outsHealthChoice Fee for service/carve outs
7 MCOs Therapies Mental Health REM
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HealthChoiceHealthChoiceHealthChoiceHealthChoice
7 M d C O i ti (MCO )7 M d C O i ti (MCO ) 7 Managed Care Organizations (MCOs)7 Managed Care Organizations (MCOs) Family chooses MCOFamily chooses MCOCovers most children on MedicaidCovers most children on Medicaid Select a primary care providerSelect a primary care provider Select a primary care providerSelect a primary care provider Authorizations for referralsAuthorizations for referrals
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Some Services Covered by Some Services Covered by H l hCh iH l hCh iHealthChoiceHealthChoice
Inpatient & Inpatient & outpatientoutpatient
Clinic servicesClinic services Prescription drugsPrescription drugs
pp Physician carePhysician care Lab & XLab & X--rayray
Prescription drugsPrescription drugs Dental careDental care
M di l i tM di l i tyy
Nursing homeNursing home Home healthHome health
Medical equipmentMedical equipment Diapers (qualified)Diapers (qualified)
Home healthHome health Medical suppliesMedical supplies
Therapies Therapies
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Fee For Service/CarveFee For Service/Carve--outs outs
No Referrals NeededNo Referrals NeededMental health servicesMental health services Therapies such as OT PT speechTherapies such as OT PT speech Therapies such as OT, PT, speech, Therapies such as OT, PT, speech,
audiologyaudiologyUse Red and White CardUse Red and White CardUse Red and White CardUse Red and White Card
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Therapy ServicesTherapy Services
PT, OT, Audiology, Speech & LanguagePT, OT, Audiology, Speech & LanguageNo referral required from PCP or MCONo referral required from PCP or MCOMay access services from any May access services from any y yy y
participating providerparticipating providerUse Red and White CardUse Red and White CardUse Red and White CardUse Red and White Card
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Mental Health ServicesMental Health ServicesMental Health ServicesMental Health Services
Administered through an organization Administered through an organization called MAPScalled MAPScalled MAPScalled MAPS
Case management for child & familyCase management for child & familyCore Service Agencies provide services atCore Service Agencies provide services atCore Service Agencies provide services at Core Service Agencies provide services at
the local level in some countiesthe local level in some countiesMay use Medicaid approved therapists in May use Medicaid approved therapists in
communitycommunity
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Mental Health ServicesMental Health ServicesMental Health ServicesMental Health Services
MAPS determines who will qualify for MAPS determines who will qualify for mental health servicesmental health services
Refers child to mental health Refers child to mental health providers/core service agencies providers/core service agencies p gp g
PrePre--authorizes nonauthorizes non--emergency careemergency care Therapeutic Behavioral ServiceTherapeutic Behavioral Service Therapeutic Behavioral Service Therapeutic Behavioral Service
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Rare & Expensive Case ManagementRare & Expensive Case Management(REM)(REM)(REM)(REM)
Qualifying diagnosesQualifying diagnosesChildren with Special Health NeedsChildren with Special Health Needs Fee for serviceFee for service Fee for serviceFee for serviceCase managementCase management
N th i ti i dN th i ti i dNo authorizations requiredNo authorizations requiredUse Red and White Card Use Red and White Card
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REM ServicesREM ServicesREM ServicesREM Services
All Medicaid services includedAll Medicaid services included All Medicaid services includedAll Medicaid services includedCoordination of services/case Coordination of services/case
managementmanagementmanagementmanagement Assisted LivingAssisted LivingCommunity SupportCommunity Support Assistive equipmentAssistive equipmentq pq p Environmental ModificationsEnvironmental Modifications
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What areWhat are waiverswaivers??What are What are waiverswaivers??
waiverswaivers
. . . and . . . and where dowhere dowhere do where do they fit?they fit?
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Waiver ProgramsWaiver Programs are different are different f M di id d MCHPf M di id d MCHPfrom Medicaid and MCHP:from Medicaid and MCHP:
11 Waivers have different medical and financialWaivers have different medical and financial1.1. Waivers have different medical and financial Waivers have different medical and financial eligibility rules so more children can qualify eligibility rules so more children can qualify for the programs because the parents’ for the programs because the parents’ income and assets are not taken into income and assets are not taken into considerationconsideration
2.2. Waivers have some additional servicesWaivers have some additional services3.3. A limited number of children can be in A limited number of children can be in
W i PW i PWaivers ProgramsWaivers Programs
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Wai ersWai ers Financial eligibility: Individual's income andFinancial eligibility: Individual's income and
WaiversWaivers Financial eligibility: Individual s income and Financial eligibility: Individual s income and
assets not family’s income assets not family’s income Acts as “payer of last resort” to privateActs as “payer of last resort” to private Acts as payer of last resort to private Acts as payer of last resort to private
insurance insurance P h t t d b i tP h t t d b i t Pays whatever not covered by private Pays whatever not covered by private insurances insurances
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Autism waiverAutism waiverAutism waiverAutism waiver
Diagnosis of AutismDiagnosis of AutismDiagnosis of AutismDiagnosis of AutismHave an IEP or IFSPHave an IEP or IFSP
A t 21A t 21 Age: up to 21 yearsAge: up to 21 years Entry: Local School System Entry: Local School System Approved Plan of CareApproved Plan of Care Enroll in Health Choice/MCOEnroll in Health Choice/MCO Enroll in Health Choice/MCO Enroll in Health Choice/MCO
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Autism Waiver ServicesAutism Waiver ServicesAutism Waiver ServicesAutism Waiver Services
Intensive Individual Support ServicesIntensive Individual Support Services Intensive Individual Support ServicesIntensive Individual Support Services Therapeutic IntegrationTherapeutic Integration Family trainingFamily training Environmental accessibility adaptationsEnvironmental accessibility adaptationsy py p Service coordinationService coordinationResidential HabilitationResidential HabilitationResidential HabilitationResidential Habilitation Supported employmentSupported employment
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DD WaiverDD WaiverDD WaiverDD Waiver
Developmental Disability or MentalDevelopmental Disability or MentalDevelopmental Disability or Mental Developmental Disability or Mental RetardationRetardation
Entry: Regional DDA officeEntry: Regional DDA office Entry: Regional DDA office Entry: Regional DDA office Age: Children and AdultsAge: Children and Adults Enroll in Health Choice/MCOEnroll in Health Choice/MCO
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DD Waiver ServicesDD Waiver ServicesDD Waiver ServicesDD Waiver Services Approved Plan of Care Approved Plan of Care Intensive Individual Support Services Intensive Individual Support Services Therapeutic IntegrationTherapeutic Integration RespiteRespite RespiteRespite Environmental Accessibility AdaptationEnvironmental Accessibility Adaptation Intensive Behavior ManagementIntensive Behavior Management Intensive Behavior Management Intensive Behavior Management
ProgramProgram Assistive technologyAssistive technology Prevocational servicesPrevocational services Residential habilitationResidential habilitation 2424 hour emergency assistancehour emergency assistance
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2424--hour emergency assistancehour emergency assistance
M d l W iM d l W iModel WaiverModel WaiverMust have complex medical needsMust have complex medical needsMust have complex medical needsMust have complex medical needs Technology dependantTechnology dependant
A l th 22 ldA l th 22 ld Age: less than 22 years oldAge: less than 22 years oldWould otherwise be hospitalizedWould otherwise be hospitalized Entry: The Coordinating CenterEntry: The Coordinating Center
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Model Waiver ServicesModel Waiver ServicesModel Waiver ServicesModel Waiver Services
Case ManagementCase ManagementCase ManagementCase ManagementHome health aideHome health aide
S i l di l i t d liS i l di l i t d li Special medical equipment and suppliesSpecial medical equipment and supplies Participation of MD in plan of care meetingParticipation of MD in plan of care meeting Private duty nursingPrivate duty nursingUse Red and White CardUse Red and White CardUse Red and White CardUse Red and White Card
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The Last Piece of the Puzzle . . .The Last Piece of the Puzzle . . .The Last Piece of the Puzzle . . .The Last Piece of the Puzzle . . .
EPSDT
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Maryland Healthy Kids/EPSDTMaryland Healthy Kids/EPSDTMaryland Healthy Kids/EPSDTMaryland Healthy Kids/EPSDT
VeryVery important service for children important service for children Available to all children up to 21 yrs.Available to all children up to 21 yrs.Available to all children up to 21 yrs.Available to all children up to 21 yrs.Comprehensive screeningComprehensive screeningDi i (E l ti /A t)Di i (E l ti /A t)Diagnosis (Evaluation/Assessment)Diagnosis (Evaluation/Assessment)All medically necessary treatmentAll medically necessary treatmentTherapeutic behavioral service Therapeutic behavioral service Included in all Medicaid optionsIncluded in all Medicaid options
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Included in all Medicaid optionsIncluded in all Medicaid options
Medicaid: TheMedicaid: ThePuzzlePuzzle
Eligibility
Importance
Eligibility
S i GettingServices Getting Care
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For More InformationFor More InformationFor More InformationFor More Information The Parents’ Place of MarylandThe Parents’ Place of Maryland
11 800800 394394 5694569411--800800--394394--56945694www.ppmd.org
Department of Health and Mental HygieneDepartment of Health and Mental Hygiene Department of Health and Mental Hygiene Department of Health and Mental Hygiene (DHMH)(DHMH)
11--800800--284284--45104510www.dhmh.state.md.us/mma/
Baltimore Health Care AccessBaltimore Health Care Access410410--649649--05210521www.bhca.org
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