EFFECTIVE ADVOCACY FOR HEALTH AND LONG-TERM CARE

Statewide Legal Advocate Training

Wenatchee, WA

October 9, 2018, 2:30-3:45 p.m.

CATEGORICAL

• Legal status in the U.S.?

• Age: <18, 18-64, or >64?

• “Disabled”? (not the same as “has a disability”)

• Need long-term services and supports (LTSS)?

• Eligible for Medicare?

• Pregnant?

• Emergency Medical Need?

FINANCIAL

• Whose finances count – “assistance unit” or “household”

• Income – Limits, exclusions, treatment of earned, in-kind, unusual receipts (“lump sum”)

• Resources – Limits, ownership, exclusions, transfers

PROCEDURAL

• Application

• Verification

• Review, renewal, termination, notice and appeals

ELIGIBILITY

DAUGHTER and GRANDMA are U.S Citizens (USC)

DAD and SISTER are Lawful Permanent Residents (LPR) who got their Green Cards on October 1, 2014. Sister is pregnant

MOM is a 24 year-old Deferred Action for Childhood Arrivals (DACA or Dreamer). She was recently diagnosed with a cancerous brain tumor. She is scheduled for surgery next week with possible chemotherapy to follow. Dad has filed an I-130 visa petition for her.

BOYFRIEND is a citizen of the Marshall Islands

NIECE is 12 years old and undocumented

LEGAL STATUS IN THE U.S.

LEGAL STATUS IN THE U.S.

1. What is the person’s status?

Lawfully Present?*Qualified?

*Not qualified?

Not Lawfully Present?

2. How long in status? Also, date of entry?

Does 5 year bar for federal means-tested benefits apply?

3. Public Charge Concerns?

• DAD and SISTER – LPRs, adjusted on 10/1/14• Lawfully Present and Qualified

– subject to 5 year bar for non-emergency Medicaid, unless exempt– may be eligible for Qualified Health Plan (QHP) and subsidies, Pregnant Women’s

medical (for sister)

• MOM – DACA, approved I-130• Lawfully Present (for state programs only), Not Qualified

– not eligible for non-emergency Medicaid or QHP and subsidies– may be eligible for Alien Medical Programs including cancer treatment, Medical

Care Services, Emergency Medicaid (in a hospital setting)– Public Charge may be an issue due to health condition

• GRANDMA’S BOYFRIEND, COFA migrant • Lawfully Present, Not Qualified

– not eligible for non-emergency Medicaid– may be eligible for COFA Islander Health Care (help with monthly premiums and out

of pocket expenses for QHPs purchased on healthplanfinder – starts 1/1/19)

• NIECE- undocumented• Not Lawfully Present

– not eligible for non-emergency Medicaid – may be eligible for Children’s Medical, emergency Medicaid, Alien Medical Programs

LEGAL STATUS IN THE U.S.

• DAD, 29 year-old LPR, got his Green Card on October 1, 2014. His earned income is $2,700/month MOM, 24 year-old DACA Dreamer, isn’t able to work outside home now; diagnosed with a cancerous brain tumor, she is scheduled for surgery next week with possible chemotherapy to follow. Dad has filed an I-130 visa petition for her. Mom and Dad are married and have a 6-year old DAUGHTER who

is a U.S. citizen.

ELIGIBILITY: DAD, MOM, DAUGHTER

DAD:

• 5-year bar (no Medicaid) but lawfully present

• HH size matters – claim niece as dependent?

• $2700 for 3-person HH is 159% FPL -QHP/subsidies

• $2700 for 4-person HH is 132% FPL –QHP/subsidies now

Medicaid on 5th

anniversary (Oct 2019)

ELIGIBILITY: Dad

MOM:

• Income of spouse too high for

Medical Care Services.

• AMP MAGI income limit 138% -

qualifies if 4-person HH

• AMP SSI-related income limit

is lower – MN Spenddown

required

• If Visa comes through- lawfully

present; could get QHP

ELIGIBILITY: Mom, Daughter

ELIGIBILITY: Mom, Daughter

DAUGHTER: • Under age 19, eligible

for no-premium Apple Health for Kids

(income below 215% FPL)

ELIGIBILITY: NIECE of Dad and Mom

• Under age 19, eligible for

no-premium Apple Health for Kids

(income below 215% FPL)

• Uncle’s income does not count

toward her eligibility – as a niece

she meets the Medicaid “nonfiler”

exception (WAC 182-506-0012(2)

and (3))

ELIGIBILITY: SISTER of Dad

• 32-year-old LPR, got her green card October 1, 2014, earns $4,400 per month, and provides support for her mother (Grandma), who she is planning to claim as a tax dependent on her 2018 taxes. She has been enrolled in a QHP with subsidies. Now she is pregnant and plans to reduce work hours to care for Grandma. She wants to get comprehensive, no-cost coverage.

ELIGIBILITY – SISTER of Dad

She wants advice on whether she can now qualify for Medicaid.

ELIGIBILITY – SISTER of Dad

• LPR eligible for QHP

• $4400 for 2-person HH is 325% FPL – QHP with subsidies

• Change of circumstances– “Point in time” or “income averaging” for Medicaid

– HH size of 3 for pregnancy medical

– Grandma’s income doesn’t count – dependent below threshold

– Income limit for Apple Health Preg. 198% FPL: $3,429/month

ELIGIBILITY: BOYFRIEND of Grandma• 67 year-old, citizen of the Marshall Islands. He

works outside the home part time; monthly income is $1,200. – 1-person MAU

– Income under 138% FPL ($1,397)

– Will be eligible starting in

January for COFA Islander

Health Care once he enrolls in

a Silver QHP – HCA pays

premiums, cost-sharing.

GRANDMA, 65-year-old U.S. citizen,

is on Medicare. In the first 6 months

of 2018, she worked outside the

home and earned $6,000. In July,

she began receiving Social Security

income of $900 per month. She has

no savings or other assets.

GRANDMA – DISABILITY, LEP, ELIGIBILITY AND SERVICES

GRANDMA – DISABILITY, LEP, ELIGIBILITY AND SERVICES

She recently had a stroke that left her unable to work, affected her mobility and cognitive functioning, and affected her ability to speak and understand English, her second language. She can now communicate more effectively in her native language. She needs help with dressing, bathing, and eating; reminders to take medications; and transportation to medical appointments. She wants to remain at home.

Language Access

Federal:• Title VI of the Civil Rights Act of 1964• Federal HHS “Guidance to Federal Financial Assistance Recipients Regarding Title VI

Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons” (2002) (www.lep.gov)

• Section 1557 of the Patient Protection and Affordable Care Act (2010)State:• Health Care Authority: 182-503-0110• Department of Social and Health Services WAC 388-271-0010; WAC 388-271-0030• Washington Law Against Discrimination RCW 59.60Other:• Reyes Consent Decree (1991)• National Standards for Culturally and Linguistically Appropriate Services (CLAS) in

Health Care in December 2000, Language Access Standards 4 – 7.

See handouts on Section 1557 summary of language access requirements both for LEP and Deaf individuals, as it relates to communication access/ effective communication.

What kind of language services?

• DSHS – Oral communication (WAC 388-271-0020)

• bilingual staff (testing); • Qualified interpreter services (phone or in-person); timely, free of

charge.

– Written communications (WAC 388-271-0030)• Fully translated written communications in primary language

– Applications, IRP, forms

• HCA WA Apple Health (WAC 182-503-0110 and RCW 74.04.025)Healthplanfinder: application in English & Spanish Health Benefit Exchange – multilingual taglines & limited resources in 20 languages.

What kind of language services?

What benefits can Grandma get?

• QMB: monthly income is < $1,012 per month

https://www.washingtonlawhelp.org/resource/qmb-slmb-qi-1-and-qdwi-programs-help-with-med?ref=MGMfj

• Medicare Pt. D Low Income Subsidy (LIS or “Extra Help”) for prescription drugs

https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/save-on-drug-costs

• COPES

https://www.washingtonlawhelp.org/resource/questions-and-answers-on-the-copes-program?ref=BEzxX

How can COPES help Grandma?

• First, DSHS has to declare her financially eligible. (Hint: she is.)

• After that, a case manager will conduct an assessment in the home.

• The assessment looks at the help she needs with what are called Activities of Daily Living, like eating, dressing, and taking her medication.

• If she qualifies, the assessment will authorize her to hire one or more caregivers to help her for a certain number of hours per month.

• She can hire a home care agency to send caregivers or she can hire an individual provider. https://www.washingtonlawhelp.org/resource/questions-and-answers-on-the-community-first-choice-program?ref=i1U0q

Community Options Program Entry System.

Will Grandma have to pay for Caregivers?

• No. Her income is less than $1,012 per month. $1,012 per month is the income ceiling for a single person.

• If her income was over $1,012, she might have to contribute some of that income to pay for her care.

What is estate recovery?• A person who receives COPES (as well as some other kinds of

Medicaid benefits) incurs a debt for the cost of that care which may have to be repaid by the person’s estate.

https://www.washingtonlawhelp.org/resource/estate-recovery-for-medical-services-paid-for?ref=kpjFl

Are there other personal care services programs?

• Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) which are intended to provide support to forestall enrollment in traditional long-term care programs like COPES.

https://www.washingtonlawhelp.org/resource/questions-and-answers-on-the-tailored-supports-for-older-adults-tsoa-and-medicaid-alternative-care-mac-programs?ref=SFXlI• Medicaid Personal Care • New Freedom• PACE• Roads to Community Living

These last four programs each have less than 800 clients.

What if Grandma was or within the Five-year Bar?

• There is a small, capped, state-only funded program for undocumented or otherwise Medicaid-ineligible immigrants who need personal care.

• As of October 1, 2018 there are:

o 6 are receiving services in their own homes

o 18 are receiving services in the community

o 20 are receiving services in nursing homes

There is a lengthy waiting list to get these state-funded benefits. 103 people are on the wait list. One person has been waiting since April 2014.

PROCEDURE: APPLICATION

MOM , 24 year-old DACA Dreamer, is scheduled for cancer surgery next week with possible chemotherapy to follow. She tried to apply for coverage through Washington Healthplanfinder but was having a hard time understanding the application process.NIECE, who is 12 years-old, lives with Mom and Dad. She is undocumented. GRANDMA already has Medicare, but in order to remain in her home after her stroke needs help with her mobility, dressing, bathing, and eating; reminders to take medications; and transportation to medical appointments. The stroke has also affected her cognitive functioning and her ability to speak and understand English, her second language. Dad’s SISTER is a 32-year-old LPR who got her green card October 1, 2014. She works outside the home, earning $4,400 per month and providing support for her mother (Grandma), who she is planning to claim as a tax dependent on her 2018 taxes. She has been enrolled in a QHP with subsidies. Now she is pregnant and plans to reduce work hours to care for her mother. She wants to get comprehensive, no-cost coverage. She wants advice on whether she can now qualify for Medicaid.Grandma’s BOYFRIEND is a citizen of the Marshall Islands who works outside the home part time, earning $1,200 monthly

PROCEDURE: APPLICATION• Application for Qualified Health Plans is possible only during annual Open

Enrollment unless Limited Special Enrollment reasons.

• State encourages use of https://www.wahealthplanfinder.org to apply, but there are challenges:

– Application for some kinds of assistance not well-supported by Healthfinderbecause they require further information about applicant’s health conditions –AEM (MOM) , Long-Term Care (GRANDMA)

– On-line application is only available in English and Spanish, possibly creating obstacles for GRANDMA and BOYFRIEND.

– Customer service support has diminished, creating obstacles for LEP people (GRANDMA and BOYFRIEND), people with disabilities (GRANDMA), and immigrants who have questions about what to put on the application and how to enroll in a plan (MOM, BOYFRIEND, NIECE)

– Report changes in circumstances through Healthplanfinder (SISTER)

• DSHS and Health Care Authority systems for LEP access and accommodating disabilities

• Navigators to help with application and enrollment process

• Effective dates vary

MEDICAID SERVICES - DELIVERY

• Most are through Managed Care Organization (MCO or Plan) through “Apple Health Managed Care”

– Statutes, regulations, HCA contracts with MCOs, and benefit books for clients (called “enrollees”)

– “Integration” of physical and behavioral health being expanded to most of state effective 1/1/19.

• Some services, including dental through 6/30/19, are still “fee for service”

MEDICAID SERVICES - DECISIONS

• The service must be “covered” for Medicaid recipients generally and “medically necessary” for the individual.

• Services are more broadly covered for children and youth through age 20 under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) mandate

• The MCO or agency may require prior approval, denial of which is subject to in-plan appeal, administrative hearing, and judicial review

MEDICAID SERVICES for DAUGHTER

• DAUGHTER is 6-year-old eligible for Medicaid and has cerebral palsy. Her medical providers have recommended physical and occupational therapy to help improve her strength and assist her in eating independently. Mom and Dad do not have a car and they are concerned about how the daughter is going to get to and from her therapies

SERVICES FOR DAUGHTER

• Under Early and Periodic Screening, Diagnosis and Treatment, any services for

daughter that are medically necessary

should be covered, even if they are

not included in the state plan.

• The state also has a duty to “arrange

for” care.

• States must offer transportation to and from medical appointments