Medicaid Eligibility Changes Are Here – Miller Trusts and Community Medicaid Impacted

After several months of planning and ongoing dialogue with Indiana Medicaid, changes to Medicaid eligibility for the disabled have taken effect on June 1st.  The major impacts of the changes are the elimination of the spend down option, the reliance on SSI and SSDI determinations for purposes of determining disability, the requirement for Miller Trusts for institutional patients or waiver patients, and the utilization of Medicare Savings Program for dual eligible patients between 100% of Federal Poverty and 185% of Federal Poverty.

• Impact on Community Medicaid

Though the spend down program was at times burdensome for patients and providers, the lack of a spend down program has real impact on those “community” Medicaid members that had access to nursing facility services under spend down.  Without spend down, an individual that makes more than 100% of Federal Poverty ($973/month) will not be eligible for Medicaid services unless they are SSI/SSDI.  Though not an everyday occurrence, nursing facilities that provided care to community Medicaid members for short term stays under the spend town program will find that those patients are no longer eligible.  Two examples of impact have come up recently from Indiana nursing facilities:

1.  Patient was not admitted to the hospital for the 3-day qualifying stay under Medicare and could not obtain Medicare coverage for the nursing facility stay and, while dually eligible under spend down, will not be eligible for Medicaid as of June 1 because the patient has income greater than 100% of Federal Poverty ($973/month).   Though the patient would be eligible for certain outpatient services paid for by Medicare and for premium and coinsurance support through Medicare Savings Program, the patient is not able to access nursing facility services under spend down and instead would have had to elect to be fully institutional and pay all income towards liability, less any deviations and Personal Needs Allowance.

2.  Patient had been admitted to the nursing facility as a Medicare patient and came to the end of the 100-day period, however needed a few more weeks or rehabilitation.  The has planned to utilized spend down as a community Medicaid member and did not want to become fully institutional as the patient would have lost all income to pay liability leaving no income to pay her rent for the apartment the patient intended to return to in a few weeks.

These examples illustrate the impact of spend down elimination on patients that do not elect, or should not be, fully institutional patients.  Nursing facilities should begin discussions with their hospital discharge planners and other hospital personnel to fully prepare for future patients that will certainly fall into these and other scenarios.

• Miller Trusts

As of close of business on May 29th Indiana Medicaid had completed 1,083 Miller Trusts that had been submitted.  There were 63 pending review at Indiana Medicaid’s legal office and 9 had been submitted to DFR and not yet turned over to Indiana Medicaid’s legal office.  The agency is not delaying implementation and termination of benefits will occur effective June 1st if Medicaid members that need Miller Trusts fail to submit the required documentation to their DFR caseworker by June 30th.  The implementation process for Miller Trusts has been frustrating as it has been difficult to follow guidance provided by Indiana Medicaid and often times determinations from DFR have not followed the guidance Indiana Medicaid issued.  IHCA has been informed that DFR personnel continue to be trained and issues that have been popping up are being corrected by DFR supervisors and regional managers.  Though that is a time consuming process, the hope is that with time the process will be smoother.

As to the termination of benefits effective June 1st, IHCA received answers to the following questions on May 29th that address submission of Miller Trust applications by June 30th and the seeking of guardianships for the same purpose.  The answers to the following questions were supplied by Tiffany Mulligan, General Counsel to the Family and Social Services Administration:

1.   Does the Miller Trust need to be approved by FSSA by June 30 in order for benefits to be reinstated effective June 1, or can it just be submitted by June 30 in order for benefits to be reinstated?

Answer:  For any member who may be experiencing an interruption in benefits on June 1 due to not having a Miller Trust, he or she can have eligibility for June reinstated by submitting a Miller Trust by June 30. The trust does not need to be approved for the reinstatement of benefits for June. While the trust is being reviewed, we will continue to consider the member eligible. If the trust is not approved, we will notify the member at least 10 days prior to losing eligibility, and the individual will obtain all appeal rights.

2.     Does the Miller Trust need to be in absolute compliance when submitted, or can it be modified after submission to meet FSSA requirements?  If so, which aspects can be modified after submission and which cannot?

Answer:  If the trust is incomplete (i.e. the trust is unsigned, does not include supporting documentation), our office (Office of General Counsel) will send it back to our Division of Family Resources and ask for additional information.  If the trust is invalid, we will send it back to DFR and recommend rejection of the trust.  As I understand it, in both cases, DFR will send the individual a pending verification form, which will list any problems with the Medicaid application.  DFR gives individuals 13 days to return the application with additional or corrected information.  They discontinue or deny eligibility if they don’t receive a response within the 13 day time period.  If they do receive additional or corrected information, DFR will consider the additional information. 

3.     Is the filing of a petition for guardianship that includes a Miller Trust adequate to continue the application, or does the court need to affirm by June 30?

Answer:   If the person has filed a petition for guardianship with a Court and attaches a Miller Trust that will be established for the individual by June 30 if the guardianship is approved, we will go ahead and process the application.  We do not wait for the court to affirm the guardianship.  A legal guardian may not be necessary if there is medical documentation showing the person is incapacitated and a family member is acting on behalf of the individual to establish the trust.  Further, we are allowing Authorized Representatives to create Miller Trusts for members as well as people who have power-of-attorney for the Medicaid member.

• Medicare Savings Program

Dually eligible patients above 100% of Federal Poverty and not disabled per SSI/SSDI are eligible for Medicare premium and copayment/coinsurance support through the Medicare Savings Program.  The premium support ends when income hits 150% of Federal Poverty, but support for Part B costs continue until income hits 185% of Federal Poverty.  All current Medicaid beneficiaries that are above 100% of Federal Poverty were to be automatically enrolled in the program as of June 1st.  Future enrollees must affirmatively enroll in program.   For more, see FAQs 22-35 at http://www.in.gov/fssa/ddrs/4861.htm#Transition_dual.

If you have questions about the eligibility changes or need assistance with Indiana Medicaid or DFR concerning an application or issue, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.