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What is Medicaid?
Medicaid comprises a group of programs that provide health insurance to Colorado residents who meet the income and resource criteria for eligibility. Medicaid provides coverage for among others, physician services, prescription drugs (not covered by Medicare Part D), inpatient/outpatient hospitalization, durable medical equipment, laboratory and x-ray serves, medical supplies, medical transportation, podiatry, hospice, immunization and home health care.
How is Medicaid different than Medicare?
Medicaid goes to persons of all ages who meet low income and other guidelines. It provides a broader range of services than Medicare.
Medicare covers most people over age 65, regardless of income. The primary benefits are doctors' office visits and hospitalization. Home health and nursing home coverage are extremely limited.
Who Qualifies for Medicaid?
Medicaid offers a program called Consumer Directed Attendant Support Services (CDASS) that allows individuals to have an extremely high level of control over their Medicaid funded home health services. CDASS is open to individuals who are eligible for Home and Community Based Services (HCBS). What this means is individuals who receive CDASS will be assigned an individualized monthly allocation of funds that can be used specifically for hiring and paying for attendant services.
Medicaid is required by federal law to engage in an estate recovery program to recoup the costs of providing medical coverage to individuals who are 55 or older, own property and receive Medicaid. Colorado has exempted estates where there is a surviving spouse or a child under 21 or a blind or disabled dependent.
Individuals who are receiving Medicaid may enroll in a Medicaid Managed Care Organization or the Primary Care Physician Program. Individuals who receive both Medicare and Medicaid are not required to enroll in a Medicaid Managed Care program.
1. Medicaid Managed Care Organization (MCO).
Home and Community Based Services (HCBS) is the umbrella under which Medicaid pays for medical care and services for those who are not eligible for straight Medicaid, but are unable to afford the needed services. When HCBS is referenced in context to seniors, usually it means the Elderly, Blind and Disabled (EBD) program, though HCBS programs exist for children, the mentally disabled, those with brain injuries and those with AIDS.
Any person receiving Medicaid can receive home health care services, provided theindividual meets the eligibility requirements. To receive home health services, the indivudal must need medically necessary services (as defined by a physician) for the treatment of an illness, injury or disability (including mental disorders); the amount, duration and frequency of service must be reasonable; the services must be part of the care plan; care must be provided on an intermittent (not 24-hour) basis, and the only alternative to home care is the hospital or emergency room.
Medicaid's Options for Long Term Care agencies (also known as Single Entry Points) are the administrative agencies responsible for approving functional requests for long term care, including nursing home placement, Home and Community Based Services, Home Care Allowance, Adult Foster Care, assisted living placement and Consumer Directed Attendant Support Services. There are 23 such agencies in Colorado, each responsible for specific counties.
The Program of All-inclusive Care for the Elderly (PACE) is a program designed to offer comprehensive health services and in-home care, including supportive services to help individuals maintain independence in the community for as long as possible. It is only open to dual eligible individuals, receiving both Medicare and Medicaid who are over age 55 (including those disabled Medicare beneficiaries between 55 and 65).
PACE is funded as a capitated health plan through Medicare for Medicaid clients. The program is subcontracted out for the full continuum of care. As of 2013, three providers with limited services areas provide PACE:
- Total Longterm Care
• Chambers Center, 3551 N. Chambers St, #A-D, Aurora, 80011 303-375-0649
• Cody East and West, 8405 W Alameda Av, Lakewood, 80226 720-974-5400
• Capitol Center, 200 E. 9th Av, Denver 80203 303-894-0144
• Pinnacle Center, 445 East 124th Av, Thornton, 80241 303-327-1189
When Medicaid recipients enter a nursing home, the Pre-Asmission Screening and Review (PASRR, pronounced pay-sar) assessment is done to determine whether they have been appropriately placed for care. It is often done in conjunction with the ULTC 100.2 and other associated forms for long term care planning by the Options for Long Term Care agency.
Spousal protection is a program designed to allow a married individual to receive long term care from Medicaid (in PACE, CDASS, HCBS or a nursing home), without requiring the spouse to divest of all income and resources for ongoing living expenses.
To get Medicaid services for long term care, an individual must have income less than 300% of the federal poverty level or $2,130/month and have resources less than $2,000 ($3,000 for a couple). If the individual has more than $2,130, they will need to apply for a Medicaid Qualifying Trust.