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Introduction to PRIVATE Living ARRANGEMENTS (PLA) Medicaid PLA is assistance provided for eligible individuals living in his/her own home or an adult care home who can't afford the cost of health what IS MEDICAID? Medicaid is a program that pays medical bills for eligible low income people who can't afford the cot of health care. The programs cost are paid by federal, state and county taxes. how is Medicaid different from Medicare? Medicare is health insurance for people over 65 and some disabled people. It is run by the federal government through the Social Security Administration. It has two parts: Part A (hospital insurance) covers inpatient care, skilled nursing facility care, home health care and hospice care. Part B (medical insurance) covers doctors' services, outpatient hospital service, and some other services not covered by Part A. Medicaid is a medical assistance program for low-income people. It is run by the state through the Division of Medical Assistance in the Department of Human Resources. It is base on federal and state regulations. To be eligible a person must meet income and assets limits and be aged, blind, disabled, a member of a family with dependent children, or a pregnant woman. Some people are covered by both Medicare and Medicaid. Medicaid pays the Medicare deductible and co-insurance and the Part B premiums for persons eligible for both Medicare and Medicaid. where and how do I apply? Apply at the county department of social services in the count yin which you live. you must sign an application form and give certain information about yourself and your family. The County agency will determine if you are eligible. Items you should take to the county agency when making an application include
what are my rights? Anyone who believes he/she is eligible may apply at the county social services department. Any person who meets the eligibility requirements and has a medical need should receive assistance. The county must determine if you are eligible within 45 days of your application (or 60 or 90 days if you are disabled). If the agency has not made a decision on your application by the 45/60/90 day limit and your application is approved, you may receive a payment for each week the agency was responsible for the delay. Any person who is dissatisfied with a decision by the county social services department may appeal. The hearing is held by the local agency except for decisions concerning disability. These are held by a state hearing officer. If you are dissatisfied with your local hearing you may also appeal to the state. Any person dissatisfied with the decision of the state hearing officer may go to court. Eligible recipients are not required to pay any portion of medical bills which are covered by the N.C. Medicaid Program and for which the provider has agreed to bill Medicaid. If you receive a medical bill that you think should have been paid by Medicaid, you may ask for a review by the State. To ask for a review, call 1-800-662-7030 or write and send the bill to: Division of Medical Assistance If you use Medicaid to pay your medical expenses but cannot arrange medical transportation on your own, you are entitled to help from the department of social services in arranging or paying for medical transportation. Contact your county department of social services and a caseworker will help you set up a plan. If you use Medicaid to pay your medical expenses, you are entitled to the same quality of health care that is available to the general public. Both federal and state laws require that the information you give is kept confidential. The N.C. Department of Human Resources does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. You can get information about state and federal laws against discrimination and about how to file an official complaint from your county social services department. If you are denied Medicaid eligibility because 1. You transferred assets or 2. Because of the value of real property you own with others (not your spouse or financially responsible parent) or a non-essential motor vehicle You have the
right to prove that the value of the resource is less than the value
determined by the county department of social services. If you can establish
a lesser value, it could result in
your being found eligible. The county department of social services will
advise you of what is acceptable proof of value. What are my responsibilities? If you receive Medicaid, you
must
It is against the law to willfully fail to tell the county department of social services the name of any person, organization, or insurance company who pays or who has paid for any services billed to Medicaid. It is also against the law to let anyone whose name is not printed on your Medicaid card use the card to have Medicaid pay for his medical services. Additionally, your social security number will be used to match against the files of other agencies such as the Social Security Administration, Employment Security Commission, and the Internal Revenue Service. Reports of information in these matches will be sent to the county department of social services to use in determining your eligibility for Medicaid. Also, you may be able to reduce the countable value of your assets by the following: -You may set aside up to $1500 of your assets for burial. All assets will count until the designation becomes final and you no longer have access to the assets. -You may prove that the value of some assets, such as motor vehicles or real property owned with others has a value less than the tax value. Ask your worker for details on the above to help you become eligible. TALK TO YOUR WORKER BEFORE YOU TRANSFER ANY REAL OR PERSONAL PROPERTY OR LIQUID ASSET. A transfer of assets could make you ineligible for up to three years. Who is eligible for Medicaid? 1. Clients who receive checks for: a. Aid to Families with Dependent Children (AFDC) b. Special Assistance to the Blind (SAB) 2. Others who may be eligible are: a. Persons receiving State/County Special Assistance for Adults (S/C SA) b. Persons receiving Supplemental Security Income (SSI) c. Other aged (65 and older), blind or disabled persons who have limited income and other assets d. Families with children under age 21 when their income and assets are low e. Children under age 21 in homes of non-relatives, foster homes, or private non-profit child caring agencies f. Single or married pregnant women who have low income and assets g. Children receiving adoption or foster care assistance What services are covered? 1. Hospital inpatient- Pre -Admission Review is required before you can be hospitalized for non-emergency care under Medicaid. Your medical condition is reviewed by medical professionals to determine if hospitalization is medically necessary. Certain surgical procedures must be done on an out-patient basis unless your medical condition requires you be hospitalized. Ask your doctor about Pre-Admission Review if you are to be hospitalized. 2. Inpatient laboratory and x-ray service 3. Hospice Care 4. Care through home health agencies 5. Services of a nurse midwife 6. Treatment in: a. Psychiatric hospitals (under age 21 and over age 64) b. Mental health center 7. Six (6) prescription drugs per month including insulin 8. Medical examinations and treatment for children and teenagers (under age 21) 9. Annual physical examinations for adults 10. Medically necessary ambulance transportation to nearest appropriate facility 11. A total of 24 visits per year will be covered from a combination of the following services. Some restrictions exist. Prior approval is required for some services. Your doctor will know which ones.
12. If you become ill while in another state, Medicaid will pay for your emergency care if the medical providers bill the State. The following services are covered with prior approval: 13.
Non-emergency care provided out-of-state more than forty miles from
14. Care in a skilled nursing or intermediate care facility 15. Durable medical equipment, such as hospital bed, wheel chair, etc. 16. Limited dental services and medically necessary orthodontia for children 17. Eyeglasses 18. Hearing aids (under age 21 only) 19. Personal care services in the home Note: People
with certain life threatening illnesses are exempt from the physician and
prescription limitations. Healthy Children and Teens program (8. above),
annual physical exams for adults (9. above), prenatal care, and emergency
room visits are also exempt. how to meet a deductible?
Helpful links Social Security Administration www.ssa.gov/ Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration or HCFA) www.hcf.gov/ Prescription drug assistance www.needymeds.com
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