32 Miss. Code. R. 22-3.4 - COMMUNITY REHABILITATION PROGRAMS

I. Grants/Scholarships (non-merit), which do not have to be repaid (See the Post-secondary Education Services section of this Resource Guide for further information.)

Medicaid - Medicaid is a Federal-State supported program which helps pay for medical services for low-income families. This is NOT an insurance program. It is supported by special appropriations made by the United States Congress and the State Legislature from general revenue Federal and State tax funds. The program varies from state to state.

If a doctor or medical facility refuses to accept Medicaid or Medicare, the counselor is required to direct the client to another physician or facility that will accept these third-party payers.

This is a very comprehensive, technical, medical assistance service program. Benefits change often (almost constantly for certain benefits) depending upon the availability of appropriated funds and current needs demand.

Eligibility is primarily based upon economic need although age, disability, and dependency (Temporary Assistance for Needy Families - TANF) are also factors to be considered. All SSI beneficiaries are eligible for Medicaid. All eligibility factors and benefit allowances are subject to change or termination at any time.

Some services currently provided are prescription drugs, clinic visits, lab tests, physician office visits, dental care, ambulance transportation, surgery, hospitalization, home health care, and family planning.

Medicaid does have some limitations such as deductibles, co-payments, per diems with limitations on number of days, and upper limit fees for all medically approved service procedures. For example, a recipient may be provided 30 in-patient hospital days in one calendar year. VR does not pay for deductible, co-payments, etc.

The recipient CANNOT be charged more than the established co-payment and/or deductible. The vendor must accept the established upper limit payment less the co-payment and/or deductible as payment in full for services rendered.

Under the HealthMACS program, the individual may choose a particular doctor or health care facility from a list of HealthMACS providers to be his/her primary health care provider. Medicaid benefits stay the same under the HealthMACS program.

The Agency may not supplement any Medicaid covered service but may purchase other uncovered, services, which are deemed vocationally necessary. When a client has both, Medicaid may be used to supplement Medicare. The VR counselor must always determine a client's current Medicaid status. To do this, write the Mississippi Medicaid Commission at Sillers Building, 550 High Street Suite 1000, Jackson, MS 39201-1399 or telephone: 601-359-6050 or toll free: 1-800-421-2408.

III. Medicaid - Disabled Child Living at Home - A child with a disability(ies) age 18 or under who lives at home may qualify for Medicaid if the following conditions are met:

IV. Medicaid - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) - Individuals under age 21 who are on Medicaid are eligible for EPSDT services. Medicaid will provide a comprehensive physical assessment, vision and hearing tests, immunizations (as needed), blood and urine tests, nutritional and developmental assessments, and health and developmental history.

The Medicaid Commission also provides, on an as needed basis, referral to a doctor for health problems; visual examination and glasses; hearing examinations and hearing aids; adolescent counseling and case management; and all other medical services for which a Medicaid recipient is eligible. It also provides, based on medical need, in-patient hospital services and rehabilitation hospital services.

V. Medicare - Medicare is administered by the Social Security Administration. It is a Federal government health insurance program for people 65 and older qualifying for Social Security payment benefits. Individuals with disabilities under age 65 drawing SSDI payments are eligible for Medicare benefits after receiving disability benefits for two years; chronic end-stage renal dialysis patients are eligible after three months after the month dialysis begins or the month of kidney transplant surgery.

VI. Mississippi Department of Health - Children's Medical Program (CMP) - CMP provides financial assistance to Mississippi families of children (birth - age 21) with special health care needs. The program is habilitative or rehabilitative; its goal is the correction or reduction of physical handicaps. It also provides assistance to the family in finding other available community resources.

Factors such as family size, income, and assets as well as the estimated total cost of treatment services determine financial eligibility for treatment services.

General categories of medically eligible conditions under CMP include, but are not limited to, the following: cleft palate, congenital heart defects, and congenital defects of the nervous system, cerebral palsy, cystic fibrosis, gastrointestinal defects, genitourinary defects, hemophilia, orthopedic conditions, scoliosis, seizure disorders, sickle cell, and spina bifida.

Certain conditions are NOT eligible under CMP. These include, but are not limited to, the following: acute illnesses (e.g., flu, measles, colds, broken bones, etc.), allergies, asthma, flat feet, hyaline membrane disease, malignancies (except where a secondary reconstructive procedure is indicated), mental disorders, rheumatic fever and heart disease (except where surgery is required), speech conditions (other than cleft palate), and spinal cord injuries.

Services provided include: clinic services, hospitalization, surgery, physical therapy, artificial appliances and limbs, wheelchairs, medication, evaluation, treatment and follow-up for any eligible condition. Hospitalization is limited to 20 days per year. CMP utilizes the usual and customary rate schedule with payment at 50 percent of that rate. Medicaid and private insurance must be the first sources of payment. CMP will not pay until all insurance has been utilized. Applications for CMP are available through the local county health department.

VII. Mississippi Workers' Compensation Commission - Workers' Compensation (WC) is a no-fault insurance plan paid for by employers and supervised by the State. Almost every working Mississippian is protected by the Workers' Compensation Act, but there are a few exceptions, such as persons employed by a company with fewer than five employees. There is no "waiting period" for coverage; the employee is covered from the date of employment. There is no deductible to be met by the worker or the employer. Any injury or illness that is job-related is covered. This Act guarantees three kinds of benefits - medical services and supplies, cash payments for lost wages, and rehabilitation services.

Medical services include, but are not limited to, the following: treatment by physicians and surgeons, mileage for out-of-town doctors' appointments, hospital and nursing services, medicine, physical therapy, and crutches. The employer's insurance company makes payments directly to the medical service provider.

The employer's insurance company makes cash compensation payments for lost work time. If the employee is off work for less than 14 days, medical benefits, but not cash compensation payments, are paid for the first five days. If the employee misses more than 14 days, cash compensation payments are made beginning with the first day he/she is off work. The time an employee receives cash benefits varies according to the extent of the injury and the loss of wages. The maximum length of time for cash benefits to be paid, as established by State legislation, is 450 weeks. The worker will not receive the full amount of his/her paycheck. Cash benefits can be as much as two-thirds of the worker's average weekly wage, up to a maximum set by the legislature, but workers' compensation payments are tax-free.

In order for the Agency to be reimbursed for service expenditures which should have been covered by Workers' Compensation, the counselor will need to send a letter to the client's/claimant's attorney with copies to the insurance carrier and the Workers' Compensation Commission. This letter should detail the service(s) provided, amount paid by the Agency for each service and request reimbursement for the specified costs once the claim has been settled.

VIII. Private Hospital and Medical Insurance - When planning physical restoration for a client who has private hospital and/or medical insurance, the counselor will advise the hospital personnel and the physicians involved that the client has insurance and provide the name of the insurer, if available. The counselor will remind all vendors in the case that the acceptance of the insurance benefits or the Agency authorization is optional. The counselor will call their attention to the advantages and disadvantages, the procedure, and their responsibility in each situation. The counselor will also advise the client of the hospital's and doctor's options, explain the Agency's position, limitations of responsibility, authority, etc. The counselor must also advise the client that he/she has the right to decline services offered by the hospital and/or the doctors if they reject the authorization and accept the insurance benefits making the client responsible for possible additional costs. The option MUST be exercised no later than the time of hospital admission and/or before any service is rendered.

If the decision is to refuse the authorization and accept the insurance benefits in lieu thereof, the hospital administrator (or representative) and the physicians involved must assume responsibility for advising the client (patient) of the decision made and work out an acceptable plan for payment of any possible cost difference. The refusal to accept authorizations as co-sponsor relieves the Agency of all responsibility for the services involved.

If the decision is to accept the authorization and to use any insurance benefits the client may have toward paying for the services, the Agency is obligated only for the amount authorized in keeping with current Agency per diems and/or fee schedules less any amount the insurance company pays. The authorization must show the total costs less the amount the insurance will pay (as close as the counselor can determine at the time the authorization is issued) and the net amount to be paid by the Agency.

The client will be instructed to notify the counselor when he/she enters and is discharged from the hospital. The counselor will advise the client to take his/her insurance policy/identification card to the hospital at the time of admission.

The Agency authorization covers all services in the hospital contract per diem and/or the current established fee schedule. If it is accepted, the hospital will not bill the client for any additional charges. The client should inform the counselor if he/she receives a bill for services that have been authorized. The counselor will assume responsibility for follow-up on cases where reimbursements are due. The Statement of Account will not be processed until all insurance benefits have been paid. In case the total number of days authorized is not needed, the unused per Diem should be canceled. If the physician determines additional hospitalization is required and informs the counselor, a supplemental authorization may be issued for the additional days. (See the OVR/OVRB Fee Schedule for exceptions to the per diem.)