Medicaid Case Management: Helping Individuals and Families Thrive

Health insurance is the number one way to protect yourself and your family from high, unexpected medical costs. However, for many low-income individuals, the prices of standard marketplace care are out of the question. The average annual health insurance premium for an American individual is an astronomical $8,435. For anyone living paycheck-to-paycheck or struggling to remain housed, this extra fee could put them over the edge into homelessness.

Luckily, the high costs of health insurance were partially addressed in the Social Security Amendments of 1965, which created Medicaid. A joint program between the federal and state governments, Medicaid (alongside Medicare for adults 65+ or those with certain disabilities) provides health coverage and related services for low-income individuals and families.

Since its inception, Medicaid has become an essential piece of the American healthcare system. A significant portion of the population depends on them for the most basic of services. Managed care is increasingly more common. As these programs grow in usage, they also become more and more complex.

Non-profits, social workers, and case workers require a good understanding of the Medicaid operation. However, additional tools can boost the ability to work within Medicaid itself to ensure your clients remain compliant. A flexible Medicaid case management software is indispensable and PlanStreet more than fits the bill. Let’s discuss more about Medicaid and how to best navigate Medicaid case management.

Medicaid Customer Service and More Information

Any case managers in healthcare services will need to learn the information for Medicaid in their state. Since the program is funded by both states and the federal government, each state has its own Medicaid program. Make sure that you’re working with the correct Medicaid office for your state. The American Council on Aging has an exhaustive list of every Medicaid phone number linked by the state.

How to Qualify for Medicaid

Medicaid eligibility can be tricky because it can change from state to state. Be sure to look at the rules on your state’s website. For example, the state of California’s Medi-Cal program has the following eligibility requirements for participants, who must be one of the following:

Over the age of 65
Pregnant
Blind or disabled
Under the age of 21
A refugee
Receiving benefits from a qualifying program, such as CalFresh, CalWorks, or Refugee Assistance.

Apply for Medicaid Year-Round

Medicaid doesn’t fall under the rules of regular health insurance. If you’re eligible for the program, you can apply for Medicaid at any time. The federal government has several enrollment strategies to ensure that everyone eligible for Medicaid or CHIP (the Children’s Health Insurance Program) receives the care they need.

Presumptive Eligibility: Individuals who are likely to be eligible for Medicaid can be enrolled before their application is finalized.
Express Lane Eligibility (ELE): Certain enrollment in other government agencies automatically approves an individual or family for Medicare.
Continuous Eligibility: Children are given continuous eligibility for a year, even if the family’s income fluctuates.
Lawfully Residing Immigrant Children and Pregnant Women: The previous five-year wait limits for immigrants who are children or pregnant women to enter Medicaid have been removed.

What is Medicaid Case Management?

The world of Medicaid is layered and complicated. For those who are entering a medical assistance program for the first time or for those who just want the best care available for themselves or a loved one, it can help to have a guide.

Medicaid case management is a service that helps Medicaid enrollees make the most of the opportunities afforded to them for medical, educational, and social services. Case managers are industry professionals who have a variety of tools and resources available to advocate on their client’s behalf with the hope of providing the services that are best suited to these individuals. Case managers have a good understanding of the community and local services that are available to their enrollees making them uniquely positioned to maximize the care of their clients.

Case managers will work with clients to identify specific goals and needs and then develop a plan to achieve those goals.

Medicaid offers many beneficial health and long-term care services that many other types of health insurance don’t. These additional benefits are typically handled by a case manager. For example, Medicaid offers non-emergency medical transportation to ensure that clients can get to and from an appointment. A case manager ensures these specialty services are instituted and paid for through Medicaid for their clients.

What Services Does Medicaid Case Management Cover?

Medicaid case management services help beneficiaries receive access to care and other services required under the umbrella of medical, social, and educational needs. Occasionally, individuals enrolled in Medicaid need more individualized services. Anyone with a chronic mental illness or who may have developmental disabilities will receive “targeted” services to better meet their needs.

Case managers work within their local systems to provide services for their clients in the following areas.

Medical services: Set up doctor’s appointments, tests, and other vital services.
Mental health services: Connect individuals to therapists, psychologists, and psychiatrists.
Specialty referrals:
Education needs and services: Intensive advising to students who may be at risk, in the foster care system, or have special needs.
Psychosocial services: Support that covers all of a child or adult’s needs: emotional, social, mental, and spiritual.
Durable medical equipment (DME) and supplies: This includes all of the equipment needed to care for yourself at home, everything from crutches to medical beds to blood sugar meters.
Financial assistance: Case managers connect low-income people to Medicaid to ensure they can receive healthcare at a lower rate.
Medical transportation: Ensuring that every person gets to and from their appointment safely. Not everyone under Medicaid can drive themselves or own a car, and this guarantees they receive the care they need.
Community resources: Non-profits, programs, jobs, and other related services local to the individual to help them feel integrated into their community.

What Is the Medicaid Waiver Program?

Federal guidelines have provided an avenue for states to develop community-based services waivers (HCBS waivers) to better meet the long-term care goals of individuals who prefer to seek care in their own community or home as opposed to a hospital or institutional setting. The waivers must target a specific group and states can operate as many waivers as they wish.

The Medicaid website outlines the four criteria for waivers under federal guidelines. The waiver programs must:

Demonstrate that providing waiver services won’t cost more than providing these services in an institution.
Ensure the protection of people’s health and welfare
Provide adequate and reasonable provider standards to meet the needs of the target population
Ensure that services follow an individualized and person-centered plan of care

Some of the services of care that are often covered under these waivers include case management, home health aides, adult day health services, personal care, and respite care. While these are the most common, states can propose other types of care that they believe will help individuals which is a unique feature of the waiver program. Essentially, these HCBS programs allow states to tailor resources to more specialized groups.

PlanStreet: Comprehensive Medicaid Case Management Software for Nonprofits

Comprehensive Medicaid case management software is one of the primary tools that Medicaid case managers use to ensure the highest quality care for their clients. PlanStreet is an industry-tested case management system that can help Medicaid waiver providers address billing needs, scheduling of services, invoicing, and identifying and correcting organizational inefficiencies.

PlanStreet’s case management software’s strengths include:

Efficiency: Tools to assess how staff’s time and resources are being used and how they can be maximized to help clients the most.
Invoicing: Provides in-the-moment looks at payment authorizations and pending invoices so that a clear and accurate financial picture is available.
Flexibility: PlanStreet works with all Medicaid waiver types including Level 1, individual options, and self-waivers.
Scheduling: The ability to automate staff schedules, manage time, and keep track of client meetings.
Payroll: Keeps track of billable vs non-billable hours and efficiently tracks payroll hours.

PlanStreet excels in its ability to be flexible and adapt to new processes and regulations. The world of Medicare and Medicaid is not only a big one but it experiences change frequently. The rules and regulations that govern the management of these programs are revisited and revised constantly to make them more efficient and accountable.

Because of this, Medicaid case management services need to be prepared to adapt quickly. Planstreet’s Medicaid program software is flexible and can be fitted to fit individualistic needs. Flexibility is a tremendous advantage with Medicaid programs specifically as there are 51 different sets of rules governing their implementation.

Another major advantage of using PlanStreet for your Medicaid case management is the ability to centralize work processes and information. Today’s offices are largely virtual so the ability to access the information you need anytime and anywhere you need it is a growing necessity. PlanStreet is a common workspace where client data, documents, and schedules are at the fingertips of anyone in the organization.

Learn more about how PlanStreet can benefit your Medicaid case management services and schedule a free introductory call with us today.