II. Eligibility factors A. Coverage 1. All individuals receiving aid or assistance under the State's approved plans under the OAA, AB, APTD and AFDC programs and persons who would be eligible under these programs except for meeting durational residence requirements or any other eligibility condition or requirement specifically prohibited in a program for medical assistance under title XIX. 2. Individuals, including children, who would be eligible under the above criteria except that their income is sufficient to meet maintenance needs as defined by the State for financial assistance eligibility. 3. All needy children under the age of 21 who are not included above. 4. Persons over 65 in institutions for the treatment of tuberculosis and mental diseases. 5. All other individuals and families whose resources are insufficient to pay for those medical care items provided under the plan. (Federal matching cannot be claimed.) B. Relationship to medical insurance programs under title XVIII of the 1. Hospital insurance benefits.-For persons over 65 who are eligible under the title XIX plan the State will meet Federal requirements regarding payment of deductibles and coinsurance. 2. Supplementary medical insurance.-The State will not pay the premium of $3.00 a month for public assistance recipients. It will meet so much of the cost of deductibles or coinsurance liability as conforms to the scope, amount and duration of medical services provided under the title XIX plan. C. Financial eligibility to determine persons who are medically needy: 1. Income scale.-Single person, $2,100; family of four, $4,200. 2. Other resources.-Single person, $525; family of four, $1,050. III. Scope of medical care provided 1. Inpatient hospital services for the prevention, diagnosis, treatment of, and rehabilitation from, a disease or injury. No durational limitation. 2. Outpatient hospital services as needed for the prevention, diagnosis and treatment of disease or injury. 3. Other laboratory and X-ray services. 4. Skilled nursing home services with no durational limitation so long as the need is certified by the patient's physician. 5. Physician's services for the prevention, diagnosis and treatment of a disease or injury furnished in the office, home, hospital, or other approved facility. 6. Dental services to be provided within budgetary limitations. 7. Drugs, biologicals, medical and surgical supplies and equipment limited to those items designated by the Department of Public Health. 8. Home health services needed for the promotion of health, prevention of disease and diagnosis and treatment of disease or injury as prescribed by the patient's physician. 9. Clinic services. 10. Prosthetic appliances. 11. Blood, blood derivatives and substitutes provided upon certification that replacement donations cannot be obtained. 12. Rehabilitation services within allowable budgetary limitations for the prevention, diagnosis, and treatment of physical, mental and social disability in approved rehabilitation centers. 13. Other services, including podiatry, ophthalmology, psychology and patient transportation. IV. Program financing The District of Columbia is entitled to receive from the Federal government a reimbursement equal to fifty percent of the cost of services furnished to persons who are eligible for title XIX reimbursement under the plan. This reimbursement will amount to approximately $10.6 million at 1967 total program cost level of $40.6 million. The Federal reimbursement would thus be about one-fourth of the total program cost. V. Number of cases served by the new program A total of 217,300 persons would be eligible under this program. 92,000 of these would not be eligible for Federal reimbursement under title XIX. SELECTED EXCERPTS FROM THE MEDICAL ASSISTANCE PROGRAM OF THE DISTRICT OF COLUMBIA, STATE PLAN UNDER TITLE XIX, STANDARDS OF ELIGIBILITY FOR MEDICAL ASSISTANCE Exhibit F "The following definitions apply to financial resources in considering them for determination of financial eligibility: "Income is defined as aggregate monies earned and/or received during the year preceding application and projected on a predictable basis through the year following application from sources such as: "Salaries "Commissions "Military Dependency Allowances "Tips "Bonuses "Net Income from Business of Profession "Annuities "Guardianships "Statutory Benefits (Social Security, Veterans Benefits, Railroad Retirement Benefits, Civil Service Retirement Benefits) "Cash Gifts (Regular and Recurring) "Interest "Royalties "Trusts "Court-ordered or Voluntary Support Payments "This definition recognizes the obligation of the applicant to supply information about his income from all pertinent sources which can be predicted reasonably for the year following the date of application. "Other Resources are defined as those assets readily convertible into cash (to mean the ability to exchange assets for cash within a 30 day period). "These assets shall be considered available to applicant to fully, or partially, meet the cost of medical care, to the extent that they exceed the exemption indicated in Table II. "In a family unit (husband and wife; husband, wife and children) only the assets of the husband or wife shall be considered, whether owned singly or jointly. Other resources are defined to include: "Cash on hand "Cash deposits in bank "Bank accounts (if held jointly with a person other than the spouse, divided equally) "Other negotiable securities readily convertible to cash (if held jointly with a person other than a spouse, divided equally) "Bonds (readily convertible to cash) "Stocks (readily convertible to cash) "Credit Union Accounts (if held jointly with a person other than spouse, divided equally) "This definition adheres to the legal requirement that assets shall be considered for payment of medical expenses only if they are readily available for such purposes. "Real Property.—With the exception of net income from such property, whatever equity an applicant for medical assistance may have in real property, whether or not it is singly, jointly, or multiply-owned, shall not be considered as available resource for medical assistance purposes. Real property shall include land, building, dwellings, grounds and improvements thereto. "Life Insurance in force, regardless of the cash surrender or loan value, shall be excluded as a resource in determining financial eligibility for medical assistance." "Provision is made for the exclusion of annual health insurance premiums which are being paid by an individual or a family. This provision is intended to provide encouragement for the retention of health insurance to protect individuals against the cost of medical expenses and, collaterally, to help to reduce the cost of tax-supported services." "Health and medical insurance benefits and other health benefits legally available to an eligible shall be applied to medical care costs before charges are made against the plan." Comparison of proposed financial eligibility levels, D.C. plan for medical assistance under title XIX COMPARISON OF FINANCIAL ELIGIBILITY FACTORS RELATING TO THE TITLE XIX MEDICAL ASSISTANCE PLAN OF 26 STATES, 2 TERRITORIES AND THE DISTRICT OF COLUMBIA, MARCH 14, 1967 1 Only the indigent by public assistance financial criteria are eligible. 2 Number estimated to be served by program during 1st year. NOTE.-There are 2 jurisdictions with maintenance levels above $4,200, 18 with levels below $4,200 and 8 that cover only persons financially eligible for public assistance. 17 of the 18 States which provide care for persons other than the public assistance cases have family of 4 income levels above the 1965 per capita income for that State, and which exceed that per capita income level by 3 to 83 percent. The proposed District of Columbia level exceeds the District of Columbia per capita income by 13 percent. Source: District of Columbia Department of Public Health. Financial eligibility-Items and accounts exempted for maintenance needs (HEW summary of State laws implementing title XIX) $3,000 50 3,800 do.. $500 1,500 Auto et al. 3, 300 _do_ 1,000 1,100 Do. 3,000 Home ($15,000 assessed value). $10,000 (2) (1) 3,600 Homestead.. 800 Yes. "Only the indigent by public assistance financial criteria are eligible. 2' No limit. • Total program cost $48,500,000. Federal title XIX reimbursement $12,400,000. This includes $2,200,000 which replaces present Federal medical assistance reimbursements that are included in the present D.C. $32,900,000 program, and which will cease when the title XIX reimbursement commences. Additional cost to the District of Columbia $5,400,000 under the title XIX program. All. MEDICAL CARE 131 [E Hon. JOHN DOWDY, DISTRICT OF COLUMBIA NURSES' ASSOCIATION, Chairman, Subcommittee #3, Committee on the District of Columbia, House of Representatives, Washington, D.C. DEAR CONGRESSMAN DOWDY: The membership and Board of Directors of the District of Columbia Nurses' Association appreciated the opportunity to file written testimony with your subcommittee in support of H.R. 3972, which would enable District of Columbia to participate in health and medical assistance benefits under the Social Security Act. We are greatly concerned about the serious gap in the health services now available to the medically indigent and urge the subcommittee to expedite its referral of H.R. 3972 to the consideration of full District Committee with a favorable recommendation. Again thank you for the favor of your many courtesies. Sincerely, WILLIAM A. LANG, |