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Children's Medical


Revised September 13, 2013



Categorically Needy Newborn Medical (F05)

 

Categorically Needy Children's Medical (F06)

 

Children's Health Insurance Program-CHIP (F07)

 

Children's Health Program (F08)

 

Children's Medically Needy Program (F99)

 


Categorically Needy Newborn Medical (F05)


NOTE:

As a result of implementation of the Affordable Care Act (ACA), effective with applications received on or after 10/01/2013 this medical program is no longer valid. Any current active AUs with this medical coverage type will continue through the AUs current certification period. Clients would then need to apply for medical through the healthplanfinder.


Who is eligible to receive F05 Medical?

 

How long is the F05 certification period?

 

How do I screen F05 medical?

 

How do I process a pending F05 medical?

 

How long is a newborn covered under their mother’s medical?

 

When is F05 AUTO opened?

 

What happens when F05 is AUTO opened?

 

What happens when AUTO open of F05 is not possible?


Who is eligible to receive F05 Medical?

 

·         A child under the age of one is eligible for categorically needy (CN) Newborn Medical assistance when:

 

o        The child's mother was eligible for and receiving coverage under a medical program at the time of the child's birth; and

 

o        The child remains with the mother and resides in the state.

 

·         See EAZ Manual – WAC 388-505-0210 Children's medical eligibility.

 

How long is the F05 certification period?

 

·         The F05 medical program may be certified up to 12 months, through the end of the month of the child’s first birthday.

 

How do I screen F05 medical?

 

To screen a F05 AU, take the following steps:

 

1.      From the Welcome Back page in aces.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.

 

2.      On the Applicant page enter the head of household’s Name, Residential and Mailing Addresses.

 

3.      On the Programs page,

 

o        Click the checkbox next to Medical, and

 

o        Click the Next button.

 

4.      Continue the screening process until you reach the Finalize page.

 

o        If the medical program does not contain F05 Coverage Group, click the Specify Program button.  The Finalize – Program Details page displays.

 

o        On the Finalize – Program Details page, select Medical Assistance (MA) from the Program drop-down box, and

 

o        Select Newborns (F05) from the Medical Coverage Group drop-down box, and

 

o        Click the Next button.

 

o        See Screening - aces.online, Screening a Client for additional information on completing screening.

 

5.      On the Finalize page:

 

o        Click the checkbox next to the F05 program.

 

o        Enter the newborn’s Date of Birth in the application date field.

 

o        Click the Commit button to commit the screening data.


NOTE:

If the newborn's date of birth is not entered as the application date, users will receive an edit message on the Finalize screen: The application date for a F05 medical coverage group has to be the same as birth date of the youngest newborn child. Click OK to use the following youngest birth date as the application date: mm/dd/yyyy.


How do I process a pending F05 medical?

 

To process a pending F05 take the following steps:

 

1.      On the AMEN, select Option O – Interview in the Selection field.

 

2.      On the STAT screen, complete the Finl Resp field as follows:

 

o        [PN] – Applicant for the newborn.

 

o        [IP] – Ineligible Person for the parents financially responsible to the newborn.

 

o        [SC] – SSI Child/Child of SSI Related Parents/Child used to determine Family Size for the siblings of the newborn. 

 

o        [NM] – Not Related and Not Financially Responsible to the Applicant for members of the household not part of the newborn’s family.

 

3.      Complete the interview following instructions in the Interview chapter.

 

4.      After committing the interview data, follow instructions in the Process Application Month chapter for all pending months.


NOTE:

The pregnancy due date on the mother’s DEM1 screen should be changed to match the actual date of birth for the newborn when processing the F05 medical.


5.    When all pending months have been processed, follow instructions in the Finalize Application chapter to complete the F05 application process.

 

·         When F05 medical is opened for the newborn, medical eligibility is sent to ProviderOne in the overnight batch process. A medical Services Card is issued for the newborn in 7 to 10 days.

 

How long is a newborn covered under their mother’s medical?

 

·         Newborns are covered under their mother’s medical Services Card for the first 21 days of life.

 

When is F05 AUTO opened?

 

·         F05 may be AUTO opened when the birth of a newborn is reported through Washington Connection if all of the following are true:

 

o    The mother is eligible for Medicaid at the time her baby is born. 

    This includes P99 AUs where the AU status is A – Active.  If a P99 is in M – Spenddown status, an F05 will not AUTO open.

 

o    The newborn has been named.

 

o    A match is made to the mother’s demographics (such as SSN, Last Name, First Name, Mom’s date of birth).

 

o    Mom’s Estimated Due Date (EDD) is within a 3 month range of the newborn’s date of birth.

 

What happens when F05 is AUTO opened?

 

·         When the birth of a newborn is reported through Washington Connection and  an F05 is AUTO opened:

 

o    The newborn’s mother is the Head of Household (HOH) on the AU regardless if she is the HOH on her qualifying medical AU.

 

o    A separate AU is opened for each newborn in the instance of multiple births to the same mother.

 

o    The certification period ranges from the newborn’s date of birth through the month of the newborn’s first birthday.

 

o    If different, the mother’s Estimated Due Date (EDD) is changed to match the newborn’s date of birth.

 

o    A “Hey Mom” - HM07 tickler is sent to Barcode/DMS to indicate the F05 AUTO opened and is indexed to the mother’s ECR as a completed assignment.

 

o    Letter 002-01 (Approval Letter) is generated and sent.


NOTE:

In instances where the newborn is already open on an F05 AU, the system determines if there is a gap in coverage.  An F05 is AUTO opened for any historical gaps in coverage months and any dual participation months are denied with Reason Code 187 - Client Already Received Benefits in Another AU for this Benefit Month - For Administrative Use Only.


What happens when AUTO open of F05 is not possible?

 

·         When the birth of a newborn is reported through Washington connection but AUTO open is not possible based on the information received, one of the following “Hey Mom” – HM ticklers is sent to Barcode/DMS:

 

o     HM01 – F05 Not Opened – Newborn Not Yet Named

    Worker action is required

 

o    HM02 – F05 Not Opened – No Qualifying Mom in ACES

    Worker action is required

 

o    HM03 – F05 Not Opened – Mom in “M” Status on P99

    Worker action is required

 

o    HM04 – F05 Not Opened – Newborn Already Active in ACES

    HM04 is created and filed in the ECR as a completed document when a match from a newborn to a Mom is made but the newborn is already active on an F05 or other medical AU.

 

o    HM05 – F05 Not Opened – Review Newborn Medical Begin Date – Gap in Coverage - Worker action is required

    There is a discrepancy in the newborn’s date of birth between ACES and the Washington Connection application.

 

o    HM06 – F05 Not Opened  - Worker Action Required

    Mom’s AU paid thru date is in a month prior to the month the baby was born, or

 

    F05 was not AUTO opened due to some other reason

 

o    HM07 –

    If F05 is AUTO opened, the HM07 is indexed to the mother’s ECR as a completed assignment.

 

    If the system is unable to AUTO open newborn F05 medical for the baby, the – HM07 tickler is assigned to a user to manually take the actions necessary to open F05 for the newborn.

 

 


Categorically Needy Children's Medical (F06)


NOTE:

As a result of implementation of the Affordable Care Act (ACA), effective with applications received on or after 10/01/2013 this medical program is no longer valid. Any current active AUs with this medical coverage type will continue through the AUs current certification period. Clients would then need to apply for medical through the healthplanfinder.


Who is eligible to receive F06 medical?

 

Can a child be eligible for F06 if the household’s income exceeds F06 income standards?

 

How long is the F06 certification period?

 

How do I screen F06 medical?

 

How do I process a pending F06 AU?

 


Who is eligible to receive F06 medical?

 

·         Children under the age of 19 are eligible for F06 when they meet certain requirements. See EAZ Manual – WAC 388-505-0210 Children's medical eligibility.

 

·         Children under the age of 21 are eligible for F06 when they meet certain requirements. See EAZ Manual – WAC 388-505-0210 Children’s medical eligibility.

 

·         For income standards see EAZ Manual – WAC 182-505-0100 Medical programs -Monthly income standards based on the federal poverty level (FPL).

 

Can a child be eligible for F06 if the household’s income exceeds F06 income standards?

 

·         Children may be eligible for F06 as a separate Medical Assistance Unit (MAU) when certain conditions exist.

 

o        See EAZ Manual - WAC 182-506-0010 Medical Assistance Units  and Medical - Sneede vs. Kizer Medical  for those conditions and instructions concerning financial responsibility and the establishment of separate MAUs as required by the Sneede vs Kizer Ninth Circuit Court decision.

 

·         Children who are not eligible to receive F06 medical, may be eligible under another program:

 

o        If all F06 eligibility requirements are met other than income, a child may be eligible for coverage under the Children’s Health Insurance Program-CHIP (F07)  or the Children’s Medically Needy Program (F99).

 

o        A child who receives SSI benefits is eligible to receive medical coverage under the S01 program.  See SSI Medical (S01).

 

o        An SSI-related child may be eligible to receive medical coverage under the S02 or S99 programs. See SSI Related Medical.

 

·         Children who were previously approved for certain medical benefits within the last 12 months may be eligible for continuous eligibility.  See Continuous Eligibility for Categorically Needy Childrens Medical.

 

How long is the F06 certification period?

 

·         The F06 medical program is certified for 12 months.

 

·         A child’s certification ends at the end of the month the child turns 19, even if the 12 months is not over.

 

o        The certification may extend beyond the end of the month of the child’s 19th birthday when certain conditions are met.  

 

·         See EAZ Manual – WAC 182-504-0015 Certification periods for categorically needy (CN) scope of care medical assistance programs for additional information.

 

·         Changes during the certification period that affect eligibility should be processed according to EAZ Manual – WAC 182-504-0125 Effect of changes on medical program eligibility.

 

How do I screen F06 medical?


NOTE:

When determining categorically needy eligibility for a household as a single MAU, you should screen an F04 AU rather than an F06 AU.  The F04 AU will trickle to a children’s medical coverage group during Finalize if appropriate.


To screen an F06 AU, take the following steps:

 

1.      From the Welcome Back page in aces.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.

 

2.      On the Applicant page:

 

o        Enter the head of household’s Name, Residential and Mailing Addresses.

 

o        Click the AREP/Payee checkbox if you will be entering an Authorized Representative or Payee to the case.  For instructions to add an Authorized Representative, see Screening – aces.online, Authorized Representatives. 

 

o        Click the Next button.

 

3.      Complete the address validation process. 

 

o        See Screening – aces.online, Address Validation for additional instructions on this process.

 

4.      On the Programs page:

 

o        Click the checkbox next to Medical.

 

o        Click the Next button.

 

5.      Continue the screening process until you reach the Finalize page.

 

o        See Screening - aces.online, Screening a Client for additional information on completing screening.

 

6.      On the Finalize page:

 

o        If the household contains both children and adults, the default program will be F04.  Click the checkbox next to the F04 program if you need to determine eligibility for the family as one MAU.

 

o        If you have already determined the family is not eligible as one MAU and wish to screen an F06 AU rather than F04, use the Specify Program option to select the F06 program.

 

o        Enter the application date.

 

o        Click the Commit button to commit the screening data.

 

How do I process a pending F06 AU?

 

To process a pending F06 AU take the following steps:

 

1.      Select AMEN, Option O – Interview.

 

2.      On the STAT screen, enter [PN] – Applicant in the Finl Resp field for each applicant.

 

o       See Medical, Sneede vs. Kizer Medical for instructions on coding the STAT screen when Sneede vs. Kizer rules apply to the AU.

 

o        See EAZ Manual - WAC 182-506-0010 Medical Assistance Units for information on who must be included in the AU.

 

3.      Complete the interview following the instructions in the Interview chapter. 

 

4.      After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months.

 

5.      After all pending months have been processed, follow the instructions in the Finalize Application chapter to complete the F06 eligibility determination.

 

o        If all F06 eligibility requirements are met other than income, the F06 AU may trickle to Children’s Health Insurance Program - CHIP (F07) or the Children’s Medically Needy Program (F99) program during finalize.  See Trickle and Sprout for additional information .

 


Children's Health Insurance Program-CHIP (F07)


NOTE:

As a result of implementation of the Affordable Care Act (ACA), effective with applications received on or after 10/01/2013 this medical program is no longer valid. Any current active AUs with this medical coverage type will continue through the AUs current certification period. Clients would then need to apply for medical through the healthplanfinder.


Who is eligible to receive F07 medical?

 

How long is the F07 certification period?

 

How is an F07 opened?

 

How do I process a pending F07?

 

What are the premium requirements for F07 medical?

 


 

Processing Alternative

Medical

PR 4837

 

Who is eligible to receive F07 medical?

 

·         Children under the age of 19 are eligible for F07 when they meet the requirements described in EAZ Manual – WAC 388-505-0210 Children's medical eligibility.

 

·         Children under the age of 21 are eligible for F07 when they meet the requirements described in EAZ Manual – WAC 388-505-0210 Children's medical eligibility.

 

·         See EAZ Manual – WAC 182-505-0100 Medical programs --Monthly income standards based on the federal poverty level (FPL).

 

How long is the F07 certification period?

 

·         F07 medical is certified for twelve months.

 

·         When the child turns nineteen the certification period ends even if the twelve-month period is not over.

 

·         The certification may extend beyond past the end of the month of the child’s 19th birthday when the conditions of WAC 182-504-0015 Certification periods for categorically needy (CN) scope of care medical assistance programs  are met.

 

·         See EAZ Manual – WAC 182-504-0015 Certification periods for categorically needy (CN) scope of care medical assistance programs.

 

How is an F07 AU opened?

 

1.    An F07 AU is initially screened into ACES as an F04, F06, or F09 AU, following the instruction in Screening – aces.online.

 

2.    An F04, F06, or F09 AU will trickle to a pending F07 during Finalize Application, if appropriate, when the AUs countable income exceeds the 200% Federal Poverty Limit (FPL) but does not exceed the 300% FPL.

 

o     The pending F07 AUTO transfers to CSO 076 in overnight batch and Alert 218 – CASE (S) TRANSFERRED TO THIS CASELOAD generates.

 

o     MEDS CSO 076 financial workers are the only ones who can process the pending F07 cases.

 

o     After CSO 076 has determined eligibility for F07, the active cases are maintained there as well.

 

How do I process a pending F07?

 

To process a pending F07 take the following steps:

 

1.    Select AMEN Option O - Interview.  Follow the steps detailed in the Interview chapter.

 

2.    On the STAT screen, enter [PN] – Applicant in the Finl Resp field for each applicant.

 

o     See Medical, Sneede vs. Kizer Medical  for instructions on coding the STAT screen when Sneede vs. Kizer rules apply to the AU.

 

o     See EAZ Manual - WAC 182-506-0010 Medical Assistance Units for information on who must be included in the AU.

 

3.    On the Chip Enrollment CHIP screen, answer the seven questions. These questions on the CHIP screen are part of the eligibility determination process for F07 medical.

                                                           

4.    On the MISC screen:

 

o     Make an entry in the BHP Plus field. See <F1> help.

 

o     Enter your User ID in the User field.

 

5.    Complete the interview following the instructions in the Interview chapter.

 

6.    After committing the interview data, follow the instructions in the Process Application Month chapter.

 

7.    Finalize the F07 from AMEN thru Option Q – Finalize.  See Finalize Application chapter.

 

What are the premium requirements for F07 medical?

 

·         Children receiving F07 medical are required to pay premiums and enroll in managed care.

 

·         See EAZ Manual – WAC 388-505-0211 Premium requirements for premium-based children's healthcare programs .

 

·         See Premiums


Children's Health Program (F08)


NOTE:

Effective January 1, 2009 F08 medical is no longer a valid medical program.


What was F08 medical?

 

·         The Children's Health Program (CHP) F08 was a medical program for children under the age of 19 who were not eligible for Medicaid due to citizenship and whose countable income was at or below 250% of the Federal Poverty Level (FPL).

 


Children’s Medically Needy Program – F99

Who processes F99 AUs?

Who is eligible for F99?

How long is the F99 certification period?

How do I process an F99 AU?

How do I authorize spenddown for an F99 AU in M Status?

How do I enter spenddown medical expenses for an F99 AU in M status?

 


 

Who processes F99 AUs?

 

·        Effective 10/1/2013 all F99 AUs are processed by Health Care Authority (HCA) users and are assigned to Region 9 in one of the following Modified Adjusted Gross Income (MAGI) CSO’s:

 

o   181 - Houses MAGI AUs that belong to Region 1 geographical/zip catchment

o   182 - Houses MAGI AUs that belong to Region 2 geographical/zip catchment

o   183 - Houses MAGI AUs that belong to Region 3 geographical/zip catchment

 

·        HCA users have the ability to screen in or reinstate F99 AUs if needed.

 

Who is eligible for F99?

 

·         Children under the age of nineteen are eligible for Medically Needy (MN) medical assistance when they meet citizenship immigrant status, social security number requirements and have income over 300% of the Federal Poverty Level (FPL).

 

·         See EAZ Manual – WAC 388-505-0210 – Children’s healthcare programs.

 

How long is the F99 certification period?

 

·         F99 AUs default to a six-month certification period but can be shortened to three-month certification periods.

 

·         See EAZ Manual – WAC 182-519-0110 Spenddown of excess income for the medically needy program.

 

How is an F99 AU opened?

 

Process Prior to 10/01/2013

 

1.    An F99 AU is initially screened into ACES as an F04, F06, or F09 AU, following the instruction in Screening – aces.online.

 

2.    An F04, F06, or F09 AU will trickle to a pending F99 during Finalize Application, if appropriate, when the AUs countable income exceeds the 300% Federal Poverty Limit (FPL).

 

o       The pending F99 AUTO transfers to CSO 076 in overnight batch and Alert 218 – CASE (S) TRANSFERRED TO THIS CASELOAD generates.

 

o       MEDS CSO 076 financial workers are the only ones who can process the pending F99 cases.

 

o       After CSO 076 has determined eligibility for F99, the active cases are maintained there as well.

 

How do I process an F99 AU?

 

To process a pending F99 AU take the following steps:

 

1.    From the AMEN screen, select Option O - Interview. 

 

2.    On the STAT screen, enter [PN] – Applicant in the Finl Resp field for each applicant.

 

o     See Sneede vs. Kizer Medical for instructions on coding the STAT screen when Sneede vs. Kizer rules apply to the AU.

 

o     See EAZ Manual - WAC 182-506-0010 Medical Assistance Units for information on who must be included in the AU.

 

3.    Complete the interview following the instructions in the Interview chapter.

 

4.    After committing the interview data, follow the instructions in the Process Application Month chapter.

 

5.    Finalize the F99 from AMEN thru Option Q – Finalize.  See Finalize Application chapter

 

6.    While pending, the AU remains an F04, F06, F07 or F09 and is processed through Interview and Process Application Months. Prior to 10/01/2013

 

7.    The F04, F06, F07 or F09 AU that is denied due to income in excess of 300% FPL trickles to an F99 in M – Pending Spenddown status during Option Q – Finalize Application. Prior to 10/01/2013

 

How do I enter spenddown medical expenses for an F99 AU in M status?

 

·         To enter medical expenses to meet the client’s spenddown liability on an F99 AU in M status, see Spenddown – How do I enter medical expenses?

 

·         After expenses have been added, follow the steps in Spenddown - How do I assign medical expenses and authorize spenddown?

 

·         See EAZ Manual – WAC 182-519-0110 Spenddown of excess income for the medically needy program.

 

How are shared cases between CSOs and MEDS processed?

 

Process Prior to 10/01/2013

 

·         Shared cases exist when MEDS has a F99 and the CSO has another assistance unit active for the household.

 

·         For shared AU's, if a non-CSO 076 user takes a non-financial action on the related AU that affects the F99, Alert 404 - ANOTHER CSO UPDATED SHARED AU, will be sent to the CSO 076 user of record for the F99 AU.

 

·         If the MEDS CSO 076 worker takes an action (financial or non-financial) on the F99 AU that causes a change to the related AU - Alert 404 will be sent to the non-CSO 076 user of record for the related AU.

 

·         See Shared Cases By More Than One CSO for additional information.

 

Modification Date: September 13, 2013