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Revised August 15, 2013



Categorically Needy 12-Month Extension (F02)

 

Children’s Health Insurance Program – CHIP (F07)

 

HealthCare for Workers with Disabilities – HWD (S08)

 


CATEGORICALLY NEEDY 12- MONTH EXTENSION (F02)

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of the Affordable Care Act (ACA), effective with applications received on or after 10/01/2013 this medical program is no longer valid.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.

·      On 8/26/13, the final quarterly reports are going to be sent.

·      On 9/18/13, the final warning letters for households that have not returned their quarterly report will be generated.

·      On 9/20/13 (monthly issuance), F02 AUs will terminate for delinquent quarterly reports.

·      On 9/21/13, all active F02 AUs will be recalculated and the fields related to the quarterly report process removed for the ongoing month November.

·      On 9/30/13, the final daily MA F02 interface file containing AUs that have paid in full will be received from OFR. The data will be processed and alerts will be generated as usual. Workers will still be allowed to reinstate MA/F02 AUs.

 

How are F02 premiums calculated?

 

How do clients pay their F02 premiums?

 

What happens to the F02 AU if the premiums are not paid?

 

What happens if late F02 premiums are paid after the AU closes?

 

How do I reinstate an F02 AU that has been closed for non-payment of premiums?

 


 

How are F02 premiums calculated?

 

·         See EAZ Manual – 388-523-0120 Medical extensions – Premium requirements.

 

How do clients pay their F02 premiums?

 

·         F02 premiums are paid directly to the Financial Services Administration (FSA).  See EAZ Manual – WAC 388-523-0120 Clarifying Information.

 

What happens to the F02 AU if the premiums are not paid?

 

·         Based on the Financial Services Administration (FSA) interface, ACES:

 

o    Closes the F02 AU for Reason Code 342 – Termination/Denial due to Non-Payment of Premium at the end of the following month.

 

o    Generates Alert 416 – CL/AU CLOSED BY BATCH, REDETERMINE MED ELIGIBILITY.

 

·         Upon receipt of Alert 416, the user must determine if good cause exists for non-payment.

 

o    If good cause does not exist, re-determine eligibility for the family members.  See EAZ Manual – WAC 388-523-0120 (5) for good cause reasons.

 

What happens if late F02 premiums are paid after the AU closes?

 

·         FSA notifies ACES when they receive a late payment from a family previously closed for Reason Code 342.

 

·         Alert 239 – DELINQUENT PAYMENT RECEIVED, DETERMINE GOOD CAUSE is generated.  This alert is generated when a premium is received by FSA, after the FSA monthly interface has reported a client has not paid their premium.

 

·         Alert 239 informs the user of record that the family is no longer in arrears and has paid the premium obligation in full.  Upon receipt of Alert 239, the user must reinstate the F02 AU for the balance of the certification period.

 

How do I reinstate an F02 AU that has been closed for non-payment of premiums?

 

·         For instructions on how to reinstate the F02 AU, see Reinstatement.

 

·         See EAZ Manual – 388-523-0120 Medical extensions – Premium requirements.

 


CHILDREN’S HEALTH INSURANCE PROGRAM – CHIP (F07)

Do all F07 recipients pay a monthly premium?

 

How are F07 premiums calculated?

 

Where does premium tier information display in ACES?

 

What is a “Locked-In” premium tier?

 

How do I remove a “Locked-In” premium tier?

 

How do clients pay their F07 premiums?

 

How can I tell what a family’s premium amount is?

 

What happens if a premium is not paid?

 

What happens when a delinquent payment is received late?

 


 

Do all F07 recipients pay a monthly premium?

 

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

 

How are F07 premiums calculated?

 

 

·         Premium amounts are based on the household’s net countable income.

 

o    Tier 1 Premiums - Households with income greater than 200% and up to 250% of the FPL will be required to pay $20 per child with a 2 premium cap per household.

 

o    Tier 2 Premiums - Households with income greater that 250% and up to 300% of the FPL will be required to pay $30 per child with a 2 premium cap per household.

 

o    Premium amounts for Non-Qualified (NQ) Non-Federally Qualified (NF) children in households with income above the 200% FPL have a higher premium amount of $98.00 per child with a 2 premium cap per household.

 

·         The order in which premiums are determined are as follows:

 

o    Federally Qualified children with Tier 1 premiums

o    Federally Qualified children with Tier 2 premiums

o    Non-Qualified/Non-Federally Qualified children

  

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

 

 


EXAMPLE

 

1.    If a household has three children, two which are citizens and the other is Non-Qualified or Non-Federally Qualified, the household will be billed for the two citizen children first. Since the cap is 2 children there is no billing for the NQ/NF child.

 

2.    If a household has two children, one child is a citizen and the other child is NQ/NF. The household is billed for the citizen child and $98.00 for the NQ/NF child.


 

Where does premium tier Information display in ACES?

 

·         Premium tier information displays in:

 

o     ACES Mainframe - on the STAT and ELIG screens in the OP field, and on the CTCN screen in the Prem Tier Level field.

 

o    Aces.online - on the Client >> Premium Payment Status page.

 

What is a “Locked-In” premium tier?

 

·         A “Locked-In” premium tier is the lowest tier level that a child active on F07 is eligible for during the child’s Continuous Eligibility tracking period.


EXAMPLE

  • A child is living with his mother, active on F07, and "Locked-in" to $20.00 Tier 1 monthly Premium.
  • The child leaves mom's home to go live with dad and h is two other children.
  • Dad's income is over 250% FPL so the 2 kids living with him are "locked-in" to Tier 2 premiums of $30.00 each, for a household premium of $60.00.
  • When the Tier 1 child is added to dad's household the household's total premium changes from $60.00 to $50.00, because the system uses the lowest "locked-in" premiums for the 2 premium cap.


How do I remove a “Locked-In” premium tier?

 

·         Enter [Reason Code 536 – Error Initial Eligibility - Removed Continuous Tracking for Child] on the STAT screen in the AU Status Reasons field of the ongoing month to reset the “locked-in” tier level from “1” to “2”.

 

How do clients pay their F07 premiums?

 

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

 

How can I tell what a family’s premium amount is?

 

·         The PREM screen is AUTO updated when an optional child, not exempt from premiums, is found eligible for F07 medical prior to ACES deadline.

 

·         Two days after ACES deadline, during the monthly issuance run, ACES sends an interface to Financial Services Administration (FSA) who will begin billing for medical coverage received the following month.  After FSA has successfully interfaced with ACES, the PREM screen will display the household’s premium amount.

 

·         The amount of the premium is determined by the amount of income in the Net Income field on the MAFI screen.

 

·         A household’s premium amount information can be viewed on the PREM screen, and will display the household premium amount and any delinquent payment information.  You can also find the PREM information by selecting <F20> from the MAFI screen.

 

·         The PREM screen is not benefit month driven. The PREM screen will display the latest premium that the Head of Household must pay per month.  Historical data can be viewed by using the As Of Date field on the AMEN screen, Option B – AU/Client Inquiry or by accessing the Premium Payment Status from client Details in aces.online.

 

What happens if a premium is not paid?

 

·         If F07 premiums are not paid for three months, the child is disenrolled from the program.  The family must then pay all past due premiums before the child can be re-enrolled.

 

·         When notification is received from FSA that a household has delinquent premiums, the following actions take place:

 

o    ACES reviews each active F07 AU for Optional Children.

 

o    Each non-exempt optional child’s Finl Resp code on the STAT screen is changed to [IC] – Ineligible Child with Reason Code 342 – Termination/Denial Due to Non-Payment of Premium and a Letter 006-08 (General Termination for an Individual) is sent.

 

o    AUs without any mandatory or optional children will close with Reason Code 342 and are sent Letter 006-01 (Termination for AU).

 

o    Alert 416 – CL/AU CLOSED BY BATCH.  RE-DETERMINE MEDICAL ELIGIBILITY generates for all F07 AUs that closed or remained active with mandatory children.

 

o    A Sanction Reason field entry 200 – Delinquent Payment Amount on the SANC screen is added to each non-exempt optional child.  The sanction Eff Start Dt is set to the ongoing benefit month.  The sanction End Dt is set at three months.

 

o    The PREM screen Premium Amount field is changed to zero and the Premium Effective Date lists the current date.

 

o    The PREM screen Delinquent Amount field and Notification Date field is updated from the FSA interface.

 

What happens when a delinquent payment is received late?

·         When notification is received from FSA that a delinquent premium amount has been paid in full, the following automated process occurs for all F07 AUs:

o    The Delinquent Amount field on the PREM screen is updated to zero.

 

o    The Full Payment Received Date field on the PREM screen is updated with information received from FSA.

 

o    A Narrative entry is AUTO added to the Head of Household indicating the premium payment has been paid in full with the date payment was received.  The entry will appear in “pink” when displayed on the NARR screen.

 

o    For all AUs closed with Reason Code 342 – Termination/Denial Due to Non-Payment of Premium or Reason Code 245 – No Eligible Household Members, and the payment received date is the same month the delinquent amount was reported, Alert 241 – DELINQUENT PAYMENT RECEIVED – REINSTATE AU is generated.

 

o    When the AU is re-opened or reinstated, the SANC screen data is kept or deleted depending on the receipt timeframe of the delinquent payment.

 

o    There are two valid reasons to enter a sanction exemption code on the SANC screen; continuous medical eligibility pending a fair hearing or department error.

 

o    For all active AUs, recalculation of eligibility will re-determine the household premium amount for the next premium interface with FSA.

 


HEALTHCARE FOR WORKERS WITH DISABILITIES – HWD (S08)

How are S08 premiums calculated?

 

How do clients pay their S08 premiums?

 

What happens if the S08 premium is not paid?

 


 

How are S08 premiums calculated?

 

·         See EAZ Manual – WAC 182-511-1250 Healthcare for workers with disabilities (HWD) – Premium payments.

 

How do clients pay their S08 premiums?

 

·         S08 premiums are paid directly to the Office of Financial Recovery (OFR)).  See EAZ Manual – WAC 182-511-1250 Clarifying Information.

 

What happens if the S08 premium is not paid?

 

·         If the premium is not paid for four consecutive months an interface from the Office of Financial Recovery communicates this information to ACES.

 

·         ACES generates Alert 235 - PREMIUM PAYMENT 120 DAYS OVERDUE. When this alert is received, the worker will close the S08 AU and redetermine eligibility for other medical programs.

 

·         If a client does not pay four consecutive monthly premiums, that person is not eligible for S08 coverage for the next four months, and must pay all premium amounts owed before S08 coverage can be approved again.

Modification Date: August 15, 2013