MEDICAL REDETERMINATION
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MEDICAL REDETERMINATION


Revised April 22, 2013


WORKER RESPONSIBILITIES


Clients who are continuously eligible

1) Children under the age of nineteen

When a child is terminated from a CN medical program, a re-determination must be completed for potential eligibility under another program.

(F05) Place all children under 1 year of age who lose coverage under another program, and whose mother was eligible for medical assistance at the time of birth, on the newborn medical program through the end of the month of their first birthday.  Add text to the approval letter to help clarify the change in program.

Sample text:  The child listed above in entitled to continued medical coverage through the end of the month in which they turn one year of age.

(F06) When ACES does not automatically open F06 coverage for a recipient child, approve F06 medical through the end of the prior certification period or twelve months from the date of the last review or application.  Add text to the approval letter to help clarify the change in program.

Sample text:  The child(ren) listed above is (are) entitled to continued medical coverage through the date above.

(K01) Children whose coverage was approved under the family institutional medical program are eligible to receive one full year of coverage.  When a child discharges from a medical facility and is no longer eligible for K01 coverage, open F06 for the balance of the certification period without requiring an application or review from the parents. 


EXAMPLE

Brady (13) is admitted to Seattle Children's Hospital following a vehicle accident.  Brady's parents apply for medical coverage for him, however, their combined income exceeds the standards for a children's medical program and he is placed on an F99 spenddown program.

Brady remains in the hospital for six weeks before being discharged to his parents' home.  Since Brady was in the hospital over 30 days, he is considered an institutionalized client and eligibility can be re-determined for him under the family institutional program (K01) which does not look at parental income. 

Upon his discharge from the hospital, Brady remains continuously eligible for medical coverage through the end of his 12 month certification.  Close the K01 coverage and open F06 without requiring an eligibility review or new application.


(F07) When ACES closes a child for non-payment of the required premium, the child remains eligible for the program and coverage will be reinstated once the payment of the delinquent premium occurs within the certification period.  If payment of the delinquent premium occurs after the certification period no reinstatement will occur.  The household will need to reapply to have ongoing eligibility determined.  If payment of the delinquent premium occurs in the last month of the certification period, benefits will be reinstated through the last month of the certification period, and the household will need to reapply to have ongoing eligibility determined.  See WAC 388-505-0211 and worker responsibilities in that section for more information.

Sample text:  Your child(ren)'s medical coverage is closing because the required premium has not been paid.  If the delinquent premium is paid your child(ren)'s medical coverage may be reinstated


EXAMPLE

The Smith family is approved for F07 medical with a certification period of January through December.  Coverage is provided for their two children for a monthly premium of $40.  The Smiths don't pay the required premium in March, April, and May.  On May 20th the Smiths receive notice their children's coverage will end unless payment of the delinquent premium is made by May 31st.  No payment is made and the AU is closed.  In early July, the Smiths make a payment of $120 to clear the balance of their delinquent premiums.   The worker receives notice from FSA via ACES that the delinquent premium has been paid and reinstates coverage for the children for June, July, and August (through the end of the initial certification period of December). 


Sample text:  The delinquent premium for your child(ren)'s coverage has been paid.  Medical coverage has been reinstated through the dates above.


EXAMPLE

The Jones' family is approved for F07 medical with a certification period of January through December.  Coverage is provided for their two children for a monthly premium of $40.  The Jones' don't pay the required premium in March, April, and May.  On May 20th the Jones' receive notice their children's coverage will end unless payment of the delinquent premium is made by May 31st.  No payment is made and the AU is closed.  In January the Jones' make a payment of $120 to clear the balance of their delinquent premiums.  Since this is outside of the certification period the work takes no action except to send the Jones' an application to see if they would like to reapply.


Sample text:  The delinquent premium for your child(ren)’s coverage has been paid.  Ongoing eligibility for medical coverage will require a new application.  Please find enclosed an application for medical assistance, or you may apply online at https://fortress.wa.gov/dshs/f2ws03esaapps/onlinecso/applying.asp


Children who turn nineteen and age out of the children's medical program are considered adults and must be considered for family, pregnancy or SSI-related medical coverage prior to terminating CN coverage.  If an Ex-Parte review of the case indicates the client claims a disability, screen in SSI-related medical (S02) coverage so that medical coverage can be continued while gathering the medical documentation needed to do a disability referral.


NOTE:

Barcode sends an interface to the ACES system to update the ELIG RVW RCVD field to a 'Y' on the MISC screen when a review is received for a client in any CN medical coverage group.  When there is a 'Y' on the MISC screen, CN benefits will continue to issue until the worker initiates the eligibility review process in ACES.


2) Pregnant Women

(P02)  Approve medical coverage under the CN pregnancy medical program if a pregnant woman becomes ineligible for family medicaid, TANF cash assistance or PWA cash assistance.  Once a pregnant woman is eligible for CN medical, they remain eligible through the 60-day post-partum period regardless of changes.  Add text to the approval letter to help clarify the change in program.

Sample text:  The person listed above is pregnant and is entitled to continued medical coverage through the date listed above.


EXAMPLE

Jill receives TANF cash assistance for herself and her son.  Division of Child Support reports she is not cooperating with them in establishing paternity for her son and places her in non-cooperation status.  The worker updates the NCPS screens to show the non-cooperation which affects the amount of her TANF grant and removes Jill from medical coverage under the F01 program.

Jill previously reported that she is pregnant and her estimated due date is recorded on her ACES DEM1 screen.  The worker adds a P02 pregnancy medical program so that Jill's medical coverage can be continued even though her cash assistance was sanctioned.


Forty-five days prior to the end of the post-partum period, the client receives an eligibility review form to complete.  It is important to complete and document the medical re-determination at this time.  If the client is not eligible under any other medical program, allow the case to trickle to the family planning (P05) program.


NOTE:

Barcode sends an interface to the ACES system to update the ELIG RVW RCVD field to a 'Y' on the MISC screen when a review is received for a client in this medical coverage group.  When there is a 'Y' on the MISC screen, CN benefits will continue to issue until the worker recalculates eligibility in ACES by updating information in ACES or by entering a 'Y' in the CALC ELIG field on the MISC screen.  ACES will not trickle to the P05 family planning coverage group if the case is not updated or recalculated from the MISC screen. 

 


Clients automatically related to a medical coverage group

1)   SSI-related aged, blind, disabled clients (including ABD cash assistance clients receiving CN medicaid based on an approved NGMA or presumptive disability).

a) Screen in an S02 for clients who are age 65 or older.  Allow the case to trickle to MN spenddown if income exceeds the CN standard.  If the client is not eligible based on resources, allow the termination to proceed and add text to the case to document that the re-determination is complete.

b) Screen in an S02 for clients who meet the disability criteria defined in WAC 182-512-0050.  Allow the case to trickle to MN spenddown if income exceeds the CN standard.  If the client is not eligible based on resources, allow the termination to proceed and add text to the case to document that the re-determination is complete.


EXAMPLE

Joe receives ABD cash assistance and CN medicaid based on an approved non-grant medical decision (NGMA) with disability end date waived.  He has no income.  In the month he turns 62 he reports to the department that he is now eligible to draw early retirement benefits from Social Security in the amount of $400.  This causes Joe's cash grant to close.  Since Joe remains related to a medical coverage group by being 'Disabled', and his income is below the SSI-related CN income level, screen in and approve an S02 medical program so his medical coverage can continue.


c)  ABD cash recipients who are presumptively eligible for SSI pending a final disability  determination by Social Security Administration remain eligible for CN medical until one of the following occurs:

  • The client is denied at any level in the SSI application process and the client fails to follow through with the next step in the application process.
  • The denial is upheld at the SSA hearing level by an Administrative Law Judge and the client does not provide proof of an appeal within 60 days.  (Contact the SSI facilitator to determine whether an appeal has been filed or review the SDX data for appeals information).
  • The client does not provide proof of an appeal and the denial is upheld at the SSA appeals level.  This concludes the disability determination process and the client is no longer relatable to a disability medical program at this point.  (Contact the SSI facilitator or review the SDX for information regarding the outcome of the appeal).
  • The client is not resource eligible for an SSI-related medical program, even if the disability determination is not final.

NOTE:

The SDX sends information regarding the SSI appeals process.  The following codes are found on the SDX1 screen in the Appeal Code field to the left of the screen:

A - Appeals Council Review

B - Reconsideration - Appeal request dismissed, withdrawn

P - Hearing - Appeal request filed

Q - Hearing - Appeal request dismissed or withdrawn

W - Appeals Council - Appeal request filed

X - Appeals Council - Appeals request dismissed or withdrawn

Y - Appeals Council - Affirmation of prior decision

Z - Appeals Council - Reversal or modification of prior decision  

In addition, new Barcode and ICMS ticklers are posted based on SDX activity and filing deadlines.  The following relate to the Appeals process:

1003 SDX:  Appeal decision

1007 SDX:  No filing after appeal decision.


2)   Family-related clients - Parents/Caretaker relatives of an eligible dependent child, or pregnant woman

When a family medical program closes, review the case record to determine if any Sneede-Kizer characteristics apply and determine if any of the adults may remain eligible for CN coverage due to the establishment of separate medical assistance units.  See WAC 182-506-0010(2) for rules relating to Sneede/Kizer.

If the adults do not qualify under Sneede/Kizer, review the case record to determine if any household member is eligible under another basis, such as pregnancy or a previously established current disability.   If not, allow the termination to proceed for the adults in the household and document in the ACES narrative.

Note:  ACES generates the 07-08 General Termination Benefits for an Individual letter but does not include the correct termination reason.  Be sure to add the reason the individual was not eligible for medical coverage and add the correct WAC to the freeform text.


EXAMPLE

Jack and Jill and their two children receive medical under the F02 family transitional medical program.  Medical is closed at the end of June when the earnings report is not returned.  The children remain eligible on the F06 program through the end of the original 12 month certification and ACES approves ongoing F06 eligibility.

The Ex-Parte review of the case shows a future EDD on Jill's DEM1 screen so she can be approved for continued medical under the pregnancy program (P02) through the end of the post partum period.  Send Jill an approval notice for her medical coverage.

Neither the ACES narrative, nor documents in the electronic case record show any potential medicaid eligibility for Jack.  Allow the termination for Jack to proceed and document the decision in the ACES narrative.


3)   Healthcare for Workers with Disabilities (HWD)

If the client is under age 65 and working and is not otherwise eligible for S02 coverage (and meets disability requirements) send a referral to the specialized medical unit to consider eligibility for the Healthcare for Workers with Disabilities (HWD) program.  Allow the termination under the original program to proceed (allowing advance and adequate notice).


NOTE:

If a client is working and has monthly gross earnings at or above the Substantial Gainful Activity (SGA) level and does not receive Title 2 (SSDI, DAC, DWB), then HWD is the only Medicaid program that may provide coverage for them.  A client who is working at SGA is not eligible for S02/S95/S99 coverage, unless their Title 2 cash benefit continues.   If their Title 2 has not ended, then HWD staff will explain their options to either enroll in HWD for CN coverage or meet their spenddown for MN coverage. 


Set a barcode tickler to the HWD unit in DMS for @HWD in CSO 157 to contact the client and determine if they wish to pursue HWD.  Since HWD is a premium based program, CN coverage should not be authorized under this program until the client has approved the premium requirement and amount. 

For HCS clients, set a barcode tickler to the HCS Regional HWD specialist to contact the client and determine if they wish to pursue HWD.


NOTE:

A working client who is eligible under a Home and Community Based CN waiver program (L22 in ACES) whose income goes over the Special Income Limit (SIL) or who accumulates excess resources should always be referred to the HWD unit prior to terminating CN medical coverage.  Both Home and Community Services (HCS) and the Division of Developmental Disabilities (DDD) have included the HWD program as an available coverage group in the CN waivers.  An ADSA client may transition from the L22 program to the S08 program and remain eligible for long-term care funding for waiver services.


Ex-Parte review for clients who do not fall into one of the above categories

Terminations where there is not enough information in the record to determine if a client is relatable to a medical program

If an ex-parte review of the record shows the client claims to have a disability but has not been referred for a disability determination, CN medical needs to be continued while supporting evidence is gathered from the client to be able to make the NGMA referral.  Take the following steps:

1)  Allow the medical coverage to close under the original AU so that a valid termination letter is generated for the client.

2)  Screen in and approve an S02, and suppress the approval letter.   Since the client is only approved pending a re-determination and has not been found 'eligible' for SSI-related medical, the department does not issue an award letter.  Follow steps outlined in the NGMA chapter of the manual to request the DSHS 14-144A and SSA-827 forms needed to make the electronic referral to DDDS. 

3)  Create a Request for Information letter giving the client twenty days to provide the department with medical evidence to support a claim for disability.  Set a barcode tickler to review for a response from the client.

Sample text:  You can no longer get medical benefits under the (TANF or family related) program.  Your record shows you claim to have a disability that prevents you from working, but we do not have any medical information in our records to support that claim.  We are continuing your medical coverage while we determine if you can get medical benefits under a different program.  Please provide the enclosed forms and any medical documents you have to support your claim of disability.  If we do not hear from you by the due date above, we will not consider you for the disability medical program and your continued medical coverage will end.

4)  Approve the S02 by updating the DEM2 to show the disability status.  Code the approval source with an 'OI' (ODI waived) code and put the end date out for four months.

5)   If the client does not respond timely, remove the disability coding from the DEM2 screen and allow the CN medical to close giving advance and adequate notice to the client.  Add freeform text to the termination letter:

Sample text:  We asked for medical information so we could see if you can get disability medical benefits.  We have not heard from you.  If you are disabled, you may apply for disability benefits through the Social Security Administration (SSA) or apply for disability medical benefits from any of our offices.

6)  If the client does respond, complete the referral for the NGMA.  Send a general correspondence (50-01) letter to the client to let them know that medical coverage will continue pending the decision on their disability claim.  Add freeform text to the letter:

Sample text:  Your disability claim has been referred to the Division of Disability Determination Services (DDDS).  If they need more medical evidence to make the determination, they will contact you.  Your medical coverage will continue while they complete the determination.

7)  Set a barcode tickler for four months to check on the status of the NGMA decision and document behind the remarks on the DEM2 screen that the disability coding is a workaround in order to continue medical during a re-determination.

Terminations where there is enough information in the case record already to determine someone is relatable to another medical program

In many cases, there is already information in the case record to determine someone is potentially relatable to a disability medical program, for example, when a NGMA referral has already been sent to DDDS or a review of the SOLQ or the SDX shows that a disability claim has already been filed with the Social Security Administration.  In these cases, follow the same steps as outline above, however sample text should be added to the termination letter (if possible) indicating that medical is being continued until the re-determination process is complete.

Sample text:  You can no longer get medical benefits under the (TANF or family medical) program.  However, your record shows that you have applied to the Social Security Administration (SSA) or Division of Disability Determination Services (DDDS) for a disability determination.  Your medical coverage is being continued while SSA/DDDS decides if you are disabled.  Please let us know as soon as SSA tells you their decision.  We will be notified directly when DDDS makes a decision on your case.

What if income causes the case to trickle to a spenddown?

If income causes the case to trickle to spenddown, allow the medically needy with spenddown letter (20-01) to go out to the client.  Add text to the MN letter to explain why CN medical coverage is not being continued.

Sample text:  Your disability claim has been referred to the Division of Disability Determination Services (DDDS) to decide if you can receive medical coverage based on a disability.  However, your current income puts you over the income standard for continuing coverage under the categorically needy program.  You must incur the stated amount in medical expenses (spenddown) before medical coverage can begin.  We will notify you when we receive a decision from DDDS on your disability claim.


EXAMPLE

Cassandra receives ABD cash assistance and is working with her SSI facilitator on the SSI application process.  In May, she becomes eligible for an L&I payment of $200 per week.  The income causes her ABD cash and the G02 CN medical to close.  Since she is still in the SSI application process, screen in an S02.  The case will trickle to S99 since her income is over the CN standard. Document that the medical re-determination is complete and set a barcode tickler for 4 months out to check on the status of her SSI application.   A NGMA referral is not needed since the client has already applied for a disability determination through SSA.  

Continue to track the case for the outcome of the DDDS decision.  If the DDDS decision does not establish disability, close the MN coverage, allowing for the advance and adequate notice period.

 


SSI Closures

For the medical redetermination process to follow when SSI closes, see

Modification Date: April 22, 2013