MEDICAL REDETERMINATION

Revised October 20, 2009

WORKER RESPONSIBILITIES

CONTINUOUS ELIGIBILITY

Children under the age of nineteen

When a child is terminated from a CN medical program, eligibility must be re-determined under another program.

(F05) Place all children under 1 year of age whose mother was receiving medicaid 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 are entitled to continued medical coverage through the end of their original twelve month eligibility period.

Children whose coverage was approved under the family institutional medical program (K01) 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.

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 medical documentation needed to do a disability referral.

NOTE:

Pregnant Women

(P02) Approve medical coverage under the CN pregnancy medical program if a pregnant woman becomes ineligible for family medical, TANF cash assistance or GA-U. 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 persion listed above is pregnant and is entitled to continued medical coverage through the end of the 60 day post partum period.

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 has previously reported to the department that she is pregnant and her estimated due date is recorded on her DEM1 screen. The worker will need to add a P02 pregnancy medical program so that Jill's medical coverage can be continued even though her cash assistance has been sanctioned.

Forty-five days prior to the end of the post-partum period, the client is sent an eligibility review to complete. It is important that a medical re-determination is also completed and documented at this time. If the client is not eligible under any other department medical program, allow the case to trickle to the family planning (P05) program and document in the ACES narrative that the re-determination process is complete.

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.

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