WORKER RESPONSIBILITIES

Revised October 19, 2009

INDIVIDUALS RELATED TO A MEDICAL COVERAGE GROUP

Aged, blind, disabled individuals (including GA clients where disability has been established or GA-X clients who are still in the SSI application process)

(S02) Screen in an SSI-related medical program for individuals who meet the disability criteria defined in WAC 288-475-0050 and whose resources are below the standard.

If the case has resources in excess of the SSI-related standard, allow the termination to proceed and document in the case that the re-determination is complete. If resources are below the standard, finalize the S02 coverage and allow the case to trickle to S95 or S99 medically needy coverage if appropriate.

EXAMPLE

Joe receives GA cash assistance and CN medical based upon an approved non-grant medical decision with disability end date waived. He has no income. In the month he turns 62 he reports to the department that he is eligible to draw early retirement benefits from social security in the amount of $400 per month. 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 medical standard, screen in and approve an S02 medical program so his medical coverage can continue.

GA-X clients who are still pending a final disability determination by Social Security Administration remain eligible for CN medical until one of the following occurs:

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 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B - Reconsideration - Appeal request dismissed, withdrawn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.

Healthcare for Workers with Disabilities (HWD)

If the client is under age 65 and working and is not otherwise eligible for S02 coverage, consider for the Healthcare for Workers with Disabilities (HWD) program. Allow the termination under the original program to proceed (allowing advance and adequate notice) and screen in an S08 coverage group.

Set a barcode tickler to the HWD unit in DMS at CSO132@HWD 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.

A working client who is eligible under a Home and Community Based CN waiver program (C01 in ACES) whose income goes over the Special Income Level (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 and the Division of Developmental Disabilities have included the HWD program as an available coverage group in their CN waivers. An ADSA client may transition from the C01 program to the S08 program and remain eligible for long term care funding for waiver services.

Family Medical

When a family medical program closes, review the case record to detemine if any Sneede/Kizer characteristics apply and if any of the adults may remain eligible for CN coverage due to the establishment of separate medical assistance units. See WAC 388-408-0055(2) for rules relating to Sneede/Kizer.

If the adults do not qualify under Sneede/Kizer, do an Ex-Parte review of the case record. Is there a report of pregnancy or a disability in the record? Is the client working with a department social worker to pursue SSI or has the client reported medical conditions or mental health concerns which have limited their ability to participate in Workfirst? If not, allow medical to open for the children and send a termination notice to the adults in the household.

ACES generates the 06-08 General Termination Benefits for an Individual letter but does not include the correct termination reason. Be sure to add the reason the case closed and the correct WAC reference to the freeform text.

EXAMPLE

Jack and Jill and their two children receive medical coverge 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 coverage.

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 medical (P02) program 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. He does not claim a disability and SOLQ does not show an application for SSI or Social Security disability. Allow the termination for Jack to proceed. The medical re-determination process is complete once it has been documented in the ACES narrative.

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