Medical Re-determination
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Medical Re-determination


Revised May 2, 2014



WAC 182-503-0510Washington apple health -- Program summary.

Clarifying Information

WHEN IS A MEDICAL RE-DETERMINATION REQUIRED?

A medical re-determination is required for individuals who lose CN coverage under any of the following medical groups:

  • SSI terminations (S01, L01 or L21)
  • SSI-Related Medicaid (S02, G03)
  • Medicaid coverage attached to TANF (F01)
  • Medicaid coverage attached to ABD cash assistance grants (G02)
  • Family Medicaid (F04, F03, F02, F10)
  • Children's Medicaid (F05, F06)
  • Pregnancy Medicaid (P02)
  • Breast and Cervical Cancer (S30)
  • Institutional Medicaid (L02, K01, I01)
  • Hospice and Home and Community Waiver programs (L22).

NOTE:

Medical re-determination does not apply to clients who lose eligibility under the Medical Care Services Program (MCS).


WHAT ARE THE EXCEPTIONS TO THE RE-DETERMINATION PROCESS?

A medical re-determination is not required in the following situations.  The client:

  • Dies
  • Moves out of state
  • Cannot be found (whereabouts unknown)
  • Is not federally qualified to receive Medicaid due to citizenship or immigration status
  • Asks the department to close medical coverage.

 

SYSTEM-GENERATED ALERTS THAT REQUIRE A MEDICAL RE-DETERMINATION

The ACES system helps with the medical re-determination process by sending alerts when CN coverage ends for an individual or for all members in an assistance unit (AU), however staff should not rely solely on system generated alerts to determine when a medical re-determination is required.  The following alerts require the department to follow up, make a re-determination decision and document that decision in the narrative.

Alert 416 - Case closed in batch

Alert 332 - F01/F04 AU Closed

Alert 322 - New MAU created for certain members of the closed AU

Alert 226 - Child aging out

Alert 268 - Pregnant member on closed AU

Alert 416 and Alert 322 - AU trickled from TANF F01 to F04

Alert 248 - SSI terminated, redetermine medical eligibility.

 

FORMS AND SIGNATURE REQUIREMENTS FOR MEDICAL RE-DETERMINATIONS

Signed application or eligibility review forms are NOT needed for:

  • Re-determinations of CN medical coverage for the same program (including MSP programs) with the same clients in the assistance unit, either prior to the end of the certification period or within 30 days after the case closed.  Reviews may be completed by phone or paper and documented in ACES.
  • Changing to a medical program which has a more stringent eligibility requirement (such as changing from HWD, with no resource test to CN SSI-related, which does have a resource test).  However, we do need to document in ACES that we asked the necessary questions for the more stringent requirements and what the answers to those questions were. Again, phone or paper re-determinations are acceptable.

Signed application or eligibility review forms ARE needed for:

  • When an individual is terminated from SSI and we must re-determine eligibility under a different program.   
  • Adding someone new to an assistance unit who has either not previously applied, or whose previous DSHS coverage ended more than 30 days earlier.
  • Medically Needy (MN) coverage, and whenever establishing a new base period.  If the review is completed by phone, the AFB must be printed out and sent to the client for signature. 
  • When an individual applies for a long-term care (LTC) service, such as COPES, nursing home care, or a DDD waiver, and is expected to receive the LTC service for longer than 30 days.  This includes SSI recipients.

WHAT TYPE OF RE-DETERMINATION IS REQUIRED?

There are three types of medical re-determinations:

1)  Clients who are eligible under continuous eligibility rules

  • Children terminated from any CN medical program or TANF cash are eligible through the end of their original 12-month certification period. 
  • Pregnant women terminated from any CN medical program or TANF cash assistance program are eligible for CN medical to continue through the end of the post partum period. 

NOTE:   A pregnant woman who applies for retroactive medical coverage and is found eligible for CN medical in any month of the retroactive period also remains continuously eligible for CN through the end of the post partum period.

2)  Clients automatically related to a program (See WAC 182-503-0510 )

  • Clients who are age sixty-five or older (including clients who receive ABD cash assistance and CN medicaid on the basis of being aged)
  • Clients who have already been determined disabled by Social Security Administration (SSA) or by the Division of Disability Determination Services (DDDS) (including clients who receive ABD cash assistance and CN medicaid on the basis of being blind or disabled via NGMA)
  • ABD clients who are presumptively eligible for SSI (former GA-X recipients) remain eligible for CN medicaid through the final outcome of the SSI appeals process.  If the client is denied SSI at the SSA hearing level and the client does not provide proof of an appeal, the client is not eligible for continued medical coverage under the SSI-related medical coverage group.  Review the record to see if the client is pregnant, but do not refer for a non-grant medical determination.
  • Adults in households which include an eligible dependent child are categorically related to a medical program.  Prior to terminating an adult from a family medical program, the department is required to review the record to determine if any Sneede/Kizer characteristics apply.   See WAC 182-506-0010  for Sneede-Kizer rules. 

STOP! Do not allow CN medical coverage to close for these clients until the re-determination process is complete.  If income causes the case to trickle to a medically needy spenddown program, the re-determination is considered complete.  Be sure to document in the ACES narrative.  See Worker Responsibilities- SSI Redetermination   for the process for SSI recipients who become ineligible for the SSI cash payment.


WAC 182-503-0510

WAC 182-503-0510

Effective October 1, 2013

WAC 182-503-0510 Washington apple health -- Program summary.



(1) The agency categorizes Washington apple health (WAH) programs into three groups based on the income methodology used to determine eligibility:

(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based WAH programs;

(b) Those that use an income methodology other than MAGI, called non-MAGI-based WAH programs, which include:

(i) Supplemental security income (SSI)-related WAH programs;

(ii) Temporary assistance for needy families (TANF)-related WAH programs; and

(iii) Other WAH programs not based on MAGI, SSI, or TANF methodologies.

(c) Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible WAH programs.

(2) MAGI-based WAH programs include the following:

(a) WAH parent and caretaker relative program described in WAC 182-505-0240;

(b) MAGI-based WAH adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;

(c) WAH for pregnant women program described in WAC 182-505-0115;

(d) WAH for kids program described in WAC 182-505-0210 (3)(a);

(e) Premium-based WAH for kids described in WAC 182-505-0215;

(f) WAH long-term care for children and adults described in chapter 182-514 WAC; and

(g) WAH alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based WAH program.

(3) Non-MAGI-based WAH programs include the following:

(a) SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:

(i) WAH for workers with disabilities (HWD) described in chapter 182-511 WAC;

(ii) WAH SSI-related programs described in chapters 182-512 and 182-519 WAC;

(iii) WAH long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;

(iv) WAH medicare savings programs described in chapter 182-517 WAC; and

(v) WAH alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.

(b) TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:

(i) WAH refugee medical assistance (RMA) program described in WAC 182-507-0130; and

(ii) WAH medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.

(c) Other programs:

(i) WAH breast and cervical cancer program described in WAC 182-505-0120;

(ii) WAH TAKE CHARGE program described in WAC 182-532-0720; and

(iii) WAH medical care services described in WAC 182-508-0005.

(4) Deemed eligible WAH programs include:

(a) WAH SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;

(b) WAH newborn medical program described in WAC 182-505-0210(2);

(c) WAH foster care program described in WAC 182-505-0211;

(d) WAH medical extension program described in WAC 182-523-0100; and

(e) WAH family planning extension described in WAC 182-505-0115(5).

(5) A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.

(6) If income is above the CNIL, a person is eligible for the MN program if the person is:

(a) A child;

(b) A pregnant woman; or

(c) SSI-related (aged sixty-five, blind or disabled).

(7) MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.

(8) A person who is eligible for the WAH MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another WAH program at any time.

(9) For the other specific program requirements a person must meet to qualify for WAH, see chapters 182-503 through 182-527 WAC.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

3) Clients for whom the Agency or its designee must do an Ex-Parte Review for eligibility

The Agency or its designee is required to review all our available records for all clients who lose coverage under a CN medical coverage group.  Examine the record of each affected client within a terminated AU or the record of the individual client if only certain household members are terminated from CN medical assistance.  This includes when an individual leaves a TANF household and is no longer eligible for medicaid as a TANF recipient. 

Review available records by checking the electronic case record for the last review form, application or other documents; checking notes in ACES or EJAS or check SOLQ for a current SSI application or social security disability.  If there is nothing in the record to indicate the client is pregnant or claims a disability, the termination can proceed and the re-determination is considered complete.  Document the decision in the ACES narrative. 

See WORKER RESPONSIBILITIES for more detailed processing instructions.

Modification Date: May 2, 2014