Medical Re-determination

Revised April 22, 2013

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).

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

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.