A medical re-determination is required for individuals who lose CN coverage under any of the following medical groups:
SSI terminations (S01 or L01)
SSI-Related Medicaid (S02, G03)
Medicaid coverage attached to TANF (F01)
Medicaid coverage attached to certain General Assistance Grants (GA-X, GA-A, GA-B, GA-D, GA-R)
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 (C01).
WHAT ARE THE EXCEPTIONS TO THE RE-DETERMINATION PROCESS?
Exceptions to the medical re-determination process are:
The client dies
The client moves out of state
The client's whereabouts are unknown
The client is not federally qualified to receive Medicaid due to citizenship or immigration status
The client asks the department to close medical coverage.
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 and make a re-determination decision and document that decision in the narrative in the case record.
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 eligbility.
WHAT TYPE OF RE-DETERMINATION IS REQUIRED?
There are three types of medical re-determinations:
1) Individuals who are eligible under continuous eligibility rules
Children and pregnant women who are terminated from any CN medical program or TANF cash assistance program are automatically eligible for CN medical to continue through the end of the original twelve month certification for children or through the end of the post partum period for pregnant women. In many cases, the ACES system automatically provides continuous eligibility for children by trickling to an F06 program, but there are some cases where ACES cannot change to a different coverage type.
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) Individuals who are automatically related to a program
Clients who have already been determined to be disabled by Social Security Administration or by the Division of Disability Determination Services (DDDS) or who are age sixty-fiver or older are automatically relatable to a medical program. This includes GA-D, GA-A and GA-B clients who are terminated from the general assistance cash program.
STOP! Do not allow CN medical coverage to close for these clients until the re-determination process has been completed. If income causes the case to trickle to a medically needy spenddown program, the re-determination is considered complete at the point. See Worker Responsibilities for the re-determination process for SSI recipients who become ineligible for the SSI cash payment.
GA-X recipients, whose SSI denial is upheld at the SSA hearing level and who do not provide proof of an appeal, are not eligible for continued medical 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. If the client provides proof that they have appealed the denial, SSI-related medical is continued through the final outcome of the appeal process. Contact the SSI facilitator to determine whether the client has appealed the SSA hearing denial.
Adults in households which include a dependent child are also 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 388-408-0055(2) for Sneede/Kizer rules.
3) Individuals for whom the Department must do an Ex-Parte Review for eligiblity
The department is required to review all our available records for all other 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 medical assistance. This includes when an individual leaves a TANF household and is no longer eligible for medical 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 checking SOLQ for a current application for SSI or social security disability. See Worker Responsibilities for examples of an Ex-Parte review. If nothing is found 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 record.
Modification Date: October 20, 2009
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