Medical Re-Determination
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Medical Re-Determination

Revised April 19, 2012

Purpose: To define medical re-determination, describe when a medical re-determination is required, and to provide step by step directions through the process.
WAC 182-504-0125Effect of changes on medical program eligibility. (Emergency rule effective 2/29/12.)
WAC 388-434-0005How often does the department review my eligibility for benefits?

Definition:  When eligibility ends for a CN Medicaid program, federal law requires the Agency (or its designee) to look at eligibility for other Medicaid programs before terminating CN coverage.  Re-determination is complete at the point the agency  considers eligibility for other Medicaid programs and documents in ACES that the reconsideration has been completed.

Without documentation of the re-determination process, the case will be found in error even if the correct action has been taken.


NOTE:

CN eligibility may end at the point of re-determination, even while waiting on a final disability determination, if income causes the CN medical (S02) to trickle to medically needy (MN) medical (S95/S99).  

 

WAC 182-504-0125

WAC 182-504-0125

Effective November 18, 2011

WAC 182-504-0125 Effect of changes on medical program eligibility. (Emergency rule effective 2/29/12.)

1.  An individual continues to be eligible for medical assistance until the agency or the agency's designee completes a review of the individual's case record and determines the individual is ineligible for medical assistance or is eligible for another medical program. This applies to all individuals who, during a certification period, become ineligible for, or are terminated from, or request termination from:

a.  A categorically needy (CN) medicaid program;

b.  A program included in apple health for kids; or

c.  Any of the following cash grants:

i.  Temporary assistance for needy families (TANF);

ii.  Supplemental Security Income (SSI); or

iii.  Aged, blind, disabled (ABD) cash assistance. See WAC 388-434-0005 for changes reported during eligibility review.

2.  If CN medical coverage ends under one program and the individual meets all the eligibility requirements to be eligible under a different CN medical program, coverage is approved under the new program. If the individual's income exceeds the standard for CN medical coverage, the agency or the agency's designee considers eligibility under the medically needy (MN) program where appropriate.

 

3.  If CN medical coverage ends and the individual does not meet the eligibility requirements to be eligible under a different medical program, the redetermination process is complete andmedical assistance is terminated giving advance and adequate notice with the following exception:

a.  An individual who claims to have a disability is referred to the division of disability determination services for a disability determination if that is the only basis under which the individual is potentially eligible for medical assistance. Pending the outcome of the disability determination, medical eligibility is considered under the SSI-related medical program described in chapter 388-475 WAC.

b.  An individual with countable income in excess of the SSI related CN medical standard is considered for medically needy (MN) coverage or medically needy (MN) with spenddown pending the final outcome of the disability determination.

4.  An individual who becomes ineligible for refugee cash assistance is eligible for continued refugee medical assistance through the eight-month limit, as described in WAC 388-400-0035(4).

 

5.  An individual who receives a TANF cash grant or family medical is eligible for a medical extension, as described under WAC 388-523-0100, when the cash grant or family medical program is terminated as a result of:

a.   An increase in earned income; or

b.  Collection of child or spousal support.

6.  Changes in income during a certification period affects eligibility for all medical programs except:

a.  Pregnant women's CN medical programs;

b.  A program included in apple health for kids, except as specified in subsection (5) of this section; or

c.  The first six months of the medical extension benefits described under chapter 388-523 WAC.

7.  A child who receives premium-based coverage under a program included in apple health for kids described in WAC 388-505-0210 and chapter 388-542 WAC must be redetermined for a nonpremiumbased coverage when the family reports:

a.  Family income has decreased to less than two hundred percent federal poverty level (FPL);

b.  The child becomes pregnant;

c.  A change in family size; or

d. The child receives SSI.

8.  An individual who receives SSI-related CN medical coverage and reports a change in earned income which exceeds the substantial gainful activity (SGA) limit set by Social Security Administration no longer meets the definition of a disabled individual as described in WAC 388-475-0050, unless the individual continues to receive a Title 2 cash benefit, e.g., SSDI, DAC, or DWB. The agency or the agency's designee redetermines eligibility for such an individual under the health care for workers with disabilities (HWD) program which waives the SGA income test. The HWD program is a premium-based program and the individual must approve the premium amount before the agency or the agency's designee can authorize ongoing CN medical benefits under this program.

 

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.

WAC 388-434-0005

WAC 388-434-0005

Effective December 1, 2011

WAC 388-434-0005 How often does the department review my eligibility for benefits?

  1. If you receive cash assistance, the department reviews your eligibility for assistance at least once every twelve months.   

  2. When it is time for your eligibility review, the department requires you to complete a review.  We use the information that you provide to determine your eligibility for all assistance programs. 

  3. If you complete an interview for assistance with a department representative and sign the printed Application for Benefits (AFB) form, you do not have to complete a separate review form.

  4. For cash assistance, an eligibility review form or the AFB must be dated and signed by both husband and wife, or both parents of a child in common when the parents live together.

  5. For medical assistance, a signature is not required to complete your review.

  6. We may review your eligibility at any time if we decide your circumstances need to be reviewed sooner.

  7. At your review, we look at:

    1. All eligibility requirements under WAC 388-400-0005 through 388-400-0035, 388-503-0505 through 388-503-0515, and 388-505-0210 through 388-505-0220.

    2. Changes since we last determined your eligibility; and

    3. Changes that are anticipated for the next review period.

  8. If you receive medical assistance, we set your certification period according to WAC 182-504-0015, WAC 182-504-0020, WAC 182-504-0025, and 388-416-0010.

  9. You are responsible for attending an interview if one is required under 388-452-0005.

  10. If you do not complete the eligibility review for cash assistance, we consider you to be withdrawing your request for continuing assistance:

    1. Your cash assistance benefits will end.

    2. Your medical benefits will continue for twelve consecutive months from the month we received your most recent application or eligibility review.

  11. We will send you written notice as described under chapter 388-458 WAC before assistance is suspended, terminated or a benefit error is established as a result of your eligibility review.

  12. If you currently receive Categorically Needy (CN) medical assistance, and you are found to no longer be eligible for benefits, we will determine if you are eligible for another program.  Until we decide if you're eligible for any other programs, your CN medical assistance will continue per WAC 182-504-0125.

  13. When you need a supplemental accommodation under 388-472-0010, we will help you meet the requirements of this section.

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.

CLARIFYING INFORMATION

This section provides a brief overview of when a medical re-determination is required.

WORKER RESPONSIBILITIES

This section discusses the medical re-determination processes for the following. Clients who:

  • Remain eligible for medicaid under continuous eligibility rules;
  • Are automatically related to a medical coverage group; they are age 65 or older, blind or disabled; pregnant or the parent or responsible relative caring for an eligible dependent child;
  • Are not automatically related to a medical coverage group and more information is needed in order to establish whether the client may qualify for medicaid under a different program.

WORKER RESPONSIBILITIES - SSI REDETERMINATION

This section discusses the re-determination process for clients who lose eligibility under the Supplemental Security Income (SSI) cash assistance program.  This section includes an overview of the automated re-determination process that ACES uses to generate reviews and notices to the client and to the agency or its designee.

WORKER RESPONSIBILITIES - SSI REDETERMINATION - SSI RELATED SPECIAL INCOME DISREGARDS

This section discusses the ACES re-determination process for clients who lose eligibility under the SSI program but who remain eligible for CN medicaid due to the SSI-related special income disregards:  Pickle, Disabled Adult Child or the Disabled Widow(er) provisions. More information can be found in Clarifying Information under WAC 182-512-0880.  

Modification Date: April 19, 2012