Medical Re-Determination

Revised June 2, 2009

Purpose: To define medical re-determination, describe when a medical re-determination is required, and to provide step by step directions through the process.

ACES PROCEDURE FOR CONTINUED SSI RELATED ELIGIBILITY

Screen in or use Add a program S02 or S08 medical AU.

Fin Resp codes are:

[PN] person being continued on Medicaid

[SP] spouse;

[SC] children

Code the DEM2 screen Disability/Incapacity fields as follows:

Remark behind DEM2 that the disability coding dated XX/XX/XX is a work-around to continue medical during a re-determination.

Allow the system to determine CN or MN based on the income/resource limits for the SSI related program.

The system sets a 12 month certification period for S02. Set an alert for 4 months to contact the social worker for a progress update. If the determination is still in progress, set an alert for 2 months. If the client is not cooperating with the determination, proceed with the termination of continued medical.

PROCEDURE FOR CLIENTS NO LONGER ELIGIBLE FOR SSI CASH

ACES sends terminated SSI clients Letter 22-05 with a review. The SDX interfaces with ACES triggering alert 248. When alert 248 is received, set a 450 alert for 15 days to check DMS for the review; the case remains open and another alert (251) is sent if the case remains open 60 days after the SSI termination.

Leave the client on their current SSI Medicaid medical coverage group (S01) while the re-determination is in progress;

If no review is returned:

Remove the SSI disability codes on DEM 2 so the case will close. Do not override 10 day advance notice;

If a review is received:

If client is over resources for S02/S95/S99, close the SSI case as stated above. Screen and process S02 and allow the denial for excess resources.

If over income for S02, close SSI case as above; screen in S02 and allow the system to trickle to S99 with spend-down. Screen in S08 if the excess income is due to earnings.

WORKING THE SSI TERMINATION REPORT

Look for the review in DMS; if older than 3 months, or not there, send out another review. Set 450 alert for return. Follow procedures above.

Clarifying Information

According to federal law, when eligibility ends for one CN Medicaid program, the department must look at eligibility for any other Medicaid program before terminating CN coverage. When an Assistance Unit is terminating, each member must be considered for all other Medicaid programs.

Federal rule is found in WAC 388-434-0005(12) and WAC 388-418-0025.

Besides correctly determining eligibility for any other Medicaid program, we must demonstrate by written documentation in the client’s electronic record that a re-determination has been completed. This written documentation belongs on the ACES Narrative screen. If the decision is not documented, the case will be found in error even if the correct action took place.

Persons in the following medical coverage groups require a re-determination:

SSI terminations (S01, L01,etc)

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 (F06)

Pregnancy Medicaid (P02)

Breast and Cervical Cancer (S30)

Institutional Medicaid (L02)

Non institutional Medicaid in Alternative Living Facility (G03)

Hospice & Home and Community Waivers (C01)

There are certain reasons for termination that do not require a re-determination action:

Death

Moved out of the State of Washington

Client not federally qualified to receive Medicaid due to immigration status

Whereabouts unknown

Client specifically requests medical to be closed

Medicaid categories to be considered during re-determination are:

Family

Children under 19

Pregnancy

Aged/Blind/Disabled

The system sends the following alerts when a re-determination of medical benefits is required for a member or members of an AU:

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

Both 416 and 322 AU trickled from TANF/F01 to F04

The system tells us certain facts about the client. We can see the age of the person (for children or aged), whether a current pregnancy is recorded, whether a disability is recorded, and if benefits are received as a result of that disability.

Client documents to review are found in DMS; and, for TANF, narration in EJAS.

Parents may be eligible for F04 when Sneede/Kizer rules are applicable.

See WAC 388-408-0055 (2) for Sneede characteristics

WORKER RESPONSIBILITIES

Conduct a medical re-determination when taking a termination action on one of the above medical coverage groups or when receiving a termination alert.

Examine the record of each affected client within a terminated AU.

AUTOMATIC CONTINUED ELIGIBILITY

Some clients have automatic entitlement to continued medical.

Place children under 1 yr. of age whose mother was receiving Medicaid at the time of their birth on the F05 program through the month of their first birthday.

Place all other children on F06 through the end of the 12th month from the last review or application. Effective with July 2005, children retain eligibility for CN Medicaid for 12 months regardless of changes. Note: a child does not qualify for the 12 months continuous coverage when aging out at 19.

Place pregnant women on the P02 program. Once eligible for CN, pregnant clients retain eligibility through the 60 day post-partum period regardless of changes to the household.

Place persons 65 or older on the SSI related program (S02).

If none of the above situations are applicable, but a person is receiving SS Disability, place client on the SSI related program (S02).

Note: SSI related (S02) may trickle to a spend-down (S99) in pending status. Finalizing spend-down concludes the re-determination process. SEE LETTERS SECTION BELOW

EX-PARTE REVIEW FOR ELIGIBIITY

For all others, search ACES, DMS and EJAS for evidence of a claim of disability or pregnancy.

GA-X recipients, whose SSI denial is upheld at hearing and who did not provide proof of an appeal, are not eligible for disability medical. Review for claim of pregnancy but do not refer for a disability determination.

If the final SSI determination is unfavorable or the client fails to follow through with appeals process: review for claim of pregnancy but do not refer for disability determination.

If nothing is found in the electronic record, SOLQ, the DMS system, or EJAS, the termination can proceed and the re-determination is considered complete. This is called an “ex-parte” review.

Conditional text on the termination letter tells the client that we have looked at all other programs.

Document the process and the action taken in the ACES Narrative. Remember, if the re-determination process is not documented, we cannot prove that we re-determined medical and the case will be found in error even when we have taken the correct action.

EXAMPLE

An AU consisting of mother, father and two children on F02 extended medical is terminated when the earnings report is not returned.
Place the children on the F06 program through the end of the 12 month cert period established for the F02;
There’s a future EDD on mom’s DEM1 screen so she can be placed on the pregnancy program (P02) through the post partum period;
Neither the electronic record (ACES) nor any document in DMS or EJAS shows potential Medicaid eligibility for dad. SOLQ does not show any application for SSI or SSA disability. His termination is allowed to proceed.
Document on the Narrative the action taken for all members with the notation that the re-determination is complete.

NOTE:

The system does not yet support transferred Medicaid eligibility across programs lines for children and pregnancy. You may be required to reduce income in order to pass the applicable standard. Be cautious of income valid value codes when the client also receives Basic Food benefits. Be sure and document that income has been lowered to meet the terms of continued eligibility.

When the record search (DMS or EJAS) indicates a claim of disability, check SOLQ for evidence of an application for SSI or SSA benefits. If yes, follow office procedure for notifying DDDS of client’s continued eligibility based on the disability application. Ask to be notified when the decision has been made or if client is not cooperating with the decision process. Open SSI related medical, S02. Allow trickle to S95/S99 due to income. Set an alert for 4 months and check with DDDS for a decision. Set an alert for another two months to check on the progress of the request. When DDDS denies the disability claim, or reports non-cooperation with the application process, the re-determination has been completed. Terminate the continued medical.

When there is a claim of disability in the record search but no evidence in the record to proceed with a DDDS referral, contact the client for medical documents. Give 20 days for a response. If no response, allow the termination to proceed. Document the action taken with a notation that the re-determination is complete.

Add freeform text to the termination letter telling the client that they may apply at Social Security Administration for disability benefits.

EXAMPLE

In a two parent TANF AU, a parent claims on the last review that he is disabled. The record search (DMS, EJAS, SOLQ) shows no evidence to substantiate the claim. Contact the client by letter for medical information regarding the claim of disability. Allow 20 days; if the client does not respond, proceed with the termination. The re-determination is then complete. Narrate the process and action taken. SEE LETTERS SECTION BELOW

EXAMPLE

In the case above, the client responds with a doctor statement. Follow your office procedure for consideration of the client for SSI related non-grant medical assistance (NGMA). Be sure to include on the referral that the client is on continued medical pending the disability decision. Follow ACES procedures to continue medical. SEE LETTERS SECTION BELOW.

LETTERS

Automatic Eligibility:

Allow system generated approval letter 002/10 or 002/12. No additional text is required; however some informational text may reduce questions.

The child listed above is entitled to continued medical through the month that they turn 1 year of age.

The child(ren) listed above are entitled to the remaining months of a 12 month continued medical eligibility period.

The person listed above is pregnant and is entitled to continued medical through the 60 day post-partum period.

The person listed above is eligible for continued medical. They are related to SSI because of age or a disability.

Ex-parte of Record for evidence of disability:

No disability claim in record; Allow system to terminate. Letter 006-01 has a text block stating that we have looked at all other programs. If other members of the terminated AU are being approved for medical, add free form text

Other members of your household will get a separate letter about their continuing medical benefits.

Record shows SSA disability application in process: System will generate the 006/01 termination letter. Add free form text. Suggested text:

You can no longer get medical benefits under the (TANF, Family Related; General Assistance) program. However your record shows that you have applied to Social Security(SSA) for disability benefits. Your medical coverage is being continued while SSA decides if you can receive disability payments. Please let us know as soon as SSA tells you their decision.

The system will generate letter 002/12 approval for medical letter when the S02 program is finalized. Suppress this notice as the continued medical is addressed as free form text on the termination letter.

If processing an S08 case, follow office procedures. The approval letter explaining the program and stating the premium amount must be sent to the client.

Record shows claim of disability, but no evidence: System will generate the 006/01 termination letter. Add free form text. Suggested text:

You can no longer get medical benefits under the (TANF, Family Related; General Assistance) program. Your record shows you claim to have a disability that prevents you from working, but we do not have any medical information in our records to support that claim. Please bring in all medical documents you have about your disability so that we can determine whether you can get medical benefits due to a disability. Please respond within 15 days. If we do not hear from you, we will not look at the disability medical program; we will not continue your medical benefits.

If no response to above letter: Generate another 006/01; add free form text. Suggested text:

We asked for medical information so we could see if you can get disability medical benefits. We have not heard from you. If you are disabled, you may apply for disability benefits through the Social Security Administration (SSA) or apply for disability medical benefits from any of our offices.

If client does respond with medical evidence, follow office procedures for a DDDS referral. Screen and finalize SSI related S02/S95/S99. Add free form text to letter 002/12. Suggested text:

Your disability claim has been referred to the Division of Disability Determination Services (DDDS). If more medical evidence is needed to make the determination, they will contact you. Your medical coverage will continue while this decision is being made.

If the client’s income places them into a pending spend-down add freeform text to the spend-down letter. Suggested text:

Your disability claim has been referred to the Division of Disability Determination Services (DDDS) to decide if you can receive medical based on a disability. We told you that your medical would continue while DDDS makes the disability decision. However, your (income/resources) puts you above the Categorically Needy (income/resource) limit. You must incur the stated amount in medical expenses before medical coverage can begin.

SSI termination/no response to review request:

Add free form text to Letter 006-01; Suggested text:

Your SSI medical coverage has ended and we asked for a review so we could look at other medical programs for you. You did not return the review and we could not establish eligibility for any other medical program.

If a GA-X client's SSI denial was upheld by an Administrative Law Judge, and the client has not filed an appeal with the SSA Appeals Council, generate 006/001; add free form text. Suggested text:

An Administrative Law Judge has upheld your SSI denial and you didn't provide proof that you filed a timely appeal. You are not eligible for SSI related medical benefits from the GA-X program.

Automatic Eligibility:

Allow system generated approval letter 002/10 or 002/12. No additional text is required; however some informational text may reduce questions.

The child listed above is entitled to continued medical through the month that they turn 1 year of age.

The child(ren) listed above are entitled to the remaining months of a 12 month continued medical eligibility period.

The person listed above is pregnant and is entitled to continued medical through the 60 day post-partum period.

The person listed above is eligible for continued medical. They are related to SSI because of age or a disability.

Ex-parte of Record for evidence of disability:

Other members of your household will get a separate letter about their continuing medical benefits.

Record shows SSA disability application in process: System will generate the 006/01 termination letter. Add free form text. Suggested text:

You can no longer get medical benefits under the (TANF, Family Related; General Assistance) program. However your record shows that you have applied to Social Security(SSA) for disability benefits. Your medical coverage is being continued while SSA decides if you can receive disability payments. Please let us know as soon as SSA tells you their decision.

If processing an S08 case, follow office procedures. The approval letter explaining the program and stating the premium amount must be sent to the client.

Record shows claim of disability, but no evidence: System will generate the 006/01 termination letter. Add free form text. Suggested text:

You can no longer get medical benefits under the (TANF, Family Related; General Assistance) program. Your record shows you claim to have a disability that prevents you from working, but we do not have any medical information in our records to support that claim. Please bring in all medical documents you have about your disability so that we can determine whether you can get medical benefits due to a disability. Please respond within 15 days. If we do not hear from you, we will not look at the disability medical program; we will not continue your medical benefits.

If no response to above letter: Generate another 006/01; add free form text. Suggested text:

We asked for medical information so we could see if you can get disability medical benefits. We have not heard from you. If you are disabled, you may apply for disability benefits through the Social Security Administration (SSA) or apply for disability medical benefits from any of our offices.

If client does respond with medical evidence, follow office procedures for a DDDS referral. Screen and finalize SSI related S02/S95/S99. Add free form text to letter 002/12. Suggested text:

Your disability claim has been referred to the Division of Disability Determination Services (DDDS). If more medical evidence is needed to make the determination, they will contact you. Your medical coverage will continue while this decision is being made.

If the client’s income places them into a pending spend-down add freeform text to the spend-down letter. Suggested text:

Your disability claim has been referred to the Division of Disability Determination Services (DDDS) to decide if you can receive medical based on a disability. We told you that your medical would continue while DDDS makes the disability decision. However, your (income/resources) puts you above the Categorically Needy (income/resource) limit. You must incur the stated amount in medical expenses before medical coverage can begin.

SSI termination/no response to review request:

Add free form text to Letter 006-01; Suggested text:

Your SSI medical coverage has ended and we asked for a review so we could look at other medical programs for you. You did not return the review and we could not establish eligibility for any other medical program.

ACES NARRATIVE

Suggested Text:

*** Redetermination***rec’d alert; AU of mom, dad, two children terminated from F02 for no earning report; children to F06; mom to P02; dad claims disability on app in DMS; no medical documents in file; request for medical evidence on 006/01 to client; set alert 15 days; dad put on cont med S02.

***Redetermination***rec’d alert; no response to request for info; closed S02; 006-01 letter sent; re-determination complete.

***Redetermination***AU of unmarried parents, mom’s child, dad’s child, common child terminated from TANF/F01 for dad’s excess UC income; S/K case; mom and her child to F04; common child toF06; dad’s child to F06; dad not eligible, no claim of disability on app or review in DMS; 006-01 sent for dad; redetermination complete.

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