IM-74 September 25, 2009; IM-1 January 07, 2009
When closing an age-eligible woman in any MHF/MHK/MHABD program, include reviewing eligibility for UWHS in the exparte process if the participant is no longer eligible for any other MO HealthNet program. When a participant is determined ineligible for any Mo HealthNet Program in FAMIS and the participant is female and between the ages of 18-55, FAMIS will automatically register an Uninsured Women’s Health Services (UWHS) application. FAMIS does not register a UWHS application if the Mo HealthNet program that is being closed is in the Legacy system.
NOTE: A woman eligible for EWHS after the 60-day postpartum eligibility for MO HealthNet for Pregnant Women ends is to remain on EWHS as long as she remains eligible. FAMIS explores eligibility for UWHS prior to EWHS ending by registering a UWHS application in the participant’s eleventh month of EWHS coverage. If all information needed to determine eligibility for UWHS is in FAMIS, FAMIS approves or rejects the participant for UWHS and sends the participant an Action (FA-450) notice informing them of the decision on the UWHS application. If additional information is needed to determine eligibility for UWHS the eligibility specialist must complete an eligibility determination and FAMIS sends a Request for Information (FA-325) notice overnight requesting any additional information needed to determine eligibility.
Automatic Registration of a UWHS Application When a Participant is No Longer Eligible for another MO HealthNet Program in FAMIS
When a participant loses eligibility for any MO HealthNet program an ex-parte review is completed. Part of the ex-parte process is exploring eligibility for the UWHS program.
For MO HealthNet programs in FAMIS that receive a Pre-Closing (FA-411) notice prior to benefits being discontinued, such as MO HealthNet for Families and MO HealthNet for Kids programs, FAMIS registers a UWHS application when a Pre-Closing (FA-411) notice is sent. If eligibility can be determined based on information currently in FAMIS, FAMIS approves the UWHS application and completes action to discontinue MHF or MHK coverage. If approved for UWHS, the participant(s) receives an Action (FA-450) notice. The notice provides information on the participant’s approval for UWHS and coverage for this program. If the participant’s Pre-Closing (PRCL) or Adverse Action Close (AACL) is voided after a UWHS application is automatically registered, the system rejects the pending UWHS application. If the system initiates another PRCL, the system will automatically register another UWHS application.
For EWHS and TMH participants who do not receive a Pre-Closing (FA-411) notice FAMIS registers a UWHS application when the participant is in their eleventh month of coverage. If the TMH coverage is ending for not returning the quarterly report form, the system will automatically register a UWHS application the month that precedes the date TMH is scheduled to close.
Example: The Smith family consists of mom, dad, son, and daughter. The household applies 9/1/09 and is eligible for MO HealthNet for Families (MHF) beginning 9/1/09. They were not eligible for prior quarter coverage. On 9/05/09, Mr. Smith begins employment and provides verification of income to the eligibility specialist. Mr. Smith’s income results in ineligibility for MHF beginning 10/1/09. The FAMIS system sends a Pre-closing (FA-411) notice and registers a UWHS application on 9/5/09 for Ms. Smith. All verification needed to determine eligibility for UWHS for Ms. Smith is in FAMIS. Ms. Smith is determined eligible for UWHS. FAMIS approves Ms. Smith’s UWHS application, sends an Action (FA-450) notice, and completes action to discontinue MHF coverage.
Example: Mr. and Mrs. Jones and their two children are receiving Transitional MO HealthNet (TMH). Their Transitional MO HealthNet coverage is ending 11-30-2009. In October FAMIS registers a UWHS application for Mrs. Jones. All information necessary to determine eligibility for UWHS is in FAMIS. Mrs. Jones is determined eligible for UWHS. FAMIS approves Mrs. Jones for UWHS coverage and sends her an Action (FA-450) notice.
The participant’s available resources are an eligibility requirement for the UWHS program. Available resource information for UWHS is recorded on the Net Worth (FMh2 or NETWORTH) screen in FAMIS. If available resource information is needed for approval of the UWHS application, the system creates an Insufficient System Data (ISD). The eligibility specialist must complete an eligibility determination (EDRES) to create an outstanding verification for available resources. FAMIS sends a Request for Information (FA-325) notice overnight to request available resource information. If verification is provided the eligibility specialist enters this information on the Net Worth (FMh2 or NETWORTH) screen and FAMIS approves or rejects the UWHS application based upon the information entered and completes action to discontinue coverage for the other MO HealthNet program. If verification is not provided by the UWHS application due date, the system rejects the UWHS application and sends the participant an Action (FA-450) notice. Action to discontinue other MO HealthNet coverage is completed following the UWHS rejection.
Example: Ms. McGee is receiving Extended Women’s Healthcare Services (EWHS). Ms. McGee is losing EWHS coverage as her 12 month eligibility period ends in October. FAMIS registers a UWHS application in September, Ms. McGee’s eleventh month of EWHS coverage. No information regarding available resources is recorded on the Net Worth (FMh2 or NETWORTH) screen in FAMIS. FAMIS creates an Insufficient System Data (ISD). The eligibility specialist completes an eligibility determination (EDRES) to create an outstanding verification for available resources and FAMIS sends Ms. McGee a Request for Information (FA-325) notice for available resource information. Ms. McGee provides the requested information and the eligibility specialist enters the information on the Net Worth (FMh2 or NETWORTH) screen in FAMIS. Ms. McGee meets all eligibility requirements for UWHS. The eligibility specialist approves her UWHS application. FAMIS sends an Action (FA-450) notice to inform Ms. McGee of her approval and coverage for UWHS and completes action to discontinue EWHS coverage.
Exploring Eligibility for UWHS When a Participant Is No Longer Eligible for a MO HealthNet Program in Legacy
FAMIS does not register a UWHS application if the MO HealthNet program that is closed or rejected in the Legacy system. For example, if a participant’s MO HealthNet for the Aged, Blind, and Disabled (MHABD) case is closing, FAMIS does not automatically register a UWHS application. However, it is required that the UWHS program be explored during the ex-parte process for the programs administered in the Legacy system. Continue to explore UWHS eligibility for any MO HealthNet programs in the Legacy system using current procedures.