Per guidelines from the Centers for Medicare and Medicaid Services (SHO #16-007), an incarcerated individual at a correctional facility, may submit an application and if found eligible will have their medical benefits suspended. Incarceration status is not an eligibility factor and does not prevent someone from applying and being found eligible for MO HealthNet (MHN), but does prevent MHN from being used, so the participant must be suspended while they are incarcerated.
NOTE: Medical claims will not be paid for the suspended participant by MO HealthNet Division (MHD). MHD may recoup payments made while a participant was incarcerated (42 CFR 435.1009 and RSMo 208.158).
An application should be processed as if the incarcerated participant is living in the home, as long as they are expected to return to the home. When benefits are suspended, the participant would still be included in an eligibility determination or household composition, depending on tax filing status. An incarcerated participant follows the same eligibility unit guidelines as if they are not incarcerated and are living in the home, as long as they are expected to return.
EXAMPLE: Anna and Bill are married and apply for MHN for themselves and their 3 children. Bill is incarcerated at Department of Corrections (DOC), but Anna will file a joint tax return and Bill is expected to return to the home when he is released. The application is approved for all 5 household members. Bill’s MHN is suspended, but he remains a member of the eligibility unit for his own eligibility and other household members’ eligibility.
If an incarcerated participant was not in the home prior to incarceration, or is not expected to return to the home upon release, the application should be completed based on the participant’s eligibility unit at the time of the application.
EXAMPLE: Connie applies for MHN for herself. She is incarcerated at Jackson County Jail. There is a previous eligibility determination that included Connie’s wife, however, she does not include her on the current application. There is no reason to assume that Connie is still living with her wife or will return to her home upon release. Process the application for Connie based on the circumstances that were reported on the application.
If the participant is eligible for MHN but is incarcerated, approve the application and take immediate action to suspend benefits as of the date when the participant is eligible and incarcerated. However, if the incarcerated participant is ineligible for MHN, reject the application.
NOTE: When a suspended participant is released, their medical benefits must be restored, if still eligible, without requiring a new application. See 1885.040.00 Suspension of MAGI Benefits for Incarcerated Individuals.
Incarcerated individuals are eligible for medical claims only for the dates they have an inpatient status in a medical facility. An incarcerated individual must:
- Have an inpatient stay of 24 hours or more at a medical facility. Time in the emergency room counts toward the 24-hour total stay when the incarcerated individual is later admitted to inpatient status, AND
- Meet all other eligibility factors for the specific program, such as resources, citizenship, age, etc.
If an incarcerated participant is approved for an inpatient stay, suspend the incarcerated participant for all dates of the month except for the period of the inpatient stay. Suspend the participant for ongoing dates once they have returned to the correctional facility.
EXAMPLE: Carl is an incarcerated individual at the Cole County Jail and was admitted to the hospital on December 15. Carl remained in the hospital until December 17 and then returned to Cole County Jail. Carl submitted an application, Inpatient Coverage for Incarcerated Participants (IM-151) and all necessary verification on December 19. Carl was found eligible for MO HealthNet for the Aged, Blind, and Disabled (MHABD).
FSD approved MHABD and MHD entered suspension for December 1 – December 14, allowed the hospital expenses for December 15- December 17, and entered suspension for December 18 and ongoing. A redetermination will be completed when FSD is notified of Carl’s release from the Cole County Jail to determine if he remains eligible for MHABD or another MO HealthNet program. If continued eligibility exists, MHN benefits will be restored, for the program he is eligible for, when he is released.
A suspended participant who has an inpatient stay does NOT need to complete a new application. The participant should complete the Inpatient Coverage for Incarcerated Participants (IM-151) and provide proof within 10 days of the end of the inpatient event. Medical facility staff, jail/prison staff, or the participant (or their representative) may submit the IM-151 to FSD. FSD reviews the information provided and makes a determination if the inpatient event qualifies for MO HealthNet coverage.
NOTE: Suspension is entered for suspended participants by a specialized unit. Refer to 2021 IM Email Memo #9 for instructions to send to the specialized unit for suspension.
FSD will notify MO HealthNet Division (MHD), the participant, and their authorized representative (if applicable) of the eligibility decision. Department of Corrections (DOC) may also receive information regarding eligibility during an inpatient event as allowed by agreements between DOC, FSD, and MHD.