IM-22 April 11, 2024; IM-29 March 30, 2023; IM-15 March 9, 2021; IM-11 February 20, 2020
Legal Basis
When individuals are incarcerated and are receiving a MO HealthNet (MHN) based program, a suspension must be completed when it is reported that the individual is in custody for a period longer than thirty (30) days.
Section 1001 of the Support Act (42 USC § 1396a) outlines the framework for the act of suspension for individuals who are in a certain class of individuals who are receiving Medicaid benefits:
- Juvenile under the age of 21, or
- Former Foster Youth up to age 26
Under the RSMo §217.930 and RSMo §221.125 MHN benefits shall be suspended, rather than cancelled or terminated, for offenders entering into a correctional facility, jail, or penal facility if the Family Support Division (FSD) is notified. Upon release from incarceration, the suspension shall end and the individual’s eligibility shall be redetermined for Medicaid eligibility. The Department of Corrections (DOC) will notify FSD within twenty (20) days of receiving information that the individual is receiving MHN. As well, DOC will notify FSD within 45 days prior to release of the individual. City, county, and private jails will report to FSD within ten (10) days.
Definitions
General
Eligibility Unit (EU) – is comprised of certain identified persons who would be considered in determining eligibility for the purpose of a benefit case
Offender – is an inmate or resident of a public institution according to the definition of “inmate of a public institution” in 42 CFR section 435.1010
- This definition includes but is not limited to an inmate serving time for a criminal offense, who is being confined in a local or state prison, jail, correction, detention facility or other penal facility, regardless of adjudication status
Incarcerated – is a confined individual who meets the definition of an offender as defined for the purposes of this rule
Suspended Participant – The participant who is incarcerated and whose MHN benefits are suspended
Redetermination – process where FSD staff reviews eligibility factors prior to or upon release of a suspended participant
Restoring Benefits – process where FSD completes redetermination to continue eligibility and activate MHN benefits upon release from prison/jail
Single Member Household – an eligibility unit with only one person who is also the head of household
Multiple Member Household – an eligibility unit with at least two people with one eligible member and one head of household
Head of Household (HOH) – an eligibility unit member who is responsible for managing the benefit case
For the purposes of MAGI
Remaining Adult – the responsible adult who is still in the home when there is an incarcerated head of household
Incarcerated Participant – someone who is actively receiving MHN and becomes incarcerated
Incarcerated Individual – eligibility unit member who is incarcerated and not receiving MAGI
Processing Elements
Incarcerated Individuals:
When it is reported to FSD that an eligibility unit member is incarcerated, staff must review the case for the incarcerated individual’s role in the case and whether or not they are receiving benefits.
- If the incarcerated individual is not actively receiving MHN and is not the head of household, the incarcerated individual will remain in the eligibility unit until release or until a reported change in circumstance that would affect his/her role in the eligibility unit.
- If the incarcerated individual is not actively receiving MHN and is the head of household of a multiple member household, the eligibility unit will remain the same until FSD is notified of a change in circumstance for the eligibility unit.
- If the incarcerated individual is actively receiving MHN, suspend coverage. The incarcerated participant will remain in the eligibility unit until release or until a reported change in circumstance that would affect his/her role in the eligibility unit
Note: If policy interpretation is required to complete the act of suspending, follow appropriate supervisory channels to complete a request for policy interpretation for case specific questions.
Suspending MO HealthNet
When FSD is notified of a participant’s incarceration, MHN will be suspended for that individual. For the purposes of eligibility, the incarcerated participant and/or incarcerated individual will remain in the eligibility unit they were a part of prior to the suspension. This composition will also be applicable to all member of the eligibility unit for continued participation in a MHN benefit program. If the expected release date is thirty (30) days or less from the reported date, FSD will not take action to suspend MHN benefits.
Example: The correctional facility reports on 9/9/2019 that John was incarcerated effective 8/28/2019 and his expected release date is 9/30/2019. FSD reviews the task on 9/9/2019 and determines that the release date is in 21 days; therefore, FSD will NOT take action as the release date is less than 30 days from the reported date.
Example: The correctional facility reports on 9/9/2019 that Bob was incarcerated effective 8/28/2019 and his expected release date is 10/9/2019. FSD reviews the task on 9/9/2019 and determines that the release date is in 30 days; therefore, FSD will take action as the release date is 30 days from the reported date
If the incarcerated participant is the head of household and a single member household, he or she will receive all FSD notices while suspended. However, if the incarcerated participant is the head of household and is part of a multiple member household with a remaining adult in the home, all FSD notices will be sent to the last known home/mailing address.
If the incarcerated participant is the head of household and part of a multiple member household with NO remaining adult in the home, FSD will send a suspension notice to the incarcerated individual and establish where to send FSD notices regarding other active eligibility unit members.
Note: The last known address may be the address of the correctional facility.
Example: FSD receives a report that John is incarcerated and he is actively receiving MO HealthNet for Families (MHF) Adult. John is NOT the head of household; therefore, all FSD notices will be sent to the last known address and suspend John’s MHN benefits.
Example: FSD receives a report that Mary (age 17) is incarcerated and she is actively receiving MO HealthNet for Kids (MHK). Mary is the head of household and part of a single member household; therefore, Mary’s home address and mailing address will be updated to the institution’s address and FSD will suspend Mary’s MHN benefits.
Example: FSD receives a report that Bob is incarcerated and he is actively receiving MHF Adult. Bob is the head of household but his daughter’s mother, Kimberly, is still in the home. Therefore, Kimberly is a responsible adult for Bob’s daughter and can receive FSD notice regarding annual renewals and changes to eligibility.
Example: FSD receives a report that Steve is incarcerated and he is actively receiving MHF Adult. Steve is the head of household of a multiple member household with no other responsible adult in the home; therefore, FSD will require Steve to appoint an authorized representative or appoint a responsible contact for the remaining eligibility unit members, unless the remaining eligibility unit members are in care of the State.
Example: FSD receives a report that Eric is incarcerated and he is actively receiving MHF Adult. Eric is the head of household of a multiple member household with no other responsible adult in the home. FSD determines the remaining eligibility unit members are in care of the State. FSD will remove the eligibility unit members who are in State care and Eric is now a head of household for a single member household.
It is reasonable to assume that earned income for the incarcerated participant has ended. Income for the incarcerated participant will end the month in which the incarceration was reported to FSD. Supplemental Security Income (SSI) will be suspended after 30 days of incarceration. Social Security Disability and Social Security Retirement income will end after an incarcerated individual is convicted, but may continue during incarceration prior to conviction. If the source of unearned income is pension/retirement (income not based on eligibility factors), it is reasonable to assume that the incarcerated participant’s income will NOT end.
Example: DOC reports on 9/9/2019 that John was placed in custody on 7/23/2019. John works for McDonalds and it is reasonable to assume that he will no longer receive paychecks from his employer. Income for John will end in September 2019.
Example: Pettis County Jail reports on 9/9/2019 that Steven was placed in custody on 9/2/2019. Steven works for Wal-Mart and it is reasonable to assume that he will no longer receive paychecks from his employer. Income for Steven will end in September 2019.
Example: St. Louis City Jail reports on 9/9/2019 that Mary was placed in custody on 9/3/2019. Mary’s income source is her pension/retirement from General Motors. Mary’s income will still count in the MHN eligibility unit budget.
Example: Jefferson City Jail reports on 9/9/2019 that Sue was placed in custody on 9/3/2019. Sue’s income source is her pension/retirement from Unilever. Sue’s income was not ended in MEDES. Her husband, John, later reports that Sue’s pension/retirement from Unilever has ended and he provides a letter from Unilever advising that her pension/retirement will be terminated on a particular date. End the income source as of that date.
Example: Kansas City Jail reports on 9/9/2019 that Jane was placed in custody on 9/3/2019. Jane’s income source is her pension/retirement from Garmin. Jane’s income was not ended in MEDES. Her husband, Bob, later reports that Jane’s pension/retirement from Garmin has ended and he did NOT provide verification. FSD will send a request verification (IM-31A) and send the Authorization for Release of Information (IM-6) to the eligibility unit.
Example: Cole County Jail reports on 9/9/2019 that Bill was placed in custody on 9/2/2019. Bill is receiving SSA benefits (disability). It is reasonable to assume that his unearned income will end because the benefit is based on eligibility factors. Income for Bill will end in September 2019.
Note: If it is reported that the incarcerated participant’s pension/retirement (unearned income) has ended, request verification and send the Authorization for Release of Information (IM-6) form. If remaining adult or suspended participant is not able to obtain verification (i.e. no legal relationship or unauthorized) the remaining adult or suspended participant must provide a signed clarifying statement regarding the situation.
Note: The act of suspension is an Adverse Action and requires proper notification. MHN benefits are to remain suspended as long as the incarcerated person remains incarcerated.
Applications Pending for Incarcerated Individuals
If an application is pending and the participant becomes incarcerated, continue processing the application. All requests for verification must be sent according to policy.
If staff are able to approve the application, approve benefits for any period including any prior-quarter months they are eligible for prior to incarceration, but the participant must be suspended beginning the first day of incarceration.
Example: Anthony applied for MHN 10/5/2019. He was incarcerated on 10/16/2019. His application was processed on 10/27/2019 and all information required was provided with his application. Staff approved his application with MHF Adult benefits beginning 10/1/2019. His benefits were suspended 10/16/2019.
If staff are unable to complete the application with information received, and if information is not provided during the application timeframes, reject the application for the appropriate reason, such as “Failure to provide verification” or “Failure to cooperate.”
Example: Amelia applied for MHN on 11/16/2019. She was incarcerated on 11/26/2019. While processing the application, staff sent a Request for Information (IM-31A) and requested pay stubs on 11/19/2019, with information due 12/2/2019. The information was not received and a second request was sent 12/3/19, due 12/13/2019. The information was not received. The application was rejected on 12/16/19 for failure to provide verification.
See 0110.005.00 Residence/Household Composition.
Suspension of Time Limited Benefits
Transitional MO HealthNet (TMH)
If the incarcerated participant is receiving TMH, suspend the medical benefit. Suspended MHN benefits will NOT count towards the three of the last six months test for TMH eligibility. If the TMH period ends prior to release FSD will complete a pre-closing ex parte for all other MHN programs.
- If eligibility exists after the TMH period, the new MHN program will be suspended and appropriate notices will be sent.
- If no eligibility exists after the TMH period, the participant’s eligibility will close and appropriate notices will be sent.
Example: Tom’s TMH eligibility was suspended due to his incarceration of six months. The remaining eligibility unit members’ TMH ended three months prior to his release. When Tom is released the TMH period has been completed, therefore, Tom is no longer eligible for TMH. Complete an ex parte review to explore eligibility for other MHN programs.
Example: John is receiving MHF Adult for one month prior to his incarceration. During John’s incarceration the remaining adult, Susie, reports new earned income that puts the eligibility unit over the threshold of MHF (report is timely). Because John and Susie are married, Susie’s income is countable for John’s eligibility household. John is not eligible for TMH because he was not eligible for and did not receive MHF in three of the last six months. However, John is now eligible for AEG, therefore, he will move to AEG after appropriate advance notice periods are observed. His AEG is suspended.
Example: Matt is receiving MHF Adult for three months prior to incarceration. Upon Matt’s release, the remaining adult, Mary, reports new earned income that puts the eligibility household over the threshold of MHF (report is timely). Because Matt and Mary are married, Mary’s income is countable for Matt’s eligibility household. Upon release, a redetermination is made and Matt is found eligible for TMH because he meets the test of three of the last six months.
MO HealthNet for Pregnant Women (MPW) or Show-Me Healthy Babies (SMHB)
If the incarcerated participant is receiving MPW or SMHB, suspend the medical benefit for pregnancy coverage. The suspended participant, if eligible, will have their postpartum period benefits, when applicable.
- If the delivery occurs prior to release or post-partum ends prior to release, the participant’s eligibility should be explored under other MHN programs.
- If eligibility exists after the pregnancy coverage, suspend the new MHN program and send appropriate notices.
- If no eligibility exists after pregnancy coverage, close the participant’s eligibility as no longer eligible for MHN and send appropriate notices.
Example: Mary was approved for MPW effective 11/1 with a due date of 6/15 and FSD receives a report of incarceration effective 2/5. FSD suspends Mary’s MPW eligibility during the incarceration period. On 5/26, FSD receives notice of inpatient services for labor and delivery; MPW is restored for eligible dates of service. In June, FSD is notified of Mary’s release and eligibility is redetermined as post-partum for 12 months.
Age Out
If the incarcerated participant is receiving MHN and will age out while incarcerated, FSD will complete an ex parte for all other MHN programs prior to when the participant reaches the specified age (see 1885.005.00 Age Out).
- If eligibility exists on the 19th birthday the new MHN program will be suspended and appropriate notices will be sent.
- If no eligibility exists on or after turning age 19, the participant’s eligibility will close due to being no longer eligible for MHN and appropriate notices will be sent as well as observation of adverse action period prior to closing eligibility.
Example: Alex is incarcerated while receiving MHK (non-premium) and his benefits are suspended. Alex will turn 19 years old and he is no longer eligible for MHK. FSD completes an ex parte, while he is incarcerated, for other MHN. He is eligible for MHN Adult Expansion Group (AEG). FSD will send appropriate notices.
Example: Beth is incarcerated while receiving MHN for the Adult Expansion Group (AEG) and her benefits are suspended. Beth will turn 65 years old and she is no longer eligible for AEG. FSD completes an ex parte, while she is incarcerated. FSD explores all other programs and she is ineligible for all other MHN programs. FSD will observe an adverse action period and send notices before closing Beth’s eligibility.
Renewals and Change in Circumstances While Suspended
The incarcerated participant’s eligibility will be included in the Annual Renewal process and any change in circumstances. It is the responsibility of the suspended individual, the remaining adult, and/or authorized representatives to complete annual renewals (when required) and report changes in a timely manner. FSD will take action on annual renewals and reported changes within a timely manner.
If there is a change to the suspended participant’s eligibility, FSD will allow the change or closure. Appropriate notices will be sent to the suspended participant, the household, and the authorized representative (if applicable). FSD will observe appropriate Adverse Action periods when a participant is found ineligible or eligible under a reduced benefit while suspended.
Note: Children under the age of 19 are subject to Continuous Eligibility for Children (CEC) if they or their parents are incarcerated. Refer to 1805.070.00 Continuous Eligibility for Children (CEC).
Inpatient Services
If a suspended participant requires inpatient care at a medical facility for 24 hours or more while they are incarcerated, the suspended individual may be eligible for MHN to pay for medical expenses. The participant, household member, or an authorized representative may notify Family Support Division (FSD) of an inpatient event by using the form Inpatient Coverage for Incarcerated Participants (IM-151). Additional information may be requested if a disability determination is required.
Note: The jail/prison or medical facility may also report the inpatient event to request payment for inpatient services. Any communication with entities outside of the household must be limited to information required to authorize payments.
FSD will review the inpatient coverage request and complete actions to determine if additional information is needed.
A new application is NOT required if the participant is suspended. However, if the incarcerated participant has previously been found ineligible for all MHN programs, a MO HealthNet Single Streamlined Addition form (IM-1ADP) or a full MHN application (see 1802.010.00 Requests for Benefits) is needed depending on the status of the MHN case (see 1802.000.00 Applications and 1802.010.80.05 Adding a Person to an Existing Application).
Note: If an incarcerated participant is receiving Women’s Health Services, but a change in circumstance exists, explore eligibility for other MHN programs at the time of the event.
FSD will notify MO HealthNet Division (MHD), the household, 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.
Redetermination and Restoring Benefits
Once FSD is notified of an incarcerated participant’s release, or pre-release, a redetermination must be completed and benefits restored upon release if the incarcerated participant remains eligible for the any level of care under MAGI.
If suspended participant is found ineligible, an ex parte review (refer to 1890.000.00 Ex Parte Review Process) for all other MHN programs must be completed. If the suspended individual is found ineligible for all MHN programs the participant will receive a ten (10) day Adverse Action period before the suspension is terminated regarding the reason for ineligibility.
Note: Children under the age of 19 are subject to Continuous Eligibility for Children (CEC) upon release. Refer to 1805.070.00 Continuous Eligibility for Children (CEC).