The 2018 SUPPORT for Patients and Communities Act (H.R. 6, P.L. 115-271), 42 USC § 1396a, requires that Medicaid benefits be suspended, rather than closed for juveniles under the age of 21 and Former Foster Care Youth under the age of 26.
SB 514 (2019) enacted RSMo §217.930 and §221.125 requires that all individuals who are incarcerated have his/her MO HealthNet (MHN) benefits suspended, rather than closed. The Department of Corrections (DOC) will notify FSD within twenty (20) days of receiving information that an incarcerated individual is receiving MO HealthNet. City, county, and private jails will report to FSD within ten (10) days of determining that an incarcerated individual is receiving MO HealthNet.
MHN benefits are suspended for individuals expected to be incarcerated for a period longer than 30 days, or who are incarcerated at the time of application. Suspended MHN benefits will be restored when the participant is released, a redetermination is completed by FSD, and the participant is found still eligible. A new application is NOT required for participants who were active prior to incarceration, if incarcerated on or after August 28, 2019.
NOTE: Any participants who had benefits terminated due to incarceration prior to August 28, 2019 MUST reapply for benefits.
NOTE: Depending on when the information is received and when the participant is expected to be released, there may be situations where FSD determines that it is not practical to suspend benefits and complete a redetermination to restore benefits in a timely manner, these cases will not be suspended.
Offender – 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 – refers to a confined individual that meets the definition of an offender as defined for the purposes of this policy.
Remaining spouse – The eligibility unit member who is still in the home when there is an incarcerated spouse.
Suspended participant – An individual who is incarcerated and whose MHN benefits are suspended.
Incarcerated individual – An eligibility unit member who is in jail or prison, he/she may or may not be an active participant.
Medical Review Team (MRT) Redetermination – Process where MRT requests and reviews medical records to determine disability.
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.
Household Composition and Home Address
During a period where a household member is incarcerated, he/she will remain a member of his/her original eligibility household, as long as it can be reasonably assumed that he/she will return to that household at the end of the incarceration.
For MO HealthNet for the Aged, Blind, and Disabled (MHABD), if one spouse is incarcerated, the case remains a couple case with resources and income limits of a married couple, as long as it is expected that the incarcerated spouse will return to the household when he/she is released.
- If the incarcerated spouse is a member of a couple case, the address must remain the last known or reported address so that the remaining spouse can continue to receive mail regarding the case. If the incarcerated individual is a single member household, the address must be updated to the facility’s address where he/she is incarcerated so that he/she can continue to receive notices regarding his/her MHABD case. The participant can also request to have the mail sent to an authorized representative as per 13 CSR 40-2.015.
For MO HealthNet for Disabled Children (MHDC), the incarcerated individual remains a member of the eligibility unit, whether the incarcerated individual is the disabled child or the child’s parent.
- If the incarcerated individual is the parent of the disabled child, the eligibility unit will continue to include the incarcerated parent, as long as it is expected that the incarcerated parent will return to the household when he/she is released.
- If the incarcerated individual is receiving MHDC, the address must remain the last known or reported address so that the remaining eligibility unit members can continue receiving information.
Changes at Incarceration
When an individual is incarcerated, changes must be reviewed at the time of suspension, however there should NOT be a complete annual renewal completed, unless it is time to complete the annual renewal. The jail or DOC should provide information regarding incarcerated individuals by completing the Suspending MO HealthNet Participants Form (IM-150). If a remaining household member reports changes to FSD, staff should complete the IM-150 to collect necessary information. If it can be assumed that there is no change, do NOT request verification. For resources such as bank accounts and vehicles, it should be assumed that they did not change at the time of incarceration.
If income can reasonably be assumed to end, then staff will end it.
- Employment income can be assumed to end the month of incarceration. If benefits for a remaining spouse are affected, attempt to verify the final pay check, but accept client statement if the remaining spouse is unable to provide verification for the incarcerated individual.
- Supplemental Security Income (SSI) will be suspended by Social Security Administration (SSA) 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 and should be verified.
- Veteran’s benefits may continue at a reduced rate and should be verified.
If income can reasonably be assumed to continue, then it will continue to be included in the benefit calculation unless verification is provided showing that the income has ended or changed. This may include, but is not limited to, income received from a trust, annuity, or pension.
EXAMPLE: Jake is receiving MHABD. He is incarcerated starting December 12, 2019. FSD receives notification from DOC on December 23, 2019 that Jake was incarcerated and has an estimated release date of December 2022. Jake’s SSA income is entered with a $0 budget beginning January 2020. Jake’s earned income is ended as of his incarceration date. Jake is also receiving VA benefits and his benefits are verified to be decreased to one-half of his benefit amount. The lower amount is budgeted for January 2020.
After the changes are updated, an Adverse Action Notice will be sent to the household to advise that the incarcerated participant’s benefits have been suspended. Benefits for the remaining spouse may also change due to an incarcerated spouse’s income ending or changing.
EXAMPLE: Joseph and Lily are married and both receiving MHABD with a $176 spend down. Joseph is incarcerated December 2020 and his MHABD is suspended. Joseph was receiving SSD and IIVE shows that his benefits were suspended and he will receive $0 for January 2021. Due to this change of income, Lily’s MHABD changes to non-spend down. A notice will be sent to show that Joseph’s benefits are suspended and Lily’s benefits changed to non-spend down beginning January 1, 2021.
EXAMPLE: Blane is receiving MHABD with a $420 spend down. His wife, Maya, is not disabled and is not an active participant, but is included in Blane’s eligibility unit as his spouse. Maya is incarcerated in April 2020. Blane reports this information on a change report in May 2020 as Maya is no longer working and the household income has changed. Maya remains a member of the household during her incarceration. As Maya’s income ended, Blane’s MHABD changed to non-spend down. A notice will be sent to Blane that his benefits will change to non-spend down effective May 1, 2020.
Closing Cash Benefits and Specific MO HealthNet Programs
If an incarcerated participant is receiving any cash benefits associated with the MHN programs such as Blind Pension (BP), Supplemental Aid to the Blind (SAB), or Supplemental Nursing Care (SNC), the cash benefit case will be closed. The participant will be moved to an MHABD case (spend down or non-spend down) and then suspended. When the participant is released and MHN benefits are restored, he/she must reapply for cash benefits, if he/she wishes to continue receiving cash benefits.
If an incarcerated participant is receiving Vendor Coverage, the participant would no longer be eligible for those benefits as no longer being in a vendor facility, but should be moved to an MHABD case (spend down or non-spend down) and then suspended.
If an incarcerated participant is receiving benefits in addition to MHN, such as Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) those benefits will also be suspended when the case is suspended during incarceration.
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 they are eligible for prior to incarceration, but the participant must be suspended beginning the first day of incarceration.
EXAMPLE: Anthony applied for MHABD 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 on 10/27/19 with non-spend down benefits beginning 10/1/2019. His benefits were suspended as of 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 MHABD on 11/16/2019. She was incarcerated 11/26/2019. While processing the application, staff sent a Request for Information (FA-325) and requested a completed MRT packet and 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.
Annual Renewals during Suspension
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 their authorized representative 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 adverse action periods and send appropriate notices when a participant is found ineligible or eligible under a reduced benefit while suspended.
Pre-closing Ex Parte Review during Suspension
If during incarceration, a pre-closing ex parte review must be completed as the spouse reports a divorce or the death of a spouse (or other separation where the incarcerated spouse will not be returning to the original eligibility household), a new application must be registered for the incarcerated individual without requiring a new application.
EXAMPLE: Lindsay and Shawn are married and are both active MHABD participants. Lindsay was incarcerated in October 2019 and her benefits were suspended. In December 2019, Shawn reported that he has moved to Colorado and he would like to close his MHABD case. An ex parte review is completed for Lindsay. An application is registered with her as the head of household and the case is completed and authorized. Lindsay is still eligible for benefits and her benefits remain suspended until she is released in April 2020.
Inpatient Services during Suspension
If a suspended participant needs inpatient care that causes him/her to be admitted inpatient to a hospital for 24 hours or more, MHN benefits must be restored without requiring a new application. The DOC or jail must notify FSD of the inpatient event so FSD can determine if the inpatient event qualifies for MO HealthNet coverage. This notification may be made using the form Inpatient Coverage for Incarcerated Participants (IM-151), but any notification must include the participant’s name, date of birth, DCN and/or Social Security Number, and the dates of service. Medical facility staff, jail/prison staff, or the participant (or their representative) may submit the IM-151 to FSD.
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.
Additional information may be requested if a disability determination is required.
EXAMPLE: Michael received MHABD benefits. He was incarcerated in October 2019 and his benefits were suspended. In December 2019, Michael required surgery and he was in the hospital from December 12 through December 14. DOC reported the inpatient event to FSD on December 16. FSD reviewed Michael’s case and saw that his benefits were suspended, but he appeared to still be eligible on all other factors. FSD reported the inpatient event to MHD and benefits were restored for December 12 to December 14, benefits were returned to suspended status as of December 15, 2019.
Home and Community Based Services (HCB), Vendor Care, and Division of Assets
When a remaining spouse requires vendor care in a facility or applies for HCB, the incarcerated spouse is to be considered the community spouse when determining division of assets and allotments. All consideration for the incarcerated spouse should be completed as if the spouse is living in the home.
EXAMPLE: Margaret and Arthur are married and are both active MHABD. Arthur is incarcerated January 2020 with an expected release date of December 2020, his MHABD is suspended. In July 2020, Margaret has a stroke and is placed at Sunshine Nursing Home. A division of assets is completed with Arthur as the community spouse. There are three bank accounts that are in both of their names and need Joyce’s name removed and there is a vehicle that is titled in Joyce’s name that needs to be changed to Arthur’s name. Joyce and Arthur must follow the guidelines regarding division of assets to make these changes. They may require assistance from their attorney, a durable power of attorney, or another authorized representative to have the resources transferred according to policy.
EXAMPLE: Gloria and Clifford are married. Clifford is active MHABD and Gloria is included in his case, but she is not disabled and has a job. Gloria is incarcerated in December 2019 with an expected release date of December 2020. She is not a participant, but she remains a member of Clifford’s eligibility unit. In February 2020, Clifford applies for Home and Community Based Services Waiver (HCB). A division of assets is completed that considers Gloria the community spouse. There were no assets that needed to be transferred as they already maintained separate bank accounts and had no other assets.
Redetermination and Restoring Benefits
When Department of Corrections (DOC) or a local/county/private jail, reports that a suspended participant is going to be released, FSD must complete a redetermination to determine if the participant is going to remain eligible when he/she is released. This process may begin up to 45 days prior to release.
This may require cooperation from the prison/jail, the suspended participant, or other members of the household. Participants may be required to complete a Report Release of MO HealthNet Participant (IM-152) form to update address, household members, income, and resources. In addition to other eligibility factors, the suspended participant must continue to be eligible based on his/her disability or age.
- If a participant was receiving MHN benefits based on a Medical Review Team (MRT) determination prior to suspension, a new MRT determination is not required if the previous MRT determination is still valid.
NOTE: If the participant’s medical condition has been reported as significantly improved, or if the MRT determination has expired, then the MRT determination is not considered valid and a new MRT determination will be required prior to restoring suspended benefits.
If the suspended participant is under the age of 65 and is not actively receiving Social Security Disability (SSD) or Supplemental Security Income (SSI), such as benefits were terminated or suspended during incarceration, then complete an MRT determination prior to restoring benefits, which should be completed before release, if possible.
- If a participant was receiving SSI prior to incarceration, the SSI disability status is valid for 12 months while the SSI is suspended. However, SSI is terminated after 12 months of incarceration and the SSI disability determination is no longer valid. An MRT determination is required for SSI participants who have been incarcerated for more than 12 months.
- If a participant was receiving SSD prior to incarceration, the SSD disability status is not in question. Social Security Administration (SSA) suspends SSD participants when they become incarcerated, and must verify all other eligibility factors prior to approving pay status, but as disability is not in question, an MRT determination is not required. Staff should not require an MRT determination prior to restoring benefits, but the participant must report the SSD income as a change when it resumes.
EXAMPLE: Bonnie is active MHABD because she is receiving Social Security Disability and Blind Pension (BP). She is incarcerated October 2019 and her MHN benefits are suspended and her BP benefits are closed. In April 2020, DOC sends a report that Bonnie is expected to be released May 17, 2020. Bonnie does not require an MRT determination as she was receiving SSD prior to incarceration. There are no other expected changes, no new resources, or new income reported by DOC or Bonnie. Redetermination is completed and benefits are scheduled to be restored as of May 17, 2020. Bonnie must reapply for BP if she wants to receive that benefit.
EXAMPLE: Brandon and Kristen are active MHABD; Kristen is HOH. Brandon is incarcerated November 2019 and his benefits are suspended. Kristen’s benefits continue and she completes annual renewals with her information and any income or resources that Brandon has. FSD receives a notice from DOC in June 2022 that Brandon’s expected release date is July 7, 2022. FSD staff contacts Kristen to verify if Brandon will be returning to her household and she reports he will. FSD staff verify income and resources for Kristen and Brandon. FSD staff sees that Brandon’s SSI was terminated while he was incarcerated. DOC helps Brandon complete an MRT packet and sends DOC medical records to be used by MRT to complete a medical determination. An MRT decision is completed finding that Brandon is eligible based on his current disability. Redetermination is completed and benefits are scheduled to be restored upon release.
Notices to the Participant and Household
If the suspended participant is found eligible for the same program as he/she was receiving prior to suspension, the participant will receive an Action Notice stating the date the benefits were restored.
If he/she is found eligible for a different program than he/she was receiving prior to suspension, the participant will receive a ten (10) day Adverse Action Notice stating the date the suspended benefits will end and will also receive notice of approval for the program he/she is eligible for.
If he/she is found ineligible, an ex parte review for all other MO HealthNet programs will be completed. If the suspended participant is found ineligible for all MO HealthNet programs then the participant will receive a ten (10) day Adverse Action Notice upon release before the suspended case is closed. Benefits WILL NOT be active during the adverse action period; benefits will remain suspended.
EXAMPLE: Brittney is active MHABD and is incarcerated May 2020; her benefits are suspended. In December 2020, Jackson County Jail contacts FSD and reports that Brittney will be released on January 13, 2021. Brittney’s MRT determination expired while she was in jail. FSD staff sends the MRT packet to Brittney at Jackson County Jail and it is completed and returned to FSD for redetermination. The MRT redetermination finds that Brittney is no longer eligible for MHABD based on her disability. An ex parte review was completed and Brittney was not eligible for any other MHN programs. An Adverse Action is sent to the address Brittney reported she would be released to with a 10 day adverse action period before her suspended case is closed. Brittney may request a hearing regarding this decision.
EXAMPLE: Robert is active MHABD based on his disability and is incarcerated November 2019; his benefits were suspended. In January 2025, DOC contacts FSD and reports that Robert will be released February 2025. DOC assists Robert by completing the Reporting the Release of MO HealthNet Participant (IM-152) and sends the information to FSD. FSD completes the redetermination and as Robert is now 65 years old and a disability determination is not required; he is eligible for MHABD based on his age. An Action Notice will be sent to Robert’s home address (reported on the Redetermination form) advising that benefits will be restored at the same level of care that he was at prior to suspension and benefits are active as of release date.