IM-193 12/28/00 MC+/MEDICAID REV FMR#47 IM80PRE MR#31 FHC
|MC+/MEDICAID REVIEW PROCEDURES
FORMS MANUAL REVISION #47:
IM-80PRE PRE-CLOSING REVIEW NOTICE
MANUAL REVISION#31 FAMILY HEALTHCARE
IMNL SECTIONS: 0905.025.10, 0905.025.16.00, 0905.025.16.05, 0905.025.16.10, 0905.025.16.15, 0905.025.16.20
|Health Care Financing Administration has
issued instructions that once an individual is determined eligible for
Medicaid or MC+, eligibility must continue uninterrupted until the individual
is determined ineligible for every category of MC+ and Medicaid.
A termination without a review for other eligibility is improper.
The extent to which and the manner in which other possible categories must
be explored will depend on the circumstances of the case and the information
available. This process is an extension of our current policy with
regard to moving individuals within the MC+ Family Healthcare programs.
The policy also applies to the aged, blind and disabled categories.
Determination of other eligibility must be conducted without the involvement of the recipient, if possible. This is known as an ex parte review. If the ex parte review does not suggest eligibility, the recipient must be given an opportunity to provide any additional information needed to establish eligibility prior to termination. As part of the process, the recipient must be given an explanation of all potential bases for MC+ and medical assistance eligibility. A Pre-Closing Review Notice (IM-80PRE) has been created to meet this need for the family healthcare programs. (See attached)
MC+ FAMILY HEALTHCARE CASES:
a. Ex-Parte Review
Prior to discontinuing an individual's coverage under any MC+ category, staff must review the individual's possible eligibility under all MC+ healthcare programs. Possible eligibility for Medical Assistance (MA) must also be explored if the individual has an established disability (receiving RSDI or SSI.), or is blind or aged. Use information from all available records, i.e. Food Stamp or Childcare records, SDX, Bendex, IIVE, IMES, etc. Keep in mind, the individual should be moved to the best healthcare benefit package for which they qualify. If eligibility exists under another category, switch the individual to the appropriate category (an IM-1 is not necessary). If discontinuing eligibility from one category and approving in another, process both transactions on the same day in order to prevent any disruption in healthcare coverage. Use the IM-33MCC to notify the recipient of changes in their healthcare coverage if moving to another MC+ category. Send an IM-32 if changing to MA. Use the IM-32NCP if approved for Non-Custodial Parent.
b. Pre-Closing Review:
If other eligibility cannot be established from the record, staff must take the process one step further by sending the Pre-Closing Review Notice to inquire about pregnancy, blindness, disability, currency of child support payments, and changes in circumstances such as income. The individual will be allowed ten (10) days to respond. If there is no response from the individual indicating any other possible eligibility, an IM-80 (Adverse Action Notice) should be initiated explaining:
If the individual responds to the Pre-Closing Review Notice within the ten (10) days indicating other possible eligibility, register the appropriate (MA, MC+ for Pregnant Women, Non-custodial Parent) application in IAPP and allow the current eligibility for that particular individual to remain open pending the eligibility determination for the other category. No new signed application from the individual is required to switch categories. If a disability or blindness is claimed, use the IM-2D when determining eligibility under Medical Assistance. If non-custodial parent eligibility is claimed, use the IM-1UA (NCP) when determining eligibility. One category of coverage should not be stopped before the other category is approved or determined ineligible.
NOTE: If the client did not respond to the expiration of the Pre-Closing Review Notice but does respond indicating other possible eligibility prior to the expiration of the IM-80, follow the same instructions above for the individual who responds to the Pre-Closing Review Notice.
If eligibility is established under another category, close the current active case and approve the other category the same date. Use the IM-32 to notify the client of approval for MA with a statement that eligibility no longer exists under MC+. Use the IM-33MCC to notify the client of switch to MC+ for Pregnant Women with a statement that eligibility no longer exists for a specified program. Use the IM-32NCP to notify the client of the switch to Non-Custodial Parent with a statement that eligibility no longer exists for a specified program.
If determined ineligible based on reported pregnancy, disability, blindness, change in circumstances or child support payments, send an IM-80 specifying the reason eligibility for MC+/Medicaid does not exist. Address the reason for the denial of the new category as well as the reason for loss of eligibility for the current MC+ program. A separate rejection notice for the new category is not required as the IM-80 notifies the client of ineligibility for all MC+/Medicaid categories and provides appeal rights. Close the active MC+ case once the IM-80 expires. The closing notice should contain both reasons as well.
NOTE: There are no appeal right with the Pre-Closing Review Notice since this is not an adverse action notice. If the final decision results in an adverse action, the IM-80 is required and normal hearing rights are allowed.
Special procedures and instructions are being issued under separate memorandum for MC+ for Pregnant Women and Transitional Medical Assistance cases which are systematically closed or extended based on the insured status.
EFFECT ON AGED, BLIND AND DISABLED MEDICAID PROGRAMS
If a change in circumstances on an aged, blind or disabled Medicaid case results in a determination to discontinue the current category of eligibility, staff must establish ineligibility under all Medicaid/MC+ categories before taking action to close the case. All information available to the worker should be carefully reviewed. If potential eligibility exists under another category, change the case address if necessary, and continue the current Medicaid while exploring other eligibility. If an individual is receiving a cash grant, action may be taken to discontinue the cash grant while not affecting the receipt of Medicaid. Once the eligibility determination is complete, transfer the recipient to the appropriate Medicaid. Initiate action to close the case (IM-80, etc.) if no other program eligibility exists.
Do not ask the client to provide new information available to the agency or to re-verify current case information. In some situations it may be necessary to obtain additional information from the client. You should not close the case while attempting to complete the new eligibility determination.
The following are examples of situations where other eligibility may exist:
SNC to Home
Mrs. Ricardo is receiving a Supplemental Nursing Care cash grant and Medicaid while residing at Mirts Manor Nursing Home. She moves to Lucille Ball Vendor Nursing Home and reports the move to her worker. The worker should immediately change the case address to Lucille Ball and take action to discontinue the cash grant. Continue as SNC Title only while investigating vendor eligibility. Once the determination is complete, the worker should add the vendor information and update the case to reflect vendor eligibility.
Mr. Cunningham receives Medicaid spenddown. During the last month of the spenddown quarter, his daughter Joni, reports that he has been placed in Happy Days Vendor Nursing Home. The worker should change the address to Happy Days and enter budget figures on IMU5, necessary to allow the case to remain open as non-spenddown while investigating vendor eligibility. Once the vendor determination is complete, the worker should change the level of care to an "N", add the vendor information and update the case to reflect vendor eligibility.
Mrs. Partridge, a SSI recipient is receiving Medicaid under the aged, blind and disabled criteria, while the Partridge family children are receiving under Medical Assistance for Families. Mrs. Partridge's SSI terminates due to the improvement of her health. The worker should carefully review the case record to explore eligibility under the Family Healthcare programs. If eligible, the worker should add her to the appropriate MC+ case.
There is no change in policy requiring the client to provide information necessary to establish eligibility. Request necessary information only, allowing ample and reasonable time limits. If requested information is not provided, take action to close the case if other potential eligibility does not exist. If not provided and potential eligibility exists for a category not requiring the requested information, explore that category.
PRE-CLOSING REVIEW NOTICE
PURPOSE: To provide official notice of the intent to adversely affect a participant's healthcare benefits unless the participant responds within ten (10) days advising of other possible eligibility for an individual based on pregnancy, disability, blindness or a change in income. Should be sent prior to sending IM-80 (Adverse Action Notice)
NUMBER OF COPIES AND DISPOSITION: Make two (2) copies. Mail one copy to the participant; file the other copy in the case record.
INSTRUCTIONS FOR COMPLETION: The form may be typed or completed in ink.
Date: Date should be the date mailed.
From: Enter the county office address.
To: Enter the appropriate name and address.
Based on information available to us, the following person(s) no longer meet the eligibility requirements for MC+ healthcare: (enter the names of persons whose coverage is being affected) because (enter an explanation to the participant in understandable language which includes)
The change in the participant's circumstances
which resulted in the proposed action;
The eligibility factor involved; and
The specific law, rule, regulation, or manual reference on which the decision is based.
If you do not respond by (enter the date (10)ten days from the mailing date) action may be taken to end healthcare coverage for the persons listed.
MC+ Service Representative, Telephone Number:
Enter the Service Representatives name and phone number.