NOTE: The SSI amounts are for information only. Use 100% of the FPL for Medicaid eligibility determinations.

The Cost of Living Adjustments will be made on the weekend of December 11, 2004. When entering IMU5 transactions prior to the mass adjustment, use the current amount of OASDI being received. After the mass adjustment, enter the new amount of OASDI benefits.

For applications approved after the mass adjustment, verify the new OASDI amount through the local Social Security office. If the new amount is unavailable and the old amount of Social Security benefits has been verified, multiply the old amount by 102.7 to arrive at the approximate new amount of benefits. A BENDEX printout will be sent to verify the new amount of benefits as soon as BENDEX data exchange is established on the individual. State office will compute the new OASDI amount and SSI amount and the resulting grant or surplus amounts. State office will do the complete adjustment:

• Send the adverse action or adjustment notice
• Adjust or close the case
• List the cases for the counties.

County staff must handle the case whenever

• A hearing is requested within the 10-day adverse action period
• The case is listed for review.

Refer to specific instructions later in this memorandum.

Which Cases Are Mass-Adjusted

• Medical Assistance for Families cases where there is no change in eligibility. (No MAF cases will be closed as a result of the mass adjustment. A listing will be produced for staff.)
• Temporary Assistance cash cases. If ineligible for the cash grant the case will be closed. A listing will be produced for staff.
• MC+ for children cases when there is no change in level of care. No C7 cases will be closed as a result of the mass adjustments. A listing will be produced for staff.
• “M” type of assistance cases with a “T” level of care.
• Vendor cases, including those with allotments.
• Nursing Care cash cases, type of assistance “N”, “R”, and “F” with payee level of care “W”, “X”, “P”, “V”, “Y” or “B”, or any GR (SSI/SP) cases. If ineligible for the cash grant, the cash grant will be closed but the level of care will be changed to a “T”. A listing will be produced for staff.
• SAB cash cases and conversation cases using AB criteria.
• General Relief Level of Care “A” cases. If ineligible for the Level of Care “A”, the Level of Care “A” will be changed to a “T”. A listing will be produced for staff.

How Cases Are Mass-Adjusted

The computer program identifies claimants that receive OASDI, either from BENDEX or from the IM database. It then updates the OASDI amount field with the new figure (actual from BENDEX or calculated from IM). The COLA increase is added to the gross and net income figures (fields 34 and 41), and a new deficit or surplus amount is calculated for field 35. If the increase appears to cause ineligibility based on a surplus of income, some cases are closed with an adverse action notice sent to the claimant and other cases are listed for review by the caseworker.

If no OASDI amount appears in field 13J, but there is OASDI income included in the gross income in field 41, the total new amount of OASDI will be added to the income in fields 41 and 34, because the system cannot tell that the figure in field 41 includes OASDI. For these cases, the worker must make the correct adjustment by entering the new amount of OASDI in fields 13J, 34, and 41. The worker must also send the IM-80 to reduce the grant.

MA spenddown cases are adjusted by changing surplus amount in Field 36. The increased spenddown amount will be for February 2005 as January invoices have been sent.

Vendor cases are adjusted by changing the surplus amount the claimant must pay the nursing home. The system generates a notice of adjustment to the nursing home in addition to the claimant notice.

If a case does not appear on BENDEX but shows OASDI on the IM database, the case may be adjusted. Cases will be adjusted by applying the 2.7% increase to the OASDI amount shown in 13J. For these cases, if the amount in 13J is wrong, the adjustment will be wrong. The worker is responsible for correcting 13J and any other affected figures. Because SMI premium information will not be available from BENDEX on percentage-adjusted cases, the program will attempt to identify premium payers and will assume the premium was $66.60 as of December 2004. Because not every premium is $66.60, a small portion of percentage-adjusted cases may be wrong due to this assumption. Therefore, each percentage-adjusted case is marked on the listing with an asterisk (*) to help caseworkers identify them in case of incorrect adjustments.

No turnaround IM-5’s are produced for this adjustment. These cases will appear on a listing titled “Cases Adjusted” sent to each county office for control purposes. In some instances, case information is incomplete or incorrect, or otherwise cannot be mass adjusted or updated. Counties must review these cases manually, using the lists provided by State office. Each case listed includes a caption to identify why the case could not be adjusted. Review these listed cases and manually adjust if necessary. For example, if the expense figure for a Temporary Assistance case is not the maximum grant amount for household size, the computer program cannot make the correct computations from an incorrect expense figure and the case cannot be adjusted.

For all types of assistance, cases that will not be adjusted include:

• Assistance group members having an OASDI amount in the IM database, which is greater than that appearing in BENDEX. (This includes cases in which the inactive payee is the only match to BENDEX, and the income field is zero.)

Listing of Cases Not Adjusted by State Office which Need Action by County Staff

There are two lists of cases not adjusted:

• Cases Needing Review for Adjustment

MC+ for Children/MAF (C7) Cases That May Have a Change in Level of Care or Ineligibility.

Cases With BENDEX Discrepancies

This list shows information for all types of assistance:

For the case: name, number, increase, expense, income, surplus or deficit, restitution amount, old grant, new grant, amount of change, type of change, old SSI and new SSI.

For the individual: name, DCN, level of care, old SSA amount, new SSA amount and claim number, if applicable.

Review all listed cases for manual adjustment.

Captions and possible actions

• BENDEX < IM—BENDEX shows less than IM (13J), which indicates probable error in 13J.
• BENDEX > IM—The IM database has an amount in Field 13J (OASDI Amt) for a payee or an individual that is less than that which appears in BENDEX, or is zero. Occurs in NC cash cases when there is SSI in Field 20 and no OASDI in 13J. Also occurs when an inactive payee is the only BENDEX match and there is no income reported. Review appropriate fields for consistency.
• Incor Exp—The expense figure is incorrect for the type of assistance or the number of household members. Review Field 33 for appropriate figures.
• Incor/1619—For MA cases, the expense figure is either incorrect for the type of assistance or the number of household members, or this is a 1619 case. Review Field 33 for correct SSI or HCB expense.
• IM No BENDEX—The IM database contains an amount in Field 13J (OASDI Amt) for the payee or individual, and NO amount appears in the BENDEX master file for the same payee or individual. Verify OASDI as needed and adjust case if OASDI continues.
• Review 13X—Field 13X (Main. Std) contains an “H” (the allotment is set by a hearing decision) or an “L” (the institutionalized spouse chooses to make an allotment less than the maximum allowable). No case at this time has been approved for an “H”. Consider changing 13X.
• OASDI > CS Inc—The OASDI amount in Field 13J (OASDI Amt) is greater than the amount in Field 13V (Income of community spouse). Review 13V and 13J. 13V must include the amount in 13J.
• Max Allot > Exp—The current maximum allotment for the case is greater than the amount entered in Field 33 (ESP/EIL). Review 33, 13V, and 13Y for consistency.
• OASDI > Dep Inc—The OASDI amount in Field 13J (OASDI Amt) is greater than the amount shown for the dependent in Field 13V (Income of Dependent). Review 13V and 13J. 13V must include the amount in 13J.
• OASDI > STD—The new OASDI amount is greater than the new SAB standard of $625.00 Investigate possible closing.
• SSI CHG—On “F” type of assistance, an amount appears in Field 20 (SSI Amt) indicating that this case contains SSI. SSI amounts are not increased by Data Processing in the mass adjustment. Adjust SSI manually and adjust SAB grant.
• REST > GRNT—For cases with restitution, the restitution amount is greater than the new grant amount.
• GRNT < $10—A Temporary Assistance case with restitution becomes a $10 minimum pay case due to the COLA increase. The system cannot adjust because there is no longer a grant from which to deduct restitution. Manual adjustment is required.
• SURP DECR—The new surplus amount is less than the current surplus amount for a non-allotment case. Review 13J, 33, and 34 for consistency.
• SSI DECR—On NC cash cases with SSI, the OASDI increase caused a SSI decrease or closing. This may indicate an OASDI increase for a reason other than the COLA.
• MA/GR—MA/GR case that matched to BENDEX. Review for manual adjustment.

Individuals with SSI in MC+ for Children Cases

This listing contains individuals appearing in MC+ for Children cases that receive SSI benefits. Individuals with “Q”, “Z”, “1”, “2”, or “3” level of care are listed. Use this listing to assure adjustments due to the increase in SSI are made.

MC+/MAF Cases Needing Review

The listing will be produced in cases where the mass adjustment would cause a Level of Care change or a MC+ or MAF case to be closed. Field staff must review these cases and take appropriate action.

Cases Adjusted—Review for Further Action

Also included on the listing of cases adjusted are the following situations, which require worker review to determine if further adjustment is needed. Individuals appearing on this listing with “Not Included” captions must be reviewed for necessary action.

• Temporary Assistance Case Adjusted—Individual with a “C” level of care not adjusted

  An individual with a “C” level of care was “Not Included” in the adjustment if we could not tell from information in the system whether the individual’s income should be included in the budget. Review to see if individual should be included in adjustment and adjust if needed.

• General Relief Case Adjusted

  An individual losing Level of Care “A” eligibility was adjusted and changed to a “T” level of care. Review to see if individual is eligible for another type of assistance and take necessary action.

• Supplemental Nursing Care Case Adjusted

  An individual losing cash eligibility was adjusted and changed to a “T” level of care. Review to see if individual is eligible for another type of assistance and take necessary action.

Hearings on Computer Adjusted Cases

The adverse action notices generated by the mass adjustment will be dated December 13, 2004. The claimant has until December 23, 2004, to request a hearing and have benefits restored to pre-adjustment levels.

If the claimant requests a hearing on or before December 23, 2004, complete an IMU5 transaction to cancel the computer adjustment (i.e., cancel-close a closed case, restore a grant, etc.) and follow usual hearing procedures. Immediately request a copy of the computer generated IM-80 from Program & Policy by calling (573) 751-3507.

If the claimant does not request a hearing on or before December 23, 2004, no further case action is necessary.

Listing of Cases Adjusted

Cases that are mass-adjusted are included on one of several listings sent to each county.

“Not Included” on the “Cases Adjusted” list requires action. All others are for information. Note that any caption flagged with an asterisk means that the case was adjusted according to a percentage calculation and may not exactly match SSA information. All lists include a footnote on each page as a reminder.

1. Cases Adjusted

   This list is sorted by county, load, and program. The claimants are listed alphabetically within program. The date of any IM-80 generated by the system for this adjustment appears in the upper right corner of the listing. NOTE: All cases appearing with a caption of “Not Included” for any individual MUST be reviewed for necessary action by the county.

   Captions

   • Not Included—This caption indicates that the individual is not included in the case budget, and therefore has no affect on the adjustment computations. However, these individuals must be reviewed by the county for necessary action. Identifying information also appears on the listing for these individuals.
   • CLOSE—The case was closed in the mass adjustment.
   • NO CHG—The mass adjustment resulted in no change to the case.
   • DECR—The grant was decreased in the mass adjustment.
   • Surp Inc—The surplus was increased in the mass adjustment.
   • Surp Inc/Allot—The surplus was increased for an allotment case in the mass adjustment.
   • Surp Dec/Allot—The surplus was decreased for an allotment case in the mass adjustment.

2. Surplus Changes as a Result of OASDI Increases

   Each vendor nursing home or institution receives a list of its residents with OASDI. This list shows the case number, case name, old surplus amount and new surplus amount. The list includes a letter to the administrator of the nursing home.

   Use the IM-62 to notify the vendor of any correction in the January surplus amount or to supply the January 2005 surplus amount for any claimant with OASDI who is not on the vendor’s listing.

   Use normal procedures for changing surplus amounts when an error is discovered:

   • For increases the effective date is the month following the expiration of the IM-80 or the signing of the IM-80A and
   • For decreases, the effective date is the month following the month of the report or discovery.

   See on-line manual 0815.000.00.

Cases Bypassed

The county is not required to act on bypassed cases. They will not be adjusted or listed.

• Refugee cases (because none currently receive OASDI)
• Transitional Medical Assistance or Child Support Related closing cases
• ETMA-Extended Transitional Medical Assistance
• MC+ for Pregnant Women cases
• EWHS-Extended Women’s Health Services
• Presumptive Eligibility for Children
• Darling cases—These are MA cases identified by an “M” indicator in Field 27 of IMU5
• Non-spenddown cases with SSI
• QMB-only cases (“Q” type of assistance)
• SLMB-only cases (“L” type of assistance)
• BCCT

Notices to Claimants

Adverse action notices and notices of adjustment will be computer generated. The following are samples of the notices being sent to claimants.

Temporary Assistance Ineligibility Letter

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, your Social Security benefits will increase by $xxx.xx in January 2005. Because of this increase, your household’s income now exceeds the allowable limits to qualify for Temporary Assistance. Effective January 2005 your cash payments will be discontinued.

Healthcare coverage for your family will continue until further notice.

If you believe this decision is not correct, you have the right to request a hearing by phone, in person, or in writing. Should you request a hearing within 10 days of the above date, unless you request that benefits not be continued, your benefits will continue until a hearing decision. If you do not request a hearing, your grant will be reduced. If you wish to request a hearing after the above action, you have 90-days from January 1, 2005, to make the request.

At the hearing, you may present the case or be represented by someone else, including an attorney. You may bring and/or question witnesses.

Temporary Assistance Cash Reductions

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, your Social Security benefits will increase by $xxx.xx in January 2005.

Since all available income must be considered in determining need for Temporary Assistance (13 CSR 40-2.310) your Temporary Assistance grant will be reduced to $xxx.xx in January 2005 because of the above change.

If you believe this decision is not correct, you have the right to request a hearing by phone, in person, or in writing. Should you request a hearing within 10 days of the above date, unless you request that benefits not be continued, your benefits will continue until a hearing decision. If you do not request a hearing, your grant will be reduced. If you wish to request a hearing after the above action, you have 90-days from January 1, 2005, to make the request.

At the hearing, you may present the case or be represented by someone else, including an attorney. You may bring and/or question witnesses.

Increase in Surplus Amount (Cases with N, I, D, or K Level of Care) No L Level of Care Individuals

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, your Social Security benefits will increase by $xxx.xx in January 2005. Since this income must be considered in determining your benefits (13 CSR 40-2.200), the amount you must pay to the nursing home or institution will be increased to $xxx.xx effective January 1, 2005.

If you believe this decision is not correct, you have the right to request a hearing by phone, in person, or in writing. Should you request a hearing within 10 days of the above date, unless you request that benefits not be continued, your benefits will continue until a hearing decision. If you do not request a hearing, your surplus will be increased effective January 1, 2005. If you wish to request a hearing after the above action, you have 90-days from January 1, 2005, to make the request.

At the hearing, you may present the case or be represented by someone else, including an attorney. You may bring and/or question witnesses.

Increase in Surplus Amount (Cases with D, I, K, or N Level of Care) With L Level of Care Individuals

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, your Social Security benefits will increase by $xxx.xx in January 2005. In addition, your spouse’s and dependent(s) Social Security benefit(s) will be increased by $xxx.xx in January 2005.

Due to these changes, the allotment you are making to you spouse and dependents will change to $xxx.xx beginning January 1, 2005. Since all available income must be considered in determining you benefits (13 CSR 40-2.200), the amount you must pay the nursing home or institution will be $xxx.xx effective January 1, 2005.

If your income increases, you may give your spouse or eligible dependents up to $xxx.xx monthly.

If you believe this decision is not correct, you have the right to request a hearing by phone, in person, or in writing. Should you request a hearing within 10 days of the above date, unless you request that benefits not be continued, your benefits will continue until a hearing decision. If you do not request a hearing, your surplus will be increased effective January 1, 2005. If you wish to request a hearing after the above action, you have 90-days from January 1, 2005, to make the request.

At the hearing, you may present the case or be represented by someone else, including an attorney. You may bring and/or question witnesses.

No Change or a Decrease in Surplus but an Increase in Claimant’s or L Level Individuals OASDI

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, your Social Security benefits will increase by $xxx.xx in January 2005. Because you are making all or part of your income available to your spouse and dependents who live at home, the amount you must pay to the nursing home beginning January 1, 2005, will continue to be $xxx.xx.

Our records indicate that you may make the entire Social Security increase available to your spouse and dependents who live at home and not have to pay any additional amount to the nursing home. If you do not wish to give the full amount of the Social Security increase to your spouse, contact your caseworker and an adjustment will be made.

If your income increases, you may give your spouse or eligible dependents up to $xxx.xx monthly.

MA Spenddown Increase

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, you Social Security benefits will increase by $xxx.xx in January 2005. Since this income must be considered in determining eligibility for benefits (13 CSR 40-2.200), your spenddown will increase to $xxx.xx effective February 1, 2005.

If you believe this decision is not correct, you have the right to request a hearing by phone, on person, or in writing. If you wish to request a hearing after the above action, you have 90 days from January 1, 2005, to make the request.

At the hearing, you may present your case or be represented by someone else including an attorney. You may bring or question witnesses.

MA Non-Spenddown to Spenddown

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, you Social Security benefits will increase by $xxx.xx in January 2005. Since this income must be considered in determining eligibility for benefits (13 CSR 40-2.200), you are no longer eligible for Medicaid on a non-spenddown basis effective December 31, 2004.

You may be eligible for Medicaid on a spenddown basis. Spenddown is like a deductible on insurance policies, in that you and/or your spouse must be charged for medical care up to a certain amount before your Medicaid coverage can begin. Your spenddown amount is $xxx.xx. Within seven (7) days of this letter you will receive a notice explaining your options for meeting spenddown from the Division of Medical Services.

If you have questions about the spenddown program, contact your caseworker or call 1-800-392-1261.

If you believe this decision is not correct, you have the right to request a hearing by phone, on person, or in writing. If you wish to request a hearing after the above action, you have 90 days from January 1, 2005, to make the request.

At the hearing, you may present your case or be represented by someone else including an attorney. You may bring or question witnesses.

SNC and SAB with Levels of Care V, W, X, Y, B, or P (May Include Decreases and Closings)

Dear: (Case Name) (Case ID) (Date)

According to the information available to the Family Support Division, you Social Security or Supplemental Security Income benefits will increase by $xxx.xx in January 2005. As a result of these changes and in accordance with 13CSR 40-2.120, your grant will be $xxx.xx beginning in January 2005. If the amount shown is zero, you are no longer eligible for a cash grant.

YOUR MEDICAID COVERAGE WILL CONTINUE UNTIL FURTHER NOTICE.

If you believe this decision is not correct, you have the right to request a hearing by phone, in person, or in writing. Should you request a hearing within 10 days of the above date, unless you request that benefits not be continued, your benefits will continue until a hearing decision. If you do not request a hearing, your case will be closed or benefits reduced. If you wish to request a hearing after the above action, you have 90-days from January 1, 2005, to make the request.

At the hearing, you may present your case or be represented by someone else including an attorney. You may bring or question witnesses.

YOUR MEDICAID COVERAGE WILL CONTINUE UNTIL FURTHER NOTICE.

If you believe this decision is not correct, you have the right to request a hearing by phone, in person, or in writing. Should you request a hearing within 10 days of the above date, unless you request that benefits not be continued, your benefits will continue until a hearing decision. If you do not request a hearing, your case will be closed or benefits reduced. If you wish to request a hearing after the above action, you have 90-days from January 1, 2005, to make the request.

At the hearing, you may present your case or be represented by someone else including an attorney. You may bring or question witnesses.

Notice to NF, IMR, or MHC Administrator of Change in Surplus

To the Administrator:

Enclosed is a list of patients for whom you receive nursing facility (NF), mentally retarded (IMR), or mental hospital (MHC) payments from the Family Support Division. According to our records, these patients currently receive Social Security benefits (OASDI) and will receive an increase in January 2005. This increase will also cause a change in the amount they must pay to your institution for their care. The attached listing shows the name and number of each patient and the old and new surplus amount. The surplus amount shown will be effective January 1, 2005, unless you receive a notice (IM-62) mailed from the county office after December 10, 2004, which indicates a different amount.

If you have an NF, IMR, or MHC patient in your institution who was approved for vendor care before December 10, 2004, and is not on this listing, please contact his/her caseworker to get the January 2005 surplus amount.

Food Stamps

Instructions for handling Food Stamp cases are covered in a separate memorandum.

• Review this memorandum with appropriate staff.
• Review cases and adjust manually as needed.