IM-125 10/24/05 WILSON VS. SHERMAN LAWSUIT SETTLEMENT

SUBJECT:

WILSON VS. SHERMAN LAWSUIT SETTLEMENT

DISCUSSION:

A settlement has been reached in the Wilson vs. Sherman lawsuit. The lawsuit was brought on behalf of the parents/caretakers terminated from Medical Assistance for Families (MAF), due the reduction in the MAF income limit implemented as a result of House Bill 11 (2005), who were not placed on Transitional Medical Assistance (TMA). The lawsuit alleged parents/caretakers were improperly terminated due to the failure of staff to review the individual case records for information that would have indicated continued eligibility for Medicaid under MAF, TMA or some other category. It further alleged that the complexity of the notices sent to the affected individuals caused improper closings as the individuals may not have understood what they needed to do if they felt they continued to be eligible for Medicaid. No finding was made by the court as to the truth or falsity of these allegations.

The settlement allows parents/caretakers that lost MAF coverage July 1, 2005 - due to the House Bill 11 change - an additional opportunity to have their coverage restored if they are eligible for some Medicaid category. Terms of the settlement require:

The attached notice be sent on November 1, 2005, to parents/caretakers terminated from MAF, not eligible for TMA, who had not had Medicaid eligibility in some category restored by October 22, 2005.

Parents/caretakers who respond to the notice by November 18, 2005, have their eligibility for Medicaid explored as if they had re-applied. These persons will be considered re-applicants. Parents/caretakers may respond by telephone, direct contact, or mail postmarked by November 18, 2005.

Re-applicants that are determined eligible for Medicaid will have their coverage re-opened retroactively to July, 1, 2005, or the date of eligibility if different.

Re-applicants that are determined eligible for Medicaid will be reimbursed for any paid medical expenses, up to the Medicaid allowable rate, from the date of eligibility through the date of approval.

Re-applicants found ineligible for Medicaid will be issued the appropriate rejection letter, with hearing rights.

Staff meetings to be conducted by county IM Supervisors to review the procedures contained in this memorandum with all caseworkers and provide the IM Policy Unit with written confirmation that the staff meetings were conducted.

Notification Procedures:

On November 1, 2005, notices will be mailed out to parents/caretakers who were terminated from MAF and not eligible for TMA as a result of HB11, and have not had eligibility for some Medicaid category restored by October 22, 2005. A sample of the “Request for Information – Medicaid” notice is attached.

The notice gives the parents/caretakers until November 18, 2005, to request a re-evaluation of Medicaid eligibility. It informs individuals that they may either call their caseworker or write to their local office and request that their eligibility for Medicaid be reviewed. The notice lists possible reasons why the individual may be eligible, the options available to get appropriate information to FSD, and that the individual will be notified of the results of the review.

Processing and Recording Requests for Reviews :

Parents/caretakers who respond to the notice by November 18, 2005, must have their eligibility for Medicaid explored (written responses must be postmarked by November 18, 2005). The method of contact (by phone, mail or in person) is to be recorded in the case record. They will be considered “re-applicants” and are not required to sign and/or complete a new application form. An application for MAF, Medicaid for Pregnant Women (MPW) or Medical Assistance (MA) MUST be registered in the IM system. Eligibility for all potential categories of Medicaid eligibility, including TMA, must be explored. The steps for processing and recording re-applicants are as follows:

Enter an application in the appropriate category on the date of request.

The type of application to register in the system is based on the information the client provides. If an individual claims eligibility based on:

A physical or mental disability or blindness -- Register an MA application;

Pregnancy – Register a MPW application;

Change in income, household size or income under MAF limits -- register only the individual requesting review on a new C7, C8, or C9 application;

Report of earnings received from a job in June 2005 (potentially eligible for TMA) – register only the individual requesting review on a new C7, C8, or C9 application; or,

Reason unable to be determined – Register a new C7, C8, or C9 application.

NOTE:A NEW case application must be registered. Do NOT put individual(s) in application status on an active C7, C8 or C9 case.

Explore eligibility for Medicaid.

Explore the individual(s)’s eligibility for Medicaid. The steps are as follows:
1. Review the case record for available information. DO NOT request information that is available in the case record or through FSD interfaces (examples: Social Security benefits through IIVE and Child Support through MACSS);
2. If additional information is needed, notify the individual(s) of the verification needed to establish eligibility. Give the individual(s) ten days to supply necessary documentation or signed authorizations for FSD to request information from the source.
  - If the individual does not supply requested information, reject the case with a reason of “21-Refused to Cooperate” on the IMU5 registered case and send the appropriate IM-33.
  - For MA determinations requiring a Medical Review Team (MRT) decision to establish disability, follow established procedures for MRT determinations.
Approving parent/caretakers for Medicaid.
If determined eligible, begin Medicaid July 1, 2005, or the date of eligibility, if ineligible for July 2005. Send the appropriate approval letter.
- For MA and MPW cases, enter “W” (for Wilson vs. Sherman) in the case identifier field (Field 27). This allows coverage to be backdated to July 1, 2005 (one month past the prior quarter for a November application), if needed.
  - Example : If approving for MA and the client was eligible back to July 1, 2005, entering the “W” allows coverage to begin July 1, 2005. If the “W” is not entered, the system will not allow coverage prior to August 1, 2005.
- For MAF and TMA cases:
  
  Close the registered “C” case with a reason code of “39-Transferred to other assistance.” DO NOT use any other closing reason .
  
  Open Medicaid for the parent(s) on the active “C” case for their children. Enter the appropriate level of care, adjust the level of care for the children, and change the case to MAF. If eligible for TMA, the case must be changed to MAF first.
  - Example 1:
    
    Ms. Jones calls and states she was working in June 2005 and is still employed. Worker registers only Ms. Jones on a C8 application (children are active Q level of care on a C7 case). Worker verifies her income is over the MAF limit. Reject the C8 application for reason 39. As the system only allows a worker to enter TMA eligibility from a MAF case, the C7 case will need to be changed to MAF first. The worker will do a case action “35”, change Ms. Jones’ “Z” loc to “T,” change the children’s “Q” loc to “T” (both with effective dates of 070105), and put in a zero income MAF budget.
    
    The next day, close the active MAF case to TMA, enter case action 29, put 06/30/06 in field 32 (Medicaid end date), and “2” in field 38A (Ext XIX code). Put in the correct MAF budget, including the income used to determine TMA eligibility. The “2” is being entered in field 38A because the first quarterly report is being waved for these cases. These individuals will be required to send in all subsequent quarterly reports.
  - Example 2:
    
    Ms. Adams calls in and states that only one of her two children receives child support of $400 per month, which is verified. Currently both of the children are open on a C7 case as loc “Q”. Register a C8 application. Using the disregard of the first $50 of child support received, Ms. Adams and her two children would be over the MAF limit if left in the same assistance group.
    
    Split the case into two assistance groups:
    1. 1 st group – Change the current active MC+ case (C7) to MAF, with Ms. Adams (T loc) and child with no child support (T loc). The child with support must be removed and opened on the newly registered case the same day to continue uninterrupted Medicaid/MC+ coverage.
    2. 2 nd group – Approve the C8 case as MC+ for Children, with Ms. Adams (Z loc), child with $400 in child support (Q loc) and child with no support (Z loc).
- Note: For re-applicants determined eligible for TMA , send form IM-33MAF to notify the parents/caretakers of the TMA eligibility. Check the box that states “We have taken the following action on your Medical Assistance for Families (MAF) case.” Then check the box that refers to the eligibility being transferred to TMA. Use the reason: “Your earnings of $_____ are over the MAF income limit for a family of your size (13 CSR 40-2.375).” State that the coverage will continue through December 31, 2005.
Rejecting parents/caretakers for Medicaid.

For parents/caretakers determined ineligible for Medicaid, use the appropriate rejection code when rejecting the cases.

Do not use rejection reason “44 – Other” when rejecting these cases. Cases will be monitored, and any cases rejected with this reason will require supervisory review to report the correct reason to Central Office.

Send a rejection letter stating why the parent/caretaker was rejected, as hearing rights must be allowed.

Notice and Notice Listings :

Each county office will receive a listing of the parents/caretakers sent notifications on November 1, 2005, as well as copies of the notification letters. The listings will note the individual’s DCN as well as the case DCN under which the individual lost coverage during the MAF mass adjustment in June.

Caseworkers are responsible for notifying their supervisor when a case is rejected or approved. Counties will collect the information and report as requested to the IM Policy Unit.

Staff Meetings :

County offices must hold staff meetings by November 2, 2005, to review this memorandum and the required procedures. The purpose of these meetings is to ensure that staff understand the policy and procedures necessary to correctly review and re-establish eligibility for these cases. It is very important that supervisors are confident that their staff understand all the policy issues involved in order for staff to accurately make a determination of eligibility. A couple of these issues include:

Assistance Grouping Rules – the policy regarding mandatory/optional assistance group members governs when income is counted/not counted. See 0905.012.10 Assistance Group (MAF) for further information about assistance groups.
Disregarding the First $50 of Child Support Income – it is important that staff understand that this process is done prior to entering the income into the system. See 0905.012.50 Child Support Disregard.

These are just a couple of issues that affect correct decisions in these and all eligibility determinations. It is important to address any policy/procedure question staff have prior to them beginning to work on these cases. If there are questions that cannot be answered or that require policy clarification, forward those to the IM Policy Unit through proper channels.

A log of staff in attendance at this mandatory meeting must be kept. Those not able to attend must meet with their supervisor on an individual or small group basis to go over the procedures by November 2, 2005, or shortly thereafter. The names of these workers must also be documented. E-mail the date the staff meetings are held to Martha Bax at Martha.J.Bax@dss.mo.gov. Copies of logs and additional documentation must be faxed to Martha Bax at 573-751-3677.

NECESSARY ACTION:

Conduct staff meetings with all appropriate staff by November 2, 2005, to review this memorandum.

Report the staff meetings to the IM Policy unit as instructed in this memorandum.

Review the policy and procedures necessary for staff to make correct decisions.

DO NOT require parents/caretakers reapplying due to receipt of the “Request for Information – Medicaid” notice to complete or sign an application.

Register a Medicaid application in the system on all parents/caretakers who contact the county office as a result of the November 1, 2005 notice and record the method of contact in the case record.

Follow the procedures in this memorandum to determine Medicaid eligibility for all parents/caretakers who contact the county office as a result of the November 1, 2005 notice.

ATTACHMENTS:

* Request for Information – Medicaid notice