| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | JULIA M. VS. SCOTT EX PARTE NOTICES TO FAMILIES WHO LOST MO HEALTHNET FOR KIDS STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) ELIGIBILITY |
DISCUSSION:
Income Maintenance Memorandum IM-67 dated July 24, 2007, explained the Julia M. vs. Scott lawsuit brought on behalf of all children residing in Missouri and who are receiving or who will receive MO HealthNet for Kids (formerly MC+) health coverage and are required to pay a premium under Section 208.640 RSMo. As part of the Julia M. vs. Scott lawsuit proceedings, Family Support Division (FSD) agreed to send a special letter to each MO HealthNet for Kids (formerly MC+) participant who between September 1, 2005, and January 16, 2008, had a MO HealthNet for Kids (formerly MC+) case closed due to non-payment of premium and did not become covered under another MO HealthNet program within 90 days following case closure due to non-payment of premium to allow an additional opportunity to have the child(ren)’s coverage restored if the child(ren) is eligible for some other MO HealthNet healthcare category.
The attached letter will be sent on February 1, 2008, to families whose children lost eligibility for MO HealthNet for Kids (formerly MC+) due to non-payment of premium from September 1, 2005, through January 16, 2008. Families who respond to the letter by February 29, 2008, will have an ex parte review of their child(ren)’s eligibility for other MO HealthNet programs explored, based on information available in the participant’s case file. Families may respond by telephone, direct contact, or mail postmarked by February 29, 2008.
Children that are determined eligible for MO HealthNet coverage will have their coverage reinstated effective the date(s) their case or eligibility was closed. In addition, families whose child(ren) are determined eligible for MO HealthNet coverage will be reimbursed for any paid medical expenses, up the MO HealthNet allowable rate, from the date of eligibility through the date of approval. Families whose child(ren) are found ineligible for MO HealthNet coverage will be issued the appropriate rejection letter, with hearing rights.
Notification Procedures:
The attached letter will be sent on February 1, 2008, to families whose children lost coverage or eligibility for MO HealthNet for Kids (formerly MC+) due to non-payment of premium from September 1, 2005, through January 16, 2008. The families that receive this letter have a child with a coverage gap of 90 days or more. It is possible that a family will receive more than one letter, as a child(ren) may have more than one 90-day gap of ineligibility due to failure to pay a premium.
The letter gives the families until February 29, 2008, to request a review for MO HealthNet eligibility. It informs families that they may either call their eligibility specialist or write to their local office to have their child(ren)’s eligibility reviewed. The notice lists the following possible reasons why the child(ren) may have been eligible for another MO HealthNet healthcare program:
- A child(ren) had a physical or mental disability;
- A child(ren) was pregnant; or
- A child(ren) age 18 up to age 19 was blind.
The notice states that if a review of a family’s case is requested, the eligibility specialist will review the case file for information to determine if a child(ren) may have been eligible for coverage, and that the family will be notified of the results of the review. The notice details how medical services may be paid for any eligible periods determined due to the review.
Copies of these letters will be made available in MOBIUS under the heading FIMEXPARTE.
Processing Requests for Reviews:
Families who respond to the notice by February 29, 2008, must have an ex parte review of their eligibility for MO HealthNet explored (written responses must be postmarked by February 29, 2008). The method of contact (by phone, mail or in person) is to be recorded in the case record.
Individuals who respond to the letter must have an application for MO HealthNet for Disabled Children (MHDC), MO HealthNet for the Aged, Blind and Disabled (MHABD), or Supplemental Aid to the Blind (SAB) and/or Blind Pension (BP) registered in the Legacy system. Contact Income Maintenance (IM) Program and Policy Unit through normal supervisory channels for specific instructions for MO HealthNet for Pregnant Women (MPW). Do not register MO HealthNet for Pregnant Women (MPW) in FAMIS without specific direction from Program and Policy. Individuals requesting a review will be considered “re-applicants” and are not required to sign and/or complete a new application form.
Eligibility for all potential categories of MO HealthNet eligibility included in the listing noted above must be explored. The steps for processing and recording re-applicants are as follows:
- Enter an application in the appropriate category (MHDC, MHABD, or SAB and/or BP). The request date is to be the date the child(ren) lost eligibility for MO HealthNet for Kids (MHK), but not prior to September 1, 2005. If the child(ren) has more than one coverage gap that is being explored, enter the earliest date.
NOTE: Do not enter an application date for a child who has an open MHDC or MHABD case. Note the date of request and the date(s) the child(ren) lost coverage. Contact IM Program and Policy Unit through normal supervisory channels to add additional coverage to an active case.
The type of application to register in the system is based on the information the family provides. If a family claims the child(ren) is eligible based on:
- A physical or mental disability or blindness -- Register a MHDC, MHABD, or SAB and/or BP application;
- Pregnancy – Note the date of request. Do not register an MPW application at this time; or
- A reason unable to be determined at time of request for review– Register a MHDC or MHABD application.
NOTE: If the application is not approved the same day it is registered, enter case action ‘96’ and code “M” in IMU5, Field 11, on the same day it is registered. This will allow the case to be approved or rejected without causing a delay to be credited to the eligibility specialist.
2. Explore the child(ren)’s eligibility for MO HealthNet coverage. The steps are as follows:
- Review the case record for available information. All information (except citizenship and identity) must be present in the case record. DO NOT request medical information if a family declares that a child(ren) is disabled; use only information in the case file to determine eligibility based on disability. The eligibility specialist must check the IIVE system to determine whether the Social Security Administration has found the participant to be disabled. The IIVE must be printed and filed in the case record for documentation.
- Approving a child(ren) determined eligible for:
If verification of citizenship and/or identity is not in the case record, but all other available information to determine eligibility is included, approve the child for MO HealthNet benefits in the appropriate category. Verification of citizenship and/or identity should be requested at the next annual reinvestigation.
- SAB, BP, MHDC or MHABD –
- For a child(ren) without a current SAB, BP, MHDC or MHABD case – Begin eligibility on the date coverage for MHK ended. Send an IM-32 approval letter. If the application is approved the same day, enter “M” as the delay code in IMU5, Field 11.
- For a child(ren) with a current SAB, BP, MHDC or MHABD case – Send the eligible dates of coverage to be added to the current case to IM Program and Policy. Send an IM-33 to the family as notification of the dates of coverage.
- For a child(ren) without a current SAB, BP, MHDC or MHABD case – Begin eligibility on the date coverage for MHK ended. Send an IM-32 approval letter. If the application is approved the same day, enter “M” as the delay code in IMU5, Field 11.
- MPW – Contact IM Program and Policy for assistance in registering and approving.
- Rejecting a child(ren) determined ineligible for:
- SAB, BP, MHDC or MHABD –
- For a child(ren) without a current SAB, BP, MHDC or MHABD case – Use the appropriate rejection code when rejecting the case. DO NOT use rejection reason “44 – Other” when rejecting these cases. Send a rejection letter stating why the child(ren) was rejected, as hearing rights must be allowed.
- For a child(ren) with a current SAB, BP, MHDC or MHABD case – The eligibility specialist does a desk rejection of the application, sending the Notice of Case Action (IM-33) stating why the child(ren) was rejected.
- For a child(ren) without a current SAB, BP, MHDC or MHABD case – Use the appropriate rejection code when rejecting the case. DO NOT use rejection reason “44 – Other” when rejecting these cases. Send a rejection letter stating why the child(ren) was rejected, as hearing rights must be allowed.
- MPW – The eligibility specialist does a desk rejection of the application, sending the MC+ Notice of Denial (IM-33MC) stating why the child(ren) was rejected. Maintain information in the physical case record.
Rejection letters:
Any rejections letters sent as a result of this ex parte review must contain the following statement:
This action has been taken because a review of your record has been completed and we did not find evidence that your child(ren) was disabled, blind, or pregnant at the time your child lost eligibility for MO HealthNet for Kids (formerly MC+) because the premium was not received. This action is required by 13 CSR 40-2.100, and Sections 208.151 and 209.040 RSMo.
Example 1:
Mr. Jacobs requests a review of 12-year-old son John’s eligibility based on a physical disability. John lost eligibility for MHK on December 1, 2005. John is currently receiving MHDC with an eligibility start date of 6/1/06. The eligibility specialist reviews the case record. Information in IIVE indicates John was approved for SSI and determined disabled in November, 2005. John is eligible for MHDC based on information available in the case file and information obtained through IIVE. The eligibility specialist contacts IM Program and Policy Unit to have coverage entered for 12/1/05 through 5/31/06. The eligibility specialist sends John a Notice of Case Action (IM-33) informing him of the decision made and to provide coverage dates.
Example 2:
Ms. House requests a review of 17-year-old daughter Elizabeth’s eligibility based on disability. Elizabeth lost eligibility for MHK on March 1, 2006. The eligibility specialist enters a MHDC application, with an application date of March 1, 2006. The case file and IIVE do not contain information verifying that Elizabeth was disabled on March 1, 2006. Elizabeth is not eligible for MHDC based on information available in the case record or through IIVE. The eligibility specialist sends Elizabeth a Notice of Case Action (IM-33) informing her that she is not eligible for MHDC. Elizabeth has 90 days from the date on the IM-33 to request a hearing on this decision.
Example 3:
Ms. Perry requests a review of 16-year-old daughter Jane’s eligibility because Jane was pregnant when her MHK eligibility was lost on February 1, 2006. The case file does not contain proof of pregnancy for Jane on February 1, 2006, but shows that Jane was approved for MHK for her child Julie born on June 1, 2006. The eligibility specialist contacts IM Program and Policy Unit for instructions on entering MPW eligibility for Jane.
Example 4:
Mr. Anderson requests a review of 10-year-old son Bradley’s eligibility based on a physical disability. Bradley lost eligibility for MHK on December 1, 2005, and does not receive MO HealthNet benefits. The eligibility specialist enters a MHDC application, with an application date of December 1, 2005. The eligibility specialist reviews the case record and IIVE. Information in IIVE indicates Bradley was approved for SSI and determined disabled in November, 2005. Bradley is eligible for MHDC based on information available in the case file and information obtained through IIVE. Bradley’s MHDC application is approved with eligibility beginning December 1, 2005. The eligibility specialist sends Bradley an Approval Notice (IM-32) to inform him of the decision made and to provide coverage dates. In this situation, the eligibility specialist must decide if eligibility factors other than disability may be in question. If so, the eligibility specialist may initiate a complete reinvestigation before the scheduled reinvestigation as a separate step.NOTE: Do not delay a decision on the ex parte review while conducting a complete reinvestigation. Notify the individual of eligibility based on the ex parte review, and then conduct the reinvestigation.
NECESSARY ACTION:
- DO NOT require families requesting a review of the child(ren)’s MO HealthNet eligibility to complete or sign an application.
- Contact IM Program and Policy to assist in entering eligibility dates for a child(ren) with an open MHDC or MHABD case.
- Contact IM Program and Policy to request assistance in entering eligibility for a child(ren) eligible for MPW.
- Follow the procedures in this memorandum to determine MO HealthNet eligibility for all children whose families contact the county office as a result of the February 1, 2008 letter.
LH
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