MEMORANDUM

TO:

ALL COUNTY OFFICES

FROM:

ALYSON CAMPBELL, DIRECTOR

SUBJECT:

UPDATE OF POVERTY INCOME GUIDELINES FOR FAMILY HEALTHCARE PROGRAMS, MO HEALTHNET FOR THE AGED, BLIND, AND DISABLED SPENDDOWN AND NON SPENDDOWN, TICKET TO WORK HEALTH ASSURANCE (TWHA) , QUALIFIED MEDICARE BENEFICIARY(QMB), SPECIFIED LOW INCOME MEDICARE BENEFICIARY(SLMB AND SLMB-2), MO HEALTHNET FOR DISABLED CHILDREN, AND QUALIFIED DISABLED WORKING INDIVIDUALS (QDWI) PROGRAMS

MANUAL REVISION #6: Sections
0210.005.30;
0805.015.45;
0855.005.40.05;
0855.005.45;
0855.005.45.05;
0860.005.15.05;
0865.010.10.10;
0870.010.05;
0900.000.00 APPENDIX D, PAGE 1;

DISCUSSION:

Effective April 1, 2011, the Federal Poverty Level (FPL) increases. Senate Bill 577 (2007) amended Section 208.153 RSMo to authorize the disregard of annual Social Security Cost of Living Adjustment (COLA) increases for the Family Healthcare, MO HealthNet for the Aged, Blind, and Disabled (MHABD) Spenddown and Non Spenddown, and Ticket to Work Health Assurance (TWHA) programs until the next Federal Poverty Level (FPL) adjustment. However, there were no COLA income increases for 2011.

The poverty income guidelines for MO HealthNet for Families, Kids, Pregnant Women, Newborn, Uninsured Women’s Health Services (UWHS), Transitional MO HealthNet (TMH) in the third quarterly reporting period, MHABD Spenddown and Non Spenddown, TWHA, Qualified Medicare Beneficiary (QMB), and Specified Low Income Medicare Beneficiary (SLMB and SLMB-2), Qualified Disabled Working Individuals, MO HealthNet for Disabled Children programs are updated. New poverty figure amounts for Temporary MO HealthNet for Pregnant Women (TEMP) eligibility will be provided to qualified providers by State Office.

This memorandum includes information on:

• FAMIS adjustments;
• Conflict of actions;
• Premium refunds;
• Request for Hearing/Continued Benefits;
• FAMIS cases not adjusted;
• Legacy adjustments;
• Hearings on Legacy adjustments;
• County Office Responsibility for Legacy cases needing review for adjustment.

FAMIS ADJUSTMENTS

The adjustments begin Saturday, March 12; FAMIS will be unavailable until the adjustments are completed. If the adjustments are not completed by the morning of March 14, staff will be notified. FAMIS will adjust active cases, based on the new FPL figures. If there is no outstanding verification or other outstanding issues at the time the adjustment is completed, the system will authorize the action(s).

Notices will be sent on all actions except actions that result in no change (NOCH action in FAMIS).

For FAMIS determinations created on or after March 14, 2011and later, FAMIS will use the new poverty amounts effective for April 2011. For determinations effective March 2011 and earlier, FAMIS will apply the previous poverty figures.

On the weekend of March 12, 2011, FAMIS will do the following adjustments for the month of April 2011:

• Increase the “Max Allowed” field (Expense fields) on the Medicaid Budget Summary (FM4K) screens by the appropriate FPL amount based on Family Healthcare program and family size.
• Increase the “Income Maximum” field on the Adult MO HealthNet Budget Summary (FMD8) screen by the appropriate FPL amount based on adult program and assistance group size.

The EU Action Log (EULOG or FM40) displays the action taken by the system and the benefit month. To view information for a Family Healthcare adjustment, select the action and press F17=INQAUTH. The Action Authorization (FM4N) screen displays. Press F16=BUDSUM. The Medicaid Category Summary (FM4H) screen displays. To view specific budget information, select the individual and press F6=DETAILS or F14=ITERATIONS to view budget and assistance grouping information for the selected individual. To view information for an Adult MO HealthNet adjustment, select the action and press F17=INQAUTH. The Action Authorization (FM4N) screen displays. Press F16-BUDSUM. The MHABD Assistance Group Summary (FMD7) screen displays. To view specific budget information, select the individual and coverage type and press F16=AGBUDSUM to view budget and assistance grouping information for the selected individual and coverage type.

CONFLICT OF ACTIONS

FAMIS will adjust the FPL figures on EUs with pending adverse actions at the time of the mass adjustment. If an adverse action is pending on another change at this time, a conflict of actions occurs. These conflicting actions must be resolved so the system can properly take action on the case. When there are conflicting actions, the eligibility specialist receives two alerts “OUTSTANDING ELIGIBILITY DETERMINATION” and “ADVERSE ACTION NEEDS RESOLVING”. The conflict must be resolved by the Eligibility Specialist. To resolve the conflict:

• Access the Action Resolution (FM50 or ACTRES) screen and determine which pending adverse action period is most appropriate to void. For example, if there is an earlier pending adverse action to close the case based upon ineligibility then the eligibility specialist would choose to void the adverse action generated from the system adjustment. Refer to the user guide “Changing an Adverse Action Status” for instructions.
• After voiding the adverse action, access the Eligibility Determination Resolution screen (FM3Y or EDRES) and run a new eligibility determination.
• Authorize the adverse action.

PREMIUM REFUNDS

Premiums paid for April coverage will be refunded to the participant if the FPL cause the case to become eligible as a non-premium case. The refund process will take approximately 8 weeks to complete.

REQUEST FOR HEARING/CONTINUED BENEFITS

The FA-410 and FA-420 Adverse Action Notices are dated March 14, 2011.

Any EU receiving an FA-410 or FA-420 Adverse Action Notice may request a hearing on the mass adjustment action within 10 days from the date of the notice.

The FA-450 and FA-460 Action Notice generated by the mass adjustment is dated March 14, 2011, unless an FA-410 or FA-420 notice was sent. Any EU receiving an FA-450 or FA-460 Action Notice may request a hearing on the mass adjustment action within 90 days from March 14, 2011.

If the EU receiving an FA-410 or FA-420 Adverse Action Notice requests a hearing on the adjustment by March 24, 2011, the EU may request benefits continue at the level before the mass adjustment until the hearing decision is made. County staff should inform the EU that if continued benefits are issued and the agency is determined to be correct, a claim will be established for the overpayment.

To continue the MO HealthNet benefits at a higher level of care for EUs who received an FA-410 or FA-420 Adverse Action Notice pending the hearing decision, update the action status to HOLD (HOL) on the Action Resolution (FM50) screen. Refer to Changing an Adverse Action Status user guide for instructions.

FAMIS CASES NOT ADJUSTED

FAMIS cases that are in the controlled flow will not be adjusted. Those cases will have the new figures applied when the case is taken through the flow. FAMIS MHABD cases that have an option between TWHA premium and MHABD Spenddown coverage or MHABD Spenddown and SLMB-2 coverage and have never had an option selected will not be adjusted. Those cases will have the new figures applied once a coverage option has been selected.

LEGACY ADJUSTMENTS

On the weekend of March 12, 2011, the Information Technology Services Division (ITSD) will adjust the expense and deficit fields for the following types of active cases: MHABD spenddown and non spenddown, TWHA, QMB, SLMB, and QDWI cases that remain on the manual conversion list.

IM-5 forms will not be generated as a result of this adjustment. The adjusted figures will display on the ICAS screen effective March 14, 2011. Participants who have a change in the spenddown status or amount, or a change in the premium status or amount will be sent the appropriate notice.  All notices will be available on MOBIUS on March 14, 2011, under the heading FIMFPLA1A.

HEARINGS ON LEGACY ADJUSTMENTS

The adverse action notices generated by the mass adjustment will be dated March 14, 2011. The participant has until March 24, 2011, to request a hearing and have benefits restored to pre-adjustment levels.

If the participant requests a hearing on or before March 24, 2011, complete an IMU5 transaction to cancel the computer adjustment (i.e., cancel-close a closed case, etc.) and follow usual hearing procedures. Immediately print a copy of the computer generated Adverse Action Notice (IM-80), available on MOBIUS.

If the participant does not request a hearing on or before March 24, 2011, no further case action is necessary.

COUNTY OFFICE RESPONSIBILITY FOR LEGACY CASES NEEDING REVIEW FOR ADJUSTMENT

Using the listing “QMB/SLMB Cases Needing Review for Adjustment”, which will be available on MOBIUS under the heading FIMFPLA2A, review listed cases as follows, convert cases to FAMIS, the day after conversion to FAMIS, process the controlled flow where FAMIS will apply the April 1, 2011 FPL amounts.

QMB SURP - These cases have a surplus calculated in Field 35. Review for continuing eligibility, including eligibility under the SLMB program.

SLMB SURP - These cases have a surplus calculated in Field 35. Review for continuing eligibility.

IM NO BNDX - These cases have an OASDI amount in Field 14M of IMU5 but no OASDI amount appearing on the BENDEX tape file. Review for accuracy of information in the IM database and make necessary corrections.

IM > BNDX - These cases have an OASDI amount in Field 14M of IMU5 that is greater than the amount appearing on the BENDEX tape file. Review for accuracy of information in the IM database and make necessary corrections.

INCOR EXP - These cases display as the result of a computer generated opening (i.e., the QMB/SLMB only case was opened when a MHABD spenddown case was auto closed, and the MHABD budget figures remain in Fields 33 through 35.) These cases display for your information only. Correct the budget figures at the next regular handling.

Using the listing “MHABD Cases Needing Adj- No OASDI”, which will be available on MOBIUS under the heading, FIMFPLA2D, review listed cases as follows:

NO OASDI - These cases have no OASDI amount in Field 14M of IMU5 but have OASDI amount appearing on the BENDEX tape file. Review for accuracy of information in the IM database.

The MO HealthNet Program Description Aged, Blind, and Disabled Program Descriptions, Family Healthcare Program Descriptions, MO HealthNet Aged, Blind, and Disabled Income Chart, and MHK/MHF/TA Income Chart have been updated on the Intranet and Internet to include the change in income limits. The MO HealthNet for Kids, MO HealthNet for Pregnant Women, MO HealthNet for the Aged, Blind, and Disabled, Uninsured Women’s Health Services Program, Do Your Children Need Health Coverage, QMB and SLMB Internet pages have been updated to include the change in income limits.