MEMORANDUM

DISCUSSION:

Effective April 1, 2013, the Federal Poverty Level (FPL) income guidelines are increased for MO HealthNet for Families (MHF), Kids (MHK), Pregnant Women (MPW), Newborn, Uninsured Women's Health Services (UWHS), Transitional MO HealthNet (TMH) in the third quarterly reporting period, MO HealthNet for the Aged, Blind and Disabled (MHABD) spend down and non- spend down, Ticket to Work Health Assurance (TWHA), Qualified Medicare Beneficiary (QMB), and Specified Low Income Medicare Beneficiary (SLMB and SLMB-2), Qualified Disabled Working Individuals (QDWI), and MO HealthNet for Disabled Children (MHDC) programs. New poverty income guidelines for Temporary MO HealthNet for Pregnant Women (TEMP) and for presumptive eligibility (PE for Kids) were provided to qualified providers and presumptive eligibility providers by Income Maintenance Program and Policy.

On the weekend of March 9, 2013, the SSA and SSI amounts which were not increased during the Cost of Living Adjustment (COLA) (see Memorandum IM-#100 of December 7, 2012), will be adjusted for MO HealthNet programs with income eligibility based on federal poverty level. This memorandum includes information on:

• FAMIS ADJUSTMENTS
• CONFLICT OF ACTIONS
• PREMIUM REFUNDS
• REQUEST FOR HEARING/CONTINUED BENEFITS
• FAMIS CASES NOT ADJUSTED
• LEGACY CASES NOT ADJUSTED
• PROGRAM DESCRIPTIONS AND OTHER RESOURCES

FAMIS ADJUSTMENTS

The adjustments begin Saturday, March 9. FAMIS will be unavailable until the adjustments are completed. If the adjustments are not completed by the morning of March 11, staff will be notified.

FAMIS will adjust active cases based on the new FPL income guidelines. 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 in FAMIS).

For FAMIS determinations created on or after March 11, 2013, FAMIS will use the new FPL income guidelines effective for April 2013. For determinations effective March 2013 and earlier, FAMIS will apply the previous FPL income guidelines.

On the weekend of March 9, 2013, FAMIS will do the following adjustments for the month of April 2013:

• 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) screen 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.
• 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.

CONFLICT OF ACTIONS

FAMIS will adjust the FPL income guidelines on eligibility units (EU) with pending adverse actions at the time of the mass adjustment. If an adverse action is pending on another change, a conflict of actions occurs. These conflicting actions must be resolved so the system can act on the case. When there are conflicting actions, the eligibility specialist (ES) receives two alerts "OUTSTANDING ELIGIBILITY DETERMINATION" and "ADVERSE ACTION NEEDS RESOLVING". To resolve the conflict the ES must:

• 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, the eligibility specialist would choose to void the adverse action generated from the FPL mass adjustment. Refer to FAMIS User Guide "Changing an Adverse Action Status" for instructions.
• After voiding the appropriate adverse action, access the Eligibility Determination Resolution screen (FM3Y or EDRES) and run a new eligibility determination.
• Authorize the adverse action.
• Enter comment supporting the decision to void the adverse action.

PREMIUM REFUNDS

Premiums paid for April coverage will be refunded to the participant if the FPL causes 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 11, 2013. 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.

If an EU receiving an FA-410 or FA-420 Adverse Action Notice requests a hearing on the adjustment by March 22, 2013, the EU may request benefits continue at the level before the FPL adjustment until the hearing decision is made. 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 any 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 FAMIS User Guide Changing an Adverse Action Status for instructions. Enter comments regarding the request for hearing and interim contacts.

The FA-450 and FA-460 Action Notice generated by the mass adjustment is dated March 22, 2012, 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 22, 2013.

FAMIS CASES NOT ADJUSTED

FAMIS is not able to adjust cases listed on the Interrupted/Incomplete Controlled Flows (CONFLOWS) or the Manual Conversion (CONVERT) screens. Those cases will not be adjusted until the conversion and the controlled flow are complete.

FAMIS MHABD cases that have an option, between TWHA premium and MHABD spend down coverage or MHABD spend down and SLMB-2 coverage, and have never had an option selected will not be adjusted. The new FPL income guidelines will be applied once a coverage option has been selected.

LEGACY CASES NOT ADJUSTED

Qualified Disabled Working Individual (QDWI) is the only program still in the Legacy system that is based on FPL income guidelines. All other cases using the FPL income guidelines have been converted to FAMIS. There are currently no legacy cases identified as QDWI. Legacy system cases will not be adjusted for the FPL increase.

PROGRAM DESCRIPTIONS AND OTHER RESOURCES

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 are updated on the Intranet and Internet to include the change in FPL 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 FPL income limits.

NECESSARY ACTION:

• Begin using the new federal poverty level income guidelines effective for April 2013 and later.
• Resolve conflicting actions.
• Review this memorandum with appropriate staff.

MKS