MEMORANDUM

DISCUSSION:

Effective April 1, 2016, the Federal Poverty Level (FPL) income guidelines are increased for the following FAMIS programs: MO HealthNet for the Aged, Blind and Disabled spend down and non-spend down, Ticket to Work Health Assurance (TWHA), Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB and SLMB-2), Qualified Disabled Working Individuals (QDWI), MO HealthNet for Disabled Children (MHDC) programs and Gateway to Better Health.

NOTE: The income limits for Family MO HealthNet programs in FAMIS remain at the pre Affordable Care Act (ACA) percentages. If contacted by a recipient who has received adverse action due to income, the case must be reviewed for eligibility under the Modified Adjusted Gross Income Methodology.

On the weekend of March 12, 2016, MO HealthNet for the Aged, Blind and Disabled programs in FAMIS with income eligibility based on the federal poverty level will be adjusted. Family MO HealthNet case will not be adjusted in FAMIS. 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

Active cases in FAMIS were adjusted based on the new FPL income guidelines. If there was no outstanding verification or other outstanding issues at the time the adjustment was completed, the system authorized the action(s). Notices were sent on all actions except actions that resulted in no change (NOCH in FAMIS).

For FAMIS determinations created on or after March 12, 2016, FAMIS will use the new FPL income guidelines effective for April 2016. For determinations effective March 2016 and earlier, FAMIS will apply the previous FPL income guidelines.

On the weekend of March 12, 2016, FAMIS completed the following adjustments for the month of April 2016:

• Increased 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 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 adjusted the FPL income guidelines on eligibility units (EU) with pending adverse actions at the time of the mass adjustment. If an adverse action was pending on another change, a conflict of actions occurred. 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 14, 2016. 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 24, 2016, 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 24, 2016, 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 24, 2016.

FAMIS CASES NOT ADJUSTED

FAMIS is not able to adjust cases listed on the Interrupted/Incomplete Controlled Flows (CONFLOWS) screen. Those cases will not be adjusted until the controlled flow is 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, MO HealthNet Aged, Blind, and Disabled Income Chart, and Medicare Cost Savings Programs (QMB and SLMB) internet pages are updated to include the change in FPL income limits

NECESSARY ACTION:

• Begin using the new federal poverty level income guidelines effective for April 2016 and later.
• Resolve conflicting actions.
• Review this memorandum with appropriate staff.

JG/mks