M E M O R A N D U M

IM-2  01/21/99  TWO YEAR EXTENSION OF TRANSITIONAL MEDICAID


SUBJECT:
TWO YEAR EXTENSION OF TRANSITIONAL MEDICAID
 
DISCUSSION:
Missouri's Medicaid 1115 Waiver provides uninsured adults who successfully complete the 12 months of Transitional Medicaid (TM) two years of extended health insurance coverage through the MC+ program.  The extension is designed to help the customer become more self-reliant by providing health care coverage for a longer period of time.  Eligibility begins 02/01/99 for customers whose TM ends 01/31/99.  To be eligible for the two-year extension, a caretaker relative must meet the following criteria:
  • Completion of the initial 12 months of TM;

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  • Employment;

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  • Uninsured;

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  • Gross income below 300% of the federal poverty level;

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  • MC+ eligible child in the home.
There are no quarterly reports required during the two-year extension.  There is no resource limit.  Reviews on the cases are to be done annually.  Self-declaration of income should be accepted, unless questionable, both during the two year extension and the initial 12 months of TM. Once an Extended Transitional Medical Assistance case is closed it can not be reopened, unless closed in error.

COMPLETION OF THE INITIAL 12 MONTHS OF TM

The Transitional Medicaid case must be in active status in the 12th month.  If the case is in suspended status it will be closed.

EMPLOYMENT

The caretaker relative (whose employment caused ineligibility for Medical Assistance for Families) must remain employed.  The reasons loss of employment would not cause ineligibility in the second six months of TM also apply for the two-year extension.

UNINSURED

The caretaker relatives in the family must not currently have insurance that provides coverage for physician's services and hospitalization.  The requirement that health insurance not have been dropped in the last six months does not apply to this group.  All of the other uninsured requirements for MC+ level of care "1" and "2" children (refer to Memorandum IM-87 dated July 23, 1998) apply.

INCOME

The family's gross income must remain below 300% of the federal poverty level (FPL) during the two-year extension.  The assistance group rules are the same as for the initial 12 months of TM.  Determination of income is the same as for MC+ for children.  There are no allowable deductions or disregards with the exception of overhead expenses for self-employment income. 

MC+ ELIGIBLE CHILD IN THE HOME

There must be an MC+ eligible child in the home for the caretaker relatives to remain eligible.  If the last eligible child leaves the home or turns age 19, the caretaker relatives are ineligible. 

The caretaker relatives also become ineligible if the children are in the premium group and lose eligibility for one of the following reasons:

  • failure to pay the premium; or

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  • access to affordable health insurance.
In these situations ineligibility is due to there not being an MC+ eligible child in the home, not failure to pay the premium or access to affordable insurance. 

COST AND COVERAGE

Customers who receive Extended Transitional Medical Assistance will receive a more restricted coverage package than that received by MC+ children and other adults under Medicaid.  The package includes most of the services covered for adult Medicaid recipients.  The major differences between this package and that received by other adult Medicaid recipients are:

  • Non-emergency medical transportation is not covered;

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  • Vision care is limited;

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  • Routine dental care is not covered;

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  • EPSDT services for caretaker relatives under age 21 are not provided.
For specific coverage questions, customers need to contact their health plan, provider, or Recipient Services at 1-800-392-2161.  Customers will be enrolled in MC+ managed care where available.  Services will be provided fee-for-service where managed health care is not available.

Cost sharing will be $10 at the time of each provider visit and $5.50 to $7 for each prescription.  The co-payment amount is based on the actual cost of the product being dispensed.  Cost sharing is due at the time the customer receives medical attention.  Failure to pay the cost sharing at the time of service can result in denial of service.

SYSTEM CHANGES

Once customers have completed their initial 12 months of Transitional Medicaid successfully, the IM system will automatically convert to extended TM if the caretaker or second parent is uninsured.  A new level of care (LOC), "E", will identify caretaker relatives receiving the extended coverage.

In the twelfth month of TM the system will determine if the caretaker and/or second parent are uninsured.  If there is an "I" (insured) in field 13-03 the case will automatically close.  The following changes will occur in the IMU5 system after payroll closing in the 12th month of TM if an "I" is not present in field 13-03:

  • FIELD 32, will have an ending date 2 years from the date the initial 12 months ended.

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  • FIELD 38A, a "5" will be placed in the field.

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  • FIELD 13E, will show a Medicaid start date that is the day after the initial Transitional Medicaid ended.

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  • FIELD 13G, will change to LOC "E".
If eligibility is extended a system-generated letter (sample attached) will be sent explaining the 2 year extension and the changes in health care coverage.

If the caretaker and second parent are both insured, a system-generated letter will notify them of the ending date of TM and the reason that they are ineligible for extended coverage.  This letter will be sent at payroll in the 11th month of TM eligibility.  It will list active children on the case, and inform the caretaker that the children's eligibility for MC+ is being explored.  If the children are already on a separate MC+ case, the letter will state their coverage has not changed.

CHILDREN ON TM

A report of children active on TM cases to be extended or closed by the system will be sent to the caseworker.  The report will list children on cases that were extended in the twelfth month.  On cases to be closed, it will list children in the 11th and 12th month of TM eligibility.

Children active on TM cases that are extended will remain on the case as a "T" LOC.  Since children are not eligible for the extension, they must be moved to an MC+ (C7) case by the caseworker. 

If the TM case is being closed the children's eligibility for MC+ should be explored.  A new application is not required.  Make the eligibility determination based on the income reported on the last quarterly report and the child's insurance status.  The children should be eligible, unless income is above the non-CHIP limit and they are insured.  If eligible, send the family an approval letter (IM-32MC).  If ineligible, send a denial letter (IM-33MC).  The family should be notified as soon as possible, but no later than 10 days after the report is received.
 
NECESSARY ACTION:
  • Review with all appropriate staff.
  • Follow the procedures in this memorandum to determine continued eligibility for Extended Transitional Medical Assistance. 
MJS
Distribution #6
[ 1999 Memorandums ]