South carolina department of health and human services medicaid policy and procedures manual

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CHAPTER 204 – MAGI Eligibility Categories


204.01 Introduction 2

204.02 Pregnant Women and Infants 2

204.02.01 Pregnant Women 2

204.02.01A Eligibility Criteria 4

204.02.01B Assumptive Eligibility 5

204.02.01C Continuous Eligibility through Postpartum Period 7

204.02.01D Retroactive Coverage 8

204.02.01E Termination of Pregnancy 8

204.02.01F Case Processing for Aliens Eligible for Emergency Services Only 9

204.02.02 Infants 10

204.02.02A Deeming Process 10

204.02.02B Newborns Placed for Adoption 13

204.02.02C Hospitalized Children 14

204.02.02D Non-Deemed Infants 15

204.03 Partners for Healthy Children 15

204.04 Parent/Caretaker Relative 19

204.04.01 Eligibility Criteria 20

204.04.02 Change in Earned Income 20

204.05 Healthy Connections Family Planning 20

204.06 Regular Foster Care 25

204.07 Former Foster Care 35

204.08 Subsidized Adoption 37

204.09 Ribicoff 42

204.10 Appendix A: Out-of-Home Placement Chart 43

204.11 Appendix B: Crosswalk 45

204.01 Introduction

(Eff. 01/01/14)

Modified Adjusted Gross Income (MAGI) methodology applies to the following eligibility categories:

  • Pregnant Women and Infants (PW)

  • Partners for Healthy Children (PHC)

  • Parent/Caretaker Relative (PCR)

  • Healthy Connections Family Planning (HCC)

  • Regular Foster Care

  • Former Foster Care (FFC)

  • Subsidized Adoption

The household composition of an Applicant applying to an eligibility category listed in this section will be determined pursuant to MAGI methodologies. For more information, see MPPM 202.
The ACA creates a protected period allowing individuals eligible for Medicaid under the aforementioned MAGI categories (and their equivalent policy predecessors) to continue receiving services for a limited period of time after new eligibility criteria go into effect. To qualify, the individual must have been eligible to receive services on December 31, 2013. Protected persons will remain eligible until the later of (i) April 1, 2014 or (ii) the individual’s next review date. However, while this protected period delays application of MAGI methodology to re-determine eligibility, eligibility may still be lost as a result of moving out of state, death, loss of a qualifying child, etc.

204.02 Pregnant Women and Infants

(Eff. 01/01/14)

This section discusses the eligibility requirements and procedures for Pregnant Women and Infants (PW), whose eligibility determination is based on MAGI criteria.

204.02.01 Pregnant Women

(Eff. 01/01/14)

The Patient Protection and Affordable Care Act (ACA) provides for Medicaid coverage to pregnant women with low income. Eligibility will be based on the income of the MAGI household, which must be less than or equal to 194% of the Federal Poverty Level (FPL) in the initial month of application, or in one of the three prior months. Additional eligibility criteria must be met if requesting retroactive coverage. (Refer to MPPM 103.01.)

Procedure for Determining Pregnant Woman Eligibility

MEDS Procedure:
1. If the applicant is eligible under MAGI rules for January 2014, virtually print the MAGI workbook into the case record in OnBase.

2. From the HMS49 screen, press the PF3 key to access the HMS07 screen.

3. Select the members that you want included in the January 2014 budget group. Use the household composition under current policy when entering this information into MEDS. Press the F16 key to access the HMS59 screen.

4. On the HMS59 screen, enter the Payment Category, the members that are applying and non-applying. Enter “ADD” in the action field.

5. Enter $0.00 on the Countable Income field on the ELD01 screen.

6. On the MEDS Notes screen, enter the actual countable income and Federal Poverty Level from the MAGI Workbook.

Because the countable income is listed on ELD01 as $0.00 it is important for auditing purposes to document the actual countable income and the FPL on the notes screen

7. Complete Make Decision on ELD01.

8. Complete Act on Decision. The applicant will receive an approval notice with the appropriate eligibility start date.

9. Virtually print the MAGI Workbook into the case record on OnBase.

10. If the applicant is ineligible for full Medicaid benefits under the 2014 Medicaid rules, but is being approved under the Former Foster Care coverage category, see the Former Foster Care Coverage section or if they are being approved for Family Planning, see the Eligible Family Planning Only under 2014 MAGI Rules section.

204.02.01A Eligibility Criteria

(Eff. 01/01/14)

To be eligible under the PW category, the woman must be pregnant, and the pregnancy, including the expected date of delivery or the date of the pregnancy ended, must be documented by self-reporting. SC DHHS can require verification from a medical provider for information such as due date, number of expected babies, or validation of pregnancy if there is a reason to expect incorrect or falsified data.

Procedure for Documenting Self-Report of Pregnancy

An individual applying as a pregnant woman must self-report the pregnancy and the expected date of delivery. If the pregnancy is indicated on Form 3400 but the (i) estimated date of delivery or (ii) number of babies is not documented, send Applicant the DHHS Form 3310, Statement of Pregnancy.

Coverage for pregnancy includes the 60-day postpartum period. The postpartum period begins either on the date of delivery or the date the pregnancy ends. The postpartum period ends on the last day of the month in which the 60th day falls.

The woman must also meet non-financial criteria that are discussed in MPPM Chapter 102, referenced below:

  • Identity MPPM 102.02

  • State Residency MPPM 102.03

  • Citizenship/Alienage MPPM 102.04

  • Enumeration/Social Security Number MPPM 102.05

  • Assignment of Rights to Third Party Medical Payments MPPM 102.07

204.02.01B Assumptive Eligibility

(Eff. 06/01/14)

Assumptive Eligibility must be used in processing applications for the Pregnant Women program. Assumptive Eligibility is not used for any other Medicaid program. If a pregnant woman applies for Medicaid, and she does not have all the necessary information needed to make a decision on her case, the Eligibility Worker must approve the case assumptively, provided the information given by the client is sufficient to determine eligibility and is not questionable.

Assumptive Eligibility cannot be used to process applications for the Pregnant Women program, for applicants eligible for emergency services only. Refer to MPPM Section 204.02.01F for more information.
It is important that a pregnant woman have coverage to access prenatal care as quickly as possible. An initial budget based on the Applicant's attestation of income, pregnancy, citizenship, and family circumstances must be completed on the day an application is received to determine eligibility for Pregnant Women. If the Eligibility Worker cannot process the application on the date received, a decision must be made by the end of the next business day, and include the reason the application could not be processed must be documented in the case record.

  • The application must be approved if the initial budget indicates the Applicant is eligible, and she self-reports meeting all other eligibility criteria, unless the worker has reason to question the information provided by the Applicant.

    • If the Eligibility Worker has reason to question the Applicant's allegations, the Eligibility Worker must discuss the case with his/her supervisor before deciding whether to withhold action on the case pending verification.

    • The record must be documented with the decision and the reason the Eligibility Worker and supervisor is questioning the Applicant's self-reported information.

    • If it is determined that the application cannot be approved until verification of income and/or family circumstances is received, the Eligibility Worker must give the Applicant 15 days to return the required information. A DHHS Form 1233-ME, Medicaid Eligibility Checklist, listing the verification needed to determine eligibility, must be given to the Applicant and a copy scanned into OnBase with a follow up of 15 days.

If the initial budget indicates the Applicant is not eligible based on the self-reported income, the application cannot be denied. The application must be pended, and the Eligibility Worker must provide the Applicant with 15 days to return the required information. A DHHS Form 1233-ME, listing the verification needed to determine eligibility must be given to the Applicant and a copy retained in the record. If the Applicant returns verification of income that makes her ineligible, the application can be denied.

For cases approved assumptively, the remaining information necessary to confirm eligibility must be verified within 30 days of requesting the needed information to allow the application to be processed within 45 days. However, an Applicant required to submit documentation of Citizenship and/or Identity for the first time can be eligible for 90 days, provided that all other required verifications are returned within 30 days of approval. Refer to MPPM 102.04.03.
If a baby is born to a pregnant woman who has been Assumptively Approved and all verifications have not been received within 30 days of request, the baby cannot be deemed automatically. The baby can be deemed automatically so long as the woman (i) has filed a complete Medicaid application, including but not limited to meeting residency, income and resource requirements; (ii) has been determined Medicaid eligible; (iii) is receiving Medicaid on the date of the child's birth; and (iv) remains (or would remain if pregnant) Medicaid eligible. If the child cannot be deemed automatically, a parent must complete an application.
If, after all verifications have been received, the pregnant woman loses eligibility due to income, citizenship and/or identity, the baby cannot be deemed automatically. An application must be made to determine the baby’s eligibility. If the Eligibility Worker is unable to obtain verification within 30 days of requesting the information necessary for the application to be processed within 45 days, the Eligibility Worker must close the case on the 31st day. If the Applicant/beneficiary reapplies within six months of the date on the closure notice, the application cannot be Assumptively Approved; all verification must be obtained before the case can be approved. In this case, the 3400 Healthy Connections Application is not approved at the initial filing unless ALL necessary verifications are provided at the interview. If all verifications are received within 30 days of closure, the original application can be used to determine eligibility. A baby born to a mother Assumptively Approved for 90 days based on Citizenship and/or Identity can be deemed as long as a parent has provided all other required verifications prior to the child’s birth.

Procedure for Determining Assumptive Eligibility

MEDS Procedure:
Pregnant Women program cases Assumptively Approved can be flagged by entering the end of the 30 days in the “Anticipated Closure Date” field on MEDELD01. This will generate an alert at the end of the 30 days. This must be done after entering the information on this screen and completing the “Make Decision” process by pressing PF15. This process will cause expected delivery + 2 months date to show on the “Anticipated Closure Date.” The postpartum date must be replaced with the end of the 30 days date. Enter the end of the 30 days date, in the action field and press . Do not Make Decision again. Then, “Act On Decision” by pressing PF24 after making sure the eligibility end date on the MEDELD02 screen is correct.
Cases Assumptively Approved must be closed if verification is not provided timely. To close the case, go to the Eligibility Decision Menu, select “Eligibility Decision” and enter the budget group number in the operand field and press . Press PF3 to go to the next “Eligibility Decision Screen” (MEDELD01), enter reason code 004 in the first “Reason for Denial/Closure” field, to remove the PPED (Protected Period End Date), and press . Make Decision is automatically called. Change the reason code to 014 (You did not send the needed information). the screen and press . Press PF3 to go to Eligibility Decision screen (MEDELD02) to verify that the eligibility end date is correct. If the end date is not correct, change by entering the correct end date, go to the Action field and . Do not “Make Decision.” “Act on Decision” by pressing PF24. The system will generate the appropriate notice and send it to the Applicant.
Note: Medicaid benefits will not terminate for at least 10 days. For example: If an Eligibility Worker closes the case on November 15, the notice sent by MEDS will inform the Applicant/ beneficiary that the case will close effective December 1. If the Eligibility Worker closes the case on November 23, then the notice sent by MEDS will inform the Applicant/ beneficiary that the case will close effective January 1. MEDS will give the appropriate 10-day notice.
If the Applicant re-applies for the Pregnant Women program within 30 days, the Eligibility Worker may use the same application. The case must not be approved until all verification of income and questionable information has been provided. The case cannot be Assumptively Approved.

204.02.01C Continuous Eligibility through Postpartum Period

(Eff. 03/18/14)

Once a pregnant woman is determined eligible and is certified for assistance, she receives benefits throughout the postpartum period, which continues 60 days from date of either the child’s birth or the end of pregnancy. Eligibility will continue during the postpartum period regardless of changes in income as long as the beneficiary remains a South Carolina resident.

In general, a minor who is pregnant and otherwise eligible should be placed in PHC. If a person under age 19 is eligible in the PW category, and her baby is born or pregnancy otherwise ends before she attains the age of 19, she should be reviewed for PHC coverage for one year or until her 19th birthday, whichever comes first.
Once the 60-day postpartum period ends, the Eligibility Worker must determine if the Applicant/beneficiary is eligible for Medicaid under any other coverage group with full benefits, i.e. PCR or PHC. If the Applicant/beneficiary is not eligible for a full benefit category then the Eligibility Worker must check eligibility for Family Planning, ex parte the application to Family Planning if eligible, and transfer the Applicant/beneficiary to the FFM. If a pregnant woman self-reports meeting categorical requirements in a new payment category, but not all information is available to make the decision, the Eligibility Worker should continue eligibility in the current category and contact the beneficiary by phone or mail a 1233E for the necessary information to make a decision in the potential category. Refer to MPPM Section 101.09.06 regarding ex parte policy and procedures.
Continuous eligibility rules (MPPM 101.09.07) also apply to pregnant women Assumptively Approved who have returned all required verifications within 30 days from the application date, or 90 days in the case of reasonable opportunity for Citizenship and/or Identity. If an application is approved in error, the Eligibility Worker must close the case allowing appropriate notice.

204.02.01D Retroactive Coverage

(Eff. 01/01/14)

If a pregnant woman was eligible in one or more months of the retroactive period, her eligibility begins the first month eligibility can be established through the end of the postpartum period without regard to income changes.

To be eligible for a retroactive determination, the beneficiary must have been: (i) pregnant during the retroactive month(s) requested, and (ii) her actual income received in the month(s) must satisfy the income criteria.

204.02.01E Termination of Pregnancy

(Eff. 01/01/14)

When an Applicant/beneficiary reports a miscarriage or that she is no longer pregnant, she is still entitled to the 60 days postpartum period. If the 3400 Healthy Connections application is submitted following a miscarriage, it is the Applicant/Beneficiary’s responsibility to provide verification of the date of miscarriage from the physician’s office or emergency room.

Procedure for Termination of Pregnancy

MEDS Procedure:

  • Go to HMS06. Put N for “Not Pregnant”.

  • Delete EDC and # of Children.

  • MOD Screen.

  • Go to ELDO1- Put in Reason Code 004 (Manual Closure)

  • MOD Screen.

  • Once you have initiated a Manual Closure, do not “Act on Decision.”

  • Replace Reason Code 004 with Reason Code 078 (Postpartum Period Ended).

  • Once you MOD Screen, follow rules for the Ex Parte Process.

Note: For Pregnant Women cases, once the 60-day post-partum period ends, the Eligibility Worker must determine if the Applicant/beneficiary is eligible for Medicaid under any other coverage group with full benefits (ex. PCR, PHC). If the Applicant/beneficiary is not eligible for a full benefit category then the Eligibility Worker must ex parte the case to Family Planning. Refer to MPPM Section 101.09.06

204.02.01F Case Processing for Aliens Eligible for Emergency Services Only

(Rev. 09/01/15)

At the time of application, the Eligibility Worker must explain to any non-citizen or qualified alien Applicants that Medicaid may only reimburse for Emergency Services (including labor and delivery). The Eligibility Worker should process the application to establish the individual’s alien status and then determine whether the individual is categorically and financially eligible (except for enumeration). Aliens eligible for emergency services only do not receive Medicaid cards.

An alien only eligible for emergency services does not receive a Medicaid card, therefore the Applicant/Beneficiary should be told to share this notification with the medical provider of the service. If the Applicant/Beneficiary fails to do this, the medical provider may request the Medicaid identification number by (i) completing DHHS Form 900, Request for Medicaid Information – Coverage of Emergency Services for Aliens, and (ii) forwarding it to the county Eligibility Worker.

MEDS Procedure:

  • The effective date of the application is the date the signed and dated application is received.

  • The Service Type field on ELD02 in MEDS MUST be set to “E” for Emergency Services and the EDC date must be keyed in MEDS.

  • Individuals will be eligible for payment of Emergency Services only for one year from the date of approval. This does not prevent the individual from applying for and being approved for payment of services at a future date.

  • After the year of coverage is over, the Eligibility Worker will get alert #582, Certification Period Ended, Verify Eligibility Decision. The case will soft close.

  • The Eligibility Worker must close the BG. The infant should be deemed in PCAT 12.

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