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

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204.03 Partners for Healthy Children

(Eff. 01/01/14)

This section discusses a range of health insurance plans for children who live in families with income at or below 208% of the FPL. The available plans include Medicaid and Medicaid Expansion through the Children’s Health Insurance Program (M-CHIP). If approved, PHC beneficiaries are eligible for full Medicaid benefits.

Effective January 1, 2014, the ACA expanded CHIP coverage as discussed below.

204.03.01 Eligibility Criteria

(Eff. 01/01/14)

Children must be under age 19 and may be eligible if they meet both the non-financial and financial criteria for this program. The financial criteria are discussed in MPPM Chapter 203. The non-financial criteria are discussed in this MPPM Chapter 204 and are 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

  • Applying for and Accepting other Benefits MPPM 102.08

204.03.02 Health Insurance

(Eff. 01/01/14)

At approval, review, or ex parte determination, Eligibility Workers must check for any indication of creditable health coverage by reviewing the Applicant’s DHHS Form 3400, Healthy Connections Application, appropriate review forms, and the TPL Policy Inquiry on MMIS. Creditable health coverage is defined as insurance with, at minimum, coverage for hospitalization, doctor visits, X-rays, and lab work. A child who currently has health insurance may be eligible for PHC.

204.03.03 Third Party Liability Insurance Coding Procedure

(Eff. 01/01/14)

Procedure for Third Party Liability Insurance Coding

MEDS Procedure:
On the HMS06 (Household Member Detail) screen, update the “TPL INSURANCE” field with the appropriate code. This is a required field.

  • Enter “Y” in the “TPL INSURANCE” field for a child with creditable health insurance coverage from any source (MPPM 204.03.01).

  • Enter “N” in the “TPL INSURANCE” field for a child with no creditable health insurance coverage.

204.03.04 Express Lane Eligibility (ELE)

(Eff. 01/01/14)

SC DHHS has an automated monthly data match with the SC Department of Social Services (SC DSS) to identify children not currently receiving Medicaid, but who are receiving benefits from the Supplemental Nutrition Assistance Program (SNAP) and/or Family Independence (FI). Children who are not on Medicaid and receiving SNAP and/or FI are automatically made eligible for Medicaid under PHC.

ELE New Enrollment Process:
The families of all eligible children receive (i) a cover letter explaining ELE; (ii) the Medicaid Approval Letter, ELD014, indicating their enrollment into Medicaid; and (iii) instructions on how to use the Medicaid Card. Initially all children are enrolled into Fee for Service (FFS) Medicaid and are not assigned to a Managed Care Plan. After receiving a Medicaid card, families will be notified through the enrollment broker about the importance of well-care visits for children and other preventative medical services. They will receive a choice enrollment package which will ask them to choose a Managed Care Plan. If the family uses the Medicaid card but does not pick a plan, they will become assignable and will have to choose a Managed Care plan. The enrollment broker will send an updated enrollment package. The family will have at least 30 days to pick a plan. If a plan is not chosen, one will be chosen for them.
If a family wishes to discontinue Medicaid coverage for their child, the request is made by calling the Healthy Connections Consumer Portal Support toll-free at 1-888-549-0820. Once notification of the request is received, the Healthy Connections Consumer Portal Support must document the request for closure on the MEDS NOTES Screen (HMS63)/ ACCESS and complete the following procedure.

Procedure for ELE New Enrollment Process

MEDS Procedure:

  1. Document the request with the following:

  • Date of the call

  • Child’s Name

  • Name of the person that called

  • The Beneficiary, Household and/or Budget Group Number

  1. On the same day, the request must be sent via email to the Member Information Management (MIM) email group. The subject line must state: “ELE Opt Out”.

  1. MIM will close the Budget Group with reason code 0L1 (You have declined Express Lane Eligibility Medicaid coverage).

MEDS will send the appropriate notice to the family.

Note: If the family should contact the Local Eligibility Office, the same procedures will apply.

A new application is required if a family member calls and requests that other children be added to Medicaid or requests Medicaid for themselves. The worker will mail the family an application along with DHHS Form 1233, Medicaid Eligibility Checklist. The family will have 30 days from receipt of requesting needed information to return the necessary information. Once all of the necessary information is received, the Eligibility Worker must perform the following procedure.

Procedure for ELE Necessary Information

MEDS Procedure:

  1. Determine eligibility using the Budget Workbook.

  1. If the child/family is eligible, determine the appropriate category.

Note: If the addition of the family member (s) causes the case to be denied or become ineligible, the current budget group cannot be closed. The children in the budget group are protected for one year from their eligibility decision date.

  1. The Eligibility Worker will then take a new application in MEDS to create a new budget group for the appropriate category. Make sure each active member of the budget group and the new family member (s) are applying in the budget group.

MEDS will set the next review date for one year from the decision date for all of the active budget group members.

Note: The application must be entered and approved in MEDS by the next business day.

DHHS plans to track those children enrolled into Managed Care or FFS, through claims submitted during a 12-month period. If a child is not enrolled in one of South Carolina’s Managed Care programs and does not use the Medicaid card after 12 months, SC DHHS will not automatically enroll the child for a second year. A closure notice, ELD020, will be sent explaining that the child is no longer eligible for the Medicaid Program.

At review, if the child (i) has enrolled into a Managed Care Plan or used the Medicaid card and (ii) continues to be receiving SNAP and/or FI, eligibility will automatically continue for another year. If the child (i) has enrolled in a Managed Care Plan or has used the Medicaid card and (ii) is no longer receiving SNAP and/or FI, the regular review process will be followed. See MPPM Section 204.06.04 concerning PHC reviews.

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