Adult Medicaid Manual MA-2160 QUALIFYING INDIVIDUALS 1 (QI1/MQB-E)

III. PROCEDURES

A. Application

1. Refer to MA-2304, Processing The Application. If an individual/couple’s income is in the QI1/MQB-E range, compute the estimated deductible for the ongoing and retro period.

2. Evaluate whether the applicant is likely to meet his deductible based on unpaid old bills, ongoing monthly expenses, and anticipated new medical expenses. Do a separate evaluation for the ongoing and retro period and document this evaluation.

(III.A.)

3. Explain to the applicant that he must choose between applying for QI1/MQB-E and only receiving payment of his Part B premium or applying for MAABD and pending to meet a deductible for either the retro and ongoing period. Be sure he understands the benefits and effective dates for both programs.

4. If the applicant chooses to apply for QI1/MQB-E it can be a one-part or two- part application. If the applicant chooses to apply for QI1/MQB-E for either the retro or ongoing period and MAABD, or MQB-Q, or MQB-B for the other part, it requires entry of two separate applications (DSS-8124).

5. Document in the case record the explanation and choice of program. If the applicant applies for QI1/MQB-E, a DMA-5095, Medicaid/WF Notice of Inquiry, is not required.

B. Application Disposition

1. Follow EIS instructions to disposition the QI1/MQB-E case.

2. For QI1/MQB-E applications dated before November of each year and not approved until on or after November, re-enrollment is not automated. At application approval the county must give or mail a re-enrollment application (DMA-5060) to the recipient. Allow at least 12 work days to return the DMA-5060. Print this date on the DMA-5060. Explain eligibility will terminate on 12/31 of the current year if the county does not receive the signed DMA-5060 and necessary verification in time to process the case by “pull” night in December. Develop an in-house tracking mechanism. Refer to IV., below for re-enrollment procedures.

3. DMA monitors the number of approvals and will notify counties when the federal funds for QI1/MQB-E will be exhausted for the current year. At that time DMA will issue instructions to dispose any pending QI1/MQB-E applications.

C. Change in Situation/Program Transfers

1. Pending QI1/MQB-E Application

If you learn a QI1/MQB-E applicant has a change in situation and is eligible for MAABD (or under another aid program/category):

a. Disposition the QI1/MQB-E application:

(1) Approve the case open/shut if the individual was eligible for QI1/MQB-E during any of the retro or ongoing period not covered by full Medicaid, or

(2) Deny the application if the a/r is eligible for full Medicaid for the entire period covered by the QI1/MQB-E application.

(III.C.1.)

b. Register a new DSS-8124 in the appropriate aid program/category. If the a/r is not in the agency, the application may be unsigned. However, the new application is subject to all application processing requirements.

c. The date of application is the date the new DSS-8124 is signed or the date the applicant (representative, nursing facility, hospital, etc.) requested assistance.

d. If otherwise eligible, the MAABD 6 month ongoing certification period or 3 month retro c.p. is based on the MAABD date of application, not the QI1/MQB-E date of application.

NOTE: If you learn a pending QI1/MQB-E application should be a MQB-Q or MQB-B application due to the income, follow EIS instructions to change the QI1/MQB-E indicator on the DSS-8124 to “N.” The date of application remains the same. The opposite is also true. If you learn a pending MQB-Q or MQB-B should be a QI1/MQB-E application, change the QI1/MQB-E indicator on the DSS-8124 to “y.” Do not change the date of application.

2. Pending MAABD application

When an individual with income in the QI1/MQB-E range who chose to pend to meet a deductible changes his mind and requests QI1/MQB-E:

a. Follow procedures in MA-2304, Processing The Application, to deny the MAABD application.

b. Register a new DSS-8124. This is a QI1/MQB-E application. This application may be unsigned if the a/r is not in the agency.

c. The date of application is the date the DSS-8124 is signed or the date the a/r requests assistance.

d. If otherwise eligible, the QI1/MQB-E certification period is based on the QI1/MQB-E month of application. However, regardless of the QI1/MQB-E date of application, QI1/MQB-E authorization can never begin earlier than the calendar month the MAABD application is denied.

3. Denied MAABD application

When an application is denied for failure to meet the deductible and the individual has income in the QI1/MQB-E range, take the following actions:

a. Contact the a/r and evaluate whether the individual is still eligible for QI1/MQB-E.

b. If so, follow instructions in 2., above, to register a new DSS-8124.

REVISED 07/01/11 – CHANGE NO. 13-11

(III.C.3.)

c. If the individual is otherwise eligible and the federal funds have not been exhausted, begin QI1/MQB-E coverage the calendar month the MAABD application is denied.

d. The end date depends on the QI1/MQB-E date of application. If the QI1/MQB-E date of application is January 1 through October 31, the end date is 12/31 of the current calendar year. If the QI1/MQB-E date of application is 11/01 or later, the end date is 12/31 of the next calendar year.

4. Ongoing QI1/MQB-E recipient becomes eligible for full Medicaid

When a QI1/MQB-E recipient has a change which makes him eligible for full Medicaid take the following actions:

a. Contact the individual or his representative and evaluate which Medicaid coverage group he needs. Explain the advantages of ongoing and retroactive coverage and reserve eligibility.

b. Review the case record to see what the recipient’s reserve was when it was approved for QI1/MQB-E. If it was below $2,000/3,000 and there is no change in situation affecting reserve, no further verification is required until the next review. If the reserve was greater than $2,000/3,000, verify reserve in the same manner that is done at redeterminations.

c. If the recipient requests retro Medicaid only, follow EIS instructions to register a DSS-8124. This is an administrative application. The date of application is the date the DSS-8124 is signed or the date the a/r requests assistance. If otherwise eligible, approve open/shut in EIS. This will allow the

QI1/MQB-E to continue for the remainder of the QI1/MQB-E certification period.

d. If the recipient requests retro and ongoing full Medicaid or ongoing Medicaid only, a DSS-8124 is not necessary. If otherwise eligible, follow EIS instructions to transfer the QI1/MQB-E to MAABD.

e. The MAABD retro c.p. is the 3 calendar months prior to the month the a/r requests assistance. The 6 month ongoing certification period begins the month the a/r requests assistance. The MAABD c.p. is not tied to the original QI1/MQB-E date of application.

f. If the QI1/MQB-E recipient is ineligible for full Medicaid, document the request and the reason the aid program/category was not changed.

5. Ongoing MAABD, MQB-Q, MQB-B, SAAD recipient loses eligibility

When a recipient is terminated from Medicaid in any aid program/category and he has income in the QI1/MQB-E range, take the following action:

a. Review the case record.

REISSUED 07/01/11 – CHANGE NO. 13-11

(III.C.5.)

b. If the individual is otherwise eligible and the federal funds have not been exhausted, follow EIS instructions to transfer the case to QI1/MQB-E.

c. QI1/MQB-E coverage cannot begin until the month following the month full Medicaid terminates.

d. The end date depends on the QI1/MQB-E date of application. If the QI1/MQB-E date of application is January 1 through October 31, the end date is 12/31 of the current calendar year. If the QI1/MQB-E date of application is 11/01 or later, the end date is 12/31 of the next calendar year.