Family and Children's Medicaid MA-3120 SSI MEDICAID

V. SSI TERMINATIONS

When SSI terminates, you must evaluate ongoing eligibility for Medicaid. The individual remains authorized after SSI is terminated while the redetermination is completed. When the SSI termination processes in EIS, the termination appears on the SSI TERMINATION REPORT. The SSI indicator changes to “N.” The case remains open with a Medicaid through date of 12/31/9999. Within 5 workdays the county dss must initiate an ex parte review to determine whether the recipient qualifies for Medicaid under any other coverage group. Send to the client the DMA-5180, SSI Check Terminated: Information Needed To Determine Medicaid Eligibility, only if there is nothing found through the ex parte process to assist you in determining ongoing eligibility in another program.

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(V.)

A. Automated Recipient Notice

When the SDX indicates a recipient is being terminated from SSI, EIS will generate an automated EIS notice to the recipient. See the DMA-5100, SSI Exparte notice.

The notice advises the recipient:

1. To contact the local SSA if he wants to appeal the SSI termination.

2. The county dss must determine whether he may continue to be eligible for Medicaid as a non-SSI recipient.

3. The county dss will contact him if further information is needed.

4. When the determination is completed, a written notice will be sent to inform the recipient of the Medicaid decision.

B. Medicaid Redetermination (“Ex parte”)

The term ex parte means to make a determination from the existing record (SDX).

1. Initiate the ex parte within 5 workdays of the date the termination appears on the SSI TERMINATION REPORT.

2. The county must complete the redetermination within 4 months of the month the case appears on the SSI TERMINATION REPORT and notify the recipient about his ongoing eligibility for Medicaid.

3. Use the DMA-5063 as the redetermination base document. The SSI recipient’s signature is not required for an ex parte determination.

4. If the recipient lives in another county, the county in which the SSI TERMINATION REPORT appears must contact the county of residence immediately and tell them of the SSI termination. Within 5 workdays the first county must send a copy of the SSI TERMINATION REPORT to the county of residence who must complete the ex parte redetermination.

5. Review all possible sources of information available to the agency, including information verified by other programs. Use as a resource the DMA-5138, Ex Parte Review Checklist (Non-MIC/NCHC Re-Enrollments). Medicaid eligibility is determined according to the rules of the appropriate Medicaid coverage group. The county must accept current verifications from other programs as accurate. Refer to MA-3410, Terminations and Deletions, for definition of what is considered current. Information on the SDX is no longer current as the SSI case is no longer active.

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6. When necessary information is unavailable or is not current, the county must request the needed information from the recipient.

a. Necessary information may be requested by telephone or in writing using the DMA-5097, Request for Information. Allow the recipient 12 calendar days from the date of the request to provide the information.

Example: If the DMA-5097 is mailed on Wednesday, January 10, to request current wage information, the deadline for providing the information is Monday, January 22.

If the recipient needs more time, allow another 12 calendar days.

b. If the recipient does not provide the requested information by the deadline, send timely notice proposing termination for failure to provide necessary information.

7. Federal regulations allow up to 4 months, if needed, to complete eligibility redeterminations for persons losing SSI.

a. Federal financial participation is available for Medicaid during the redetermination. The redetermination and notice of decision must be completed within the four month period.

b. The four month period begins the month the case appears on the SSI TERMINATION REPORT. (Ex: The case appears on the SSI TERMINATION REPORT in July. July, August, September and October are continuation months. The redetermination and notice of decision must be effective no later than October 31.)

c. Counties may be liable for chargebacks of Medicaid expenditures for ineligible cases if Medicaid must be extended longer than 4 months to complete a redetermination and/or send timely notice of termination.

C. Redetermination Results

When all necessary information has been obtained and/or requested, determine whether the recipient is eligible for Medicaid under any category. One of several eligibility outcomes is possible:

• Recipient is eligible for full Medicaid without a deductible; or
• Recipient will be eligible for full Medicaid if he meets a deductible; or
• Recipient is eligible as Breast and Cervical Cancer Medicaid, MQB, Q, B, E or Family Planning Waiver; or

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(V.C.)

• Recipient is eligible for Work First (Follow inclusion rules when adding recipient to Work First case.); or
• Recipient is ineligible for any Medicaid coverage; or
• Recipient did not provide necessary information so is ineligible.

1. If eligibility is established in any aid program/category the certification period begins with the current processing month in EIS.

Example: Review completed September 27. The current processing EIS month is November. The appropriate certification period begins November 1.

2. If the recipient is eligible for Medicaid but must meet a deductible, determine if the recipient can meet the deductible.

He can if:

a. His deductible amount is $300 or less, or

b. His predicted expenses are within $300 of meeting the deductible.

3. If it is determined that the recipient can meet his MAABD deductible:

a. Put the case in deductible status.

b. Follow deductible policy in MA-3315, Medicaid Deductible, to apply medical expenses to the deductible.

c. Indicate the deductible amount on the automated notice.

d. EIS will generate an automated timely notice.

e. If the recipient wants to receive Family Planning Waiver while meeting a deductible, enter a DSS-8124 to open a FPW case. When the a/r meets the deductible, send an adequate notice to terminate the FPW case.

4. If it is determined that the recipient can meet a MAF deductible:

a. Terminate the MAABD case.

b. EIS will generate an automated notice.

c. Enter an administrative DSS-8124 re-application for an MAF case.

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(V.C.4)

d. Pend the application to meet the deductible. (MAF cases cannot be approved in EIS in deductible status. If the recipient wants to receive Family Planning Waiver (FPW) while meeting a deductible, enter another DSS-8124 to open a Family Planning Waiver case. When the a/r meets the deductible, send an adequate notice to terminate the Family Planning Waiver case.

e. If the caretaker has applied for or receives Medicaid in any aid program/category except MPW or asks to receive Child Support services and agrees to cooperate, you must refer the case to IV-D. Research ACTS to determine if there already is a referral. If there is not and the information for referral is available, make the referral. If the information for referral is unavailable, refer to IV-D at next redetermination.

5. Terminate the case (MAABD or MAF) if it is determined that the individual’s deductible is greater than $300 or his predicted medical expenses are not within $300 of meeting the deductible.

6. If it is determined that the recipient is eligible as MIC:

a. Terminate the MAABD case.

b. Enter an administrative DSS-8124 to open an MIC case.

c. EIS will generate an automated notice.

d. If the caretaker has applied for or receives Medicaid in any aid program/category except MPW or asks to receive Child Support services and agrees to cooperate, you must refer the case to IV-D. Research ACTS to determine if there already is a referral. If there is not and the information for referral is available, make the referral. If the information for referral is unavailable, refer to IV-D at next redetermination.

7. MAF Caretaker Evaluation

To receive as a caretaker the individual must meet the requirements in the Family and Children’s manual section MA-3235, Caretaker Relative Eligibility.

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8. If the recipient is eligible as MQB only, transfer the case to MQB. EIS will generate an automated notice.

9. Terminate the MAABD if recipient is ineligible for Medicaid under any category, following timely notice procedures.

10. Terminate the MAABD case if information that was unavailable to the agency was requested and the recipient did not respond. Timely notice procedures apply.

11. SSI Open/Shuts

Sometimes SSI is approved for a finite period in the past. If the individual comes to the dss with an approval letter for a prior period, determine if the individual is on the SSI TERMINATION REPORT.

a. Take an application if the individual is not on the SSI TERMINATION REPORT. Follow application procedures in MA-3200, Initial Contact, through MA-3215, Processing the Application.

b. See EIS 4200 Part Four instructions for SSI Open/Shut cases.