016.20.97 Ark. Code R. 025
At revaluation, all eligibility factors (including appropriateness of care and cost effectiveness) will be redetermined (Re. MS 2090.1). Disability will be redetermined as specified in MS 2090.4. Completion of forms DCO-777, DCO-662, DCO-75, DCO-662, DCO-707, DC0-769, DC0-2602 and DCO-2603 is necessary at reevaluation. The DCO-87 must be coded for the next reevaluation, MRT reexamination, or any expected changes.
When a change occurs that affects eligibility, the county office worker will notify the TEFRA Committee when closure will be made. A copy of the DCO-700 used to notify the individual or a memorandum (when an DCO-55 is sent) will be used for the 0MS notification.
Ten day advance notice of closure via the DCO-700 or DC0-55 will be given, unless advance notice is not required (Re. MS.3633). Form DCO-57 will be completed for the close (C) action effective the date notice expires.
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Aliens who are not qualified aliens(as defined at MS 3310 #3) are eligible for emergency services only if the following conditions are met.
. Placing the patient's health in serious jeopardy,
. Serious impairment to bodily functions, or
. Serious dysfunction of any bodily organ or part.
Verification and documentation of the emergency condition must be obtained through the attending physician's statement that the alien met the criteria in paragraph 2. In addition, the alien will provide other supporting documentation of the emergency that may include hospital and emergency room records, ambulance receipts, collateral statements, media reports, etc.
If certified in a family type Medicaid category, only the alien(s) with the emergency medical condition(s) may be entered in closed status for fixed eligibilty as an eligible member(s); all other citizen or qualified alien family members included in the budget will be entered in closed status with no medical eligibility.
NOTE: When determining eligibility for an adult, deem the income of a non-qualified alien spouse to the applicant, but do not include his or her needs in the need standard. A citizen or qualified alien spouse's income must be counted in full, with his or her needs included. The income and needs of non-qualified alien children will be disregarded. A citizen or qualified alien child's income and needs may be included if needed.
When determining eligibility for a child, deem the income of a nonqualified alien parent(s) to the applicant, but do not include needs of the parent(s) in the need standard. Income of a citizen or qualified alien parent(s) m"st be counted in full, with the needs included. The income and needs of non-qualified alien siblings will be disregarded. A citizen or qualified alien sibling's income and needs may be included if needed.
A period of eligibility will be granted only to cover the period of time in which the necessity for emergency services existed. The period of eligibility will be a fixed retroactive period, and Medicaid begin and end dates will be entered.
The certified alien(s) will be eligible for all medical services relating to the emergency, including transportation.
Retroactive Eligibility
The State is required to provide retroactive eligibility, for up to three full months prior to the date of application, to applicants who:
Retroactive eligibility will be provided to applicants who were otherwise eligible in the month services were received, regardless of whether they were ineligible at other times during the retroactive period. Retroactive eligibility is separate and apart from current eligibility, i.e., applicants not eligible for the current period may be eligible for the retroactive period. Retroactive eligibility determinations are required for all categories, except AAS/ACS, DDS/ACS, QMB, SMB, QDWI, and PW-PE Retroactive coverage for Newborns will not be given prior to the date of birth.
An application for retroactive eligibility may be made on behalf of deceased persons and eligibility will be provided if they were eligible when the services were received.
For cases in which an applicant has not resided in Arkansas for three full months prior to the date of application, the retroactive period begins with the date the individual established residency in Arkansas. The "previous state" is responsible for the retroactive period prior to the time the applicant established residency in Arkansas. The County Office is responsible for providing the "previous state" with information necessary to determine eligibility for its portion of the retroactive period.
Services for the retroactive period are subject to the same restrictions as services, for the current period (i.e., utilization review, benefit limitations, medical necessity, etc.). Prior authorization cannot be a condition of payment for services received during the retroactive period. However, such services are subject to the same Title XIX Utilization Review standards as all other services financed under the State's
Title XIX program. The State is not required nor obligated to pay for services which have been retroactively determined by Utilization Review to be unnecessary.
For cases in which an applicant has made partial or full payment for services received during the retroactive period, the state will make payment to the servicing provider if:
The case record must document that both these requirements have been met before facility services can be authorized.
Current recipients of U-18, SSI, and Foster Children (Cat. 91 and 92) for whom the Agency has legal responsibility automatically meet the categorical eligibility requirement.
However, if, during the processing of an LTC application, any question regarding the categorical eligibility of these individuals should arise, the question will be resolved with either Agency or SSA personnel before proceeding further with the application. The question and resolution should be documented in the case record.
If the eligibility of an SSI recipient is questionable, a statement will be obtained from SSA (preferably written) to document its awareness and treatment of the eligibility factor. If there appears to be a policy conflict between DCO and SSA, the DCO Medicaid Eligibility Unit will be contacted.
Categorical eligibility for individuals other than U-18, SSI, or Foster Children will be determined according to SSI-related AABD facility eligibility criteria as follows:
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individual who does not meet alienage requirements, including nonimmigrants and individuals paroled for less than one year, may receive treatment for only emergency medical conditions, provided that they meet all eligibility requirements other than the alienage requirements (Re. MS 2095). Organ transplants and routine prenatal or postpartum care cannot be provided under the emergency services provisions. However, all labor and delivery is considered emergency labor and delivery;
NOTE: The resource standards above apply to all AABD Medicaid categories (the resource standards are doubled for QMBs, SMBs, and QDWIs), except when one spouse enters LTC and the other does not (Re. MS 3337-3338) or when both spouses enter LTC in the same month. When both spouses enter LTC in the same month, the couple's standard will apply for the month of entry, but the resources of each will be compared to the individual standard in the month after entry into LTC (Re. MS 3330.1);
Evidence of institutional status includes any written document, record, etc. from a hospital and/or nursing facility which verifies that the individual was in the hospital and/or nursing facility for 30 consecutive calendar days (Re. 3310).
When an individual cannot meet the institutional status requirement, the application will be denied, unless the individual dies before meeting the 30 day requirement. In that case, certification may be made for the actual days spent in the facility.
When an individual has met the institutional status requirement of 30 consecutive days, eligibility for facility services will be effective the date of entry into the facility if all other eligibility requirements are met, unless the individual is in an ICF/MR or was subject to PASARR (Re. MS 3420).
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Note: The institutional status requirement does not apply to individuals who were certified for SSI, U-18, or Foster Care (Cat. 91 or 92) in the month of facility entry.
Individuals who become ineligible for SSI, U-18, or Foster Care (Cat. 91 or 92) following the month of LTCF entry, will have their categorical eligibility determined according to SSI-related AABD facility eligibility criteria, with the exception of the institutional status requirement.
Use primary evidence when possible; if not, use alternative evidence.
To overcome a material discrepancy in the age of an individual, usually the earliest recorded document is used. (Note: Written documentation is necessary).
The County Office will accept SSA date of birth when:
Blindness or disability must be established by one of the following means:
The type of documentation used will be entered into the case narrative and a copy filed in the case records, if available.
The following disability guidelines will apply to all AD Medicaid applicants where disability is an eligibility factor and disability has not been determined. A disability decision made by SSA on a specific disability is controlling for that disability until the decision is changed by SSA. When DCO makes a disability determination, a later contrary SSA determination will supersede the state determination. If SSA has made a decision that a person is not disabled, that decision is binding on DCO for one year with exceptions noted in 3322.3.
Because SSA decisions are controlling, any new evidence or allegations relating to previous SSA determinations must be presented to SSA for reconsideration within 60 days of the SSA denial notice. If the decision has not been appealed within 60 days, the ' individual may still request a reopening of the decision within one year.
v" Therefore, the Agency must refer to SSA, for reconsideration or reopening of a determination, all applicants who allege new information or evidence which affects previous SSA determinations of "not disabled", except in cases specified in 3322.3. When the conditions in 3322.3 are met, counties will be required to make an eligibility determination for Medicaid.
Counties may also refer to SSA, for SSI application, those individuals whose income and resources are below SSI limits, because it would be to their advantage to receive both cash assistance and Medicaid.
When individuals apply for Medicaid and meet one or more of the conditions below, the DCO-106, DCO-107's and/or DHS-81's, and DCO-108, along with copies of the Social Security Disability or SSI denial letter (if applicable and available) and WTPY, if appropriate, will be submitted to MRT (Re. MS 3323), provided it appears that the other eligibility factors are met.
The Agency will determine eligibility if any one of the following conditions exists:
OR
AD applicants who do not meet a criterion specified above will be denied without further development. The DCO-106 will be used to document the applicant's statements/allegations regarding his disability status.
, To verify the Social Security Disability or SSI status of an individual the county will:
The pay status code series beginning with "N"s are the denial codes on WTPY. A brief description of the denial code is included on the query response.
When an individual applies for both Medicaid and Social Security Disability or SSI, and the application with SSA is still pending, the county should initiate an MRT determination of disability if the individual appears to meet all other eligibility requirements. The Agency will have 90 days from the date of Medicaid application to make this determination. While an MRT decision is pending, the county office worker should check the Social Security Disability or SSI status of the applicant 30 days after the Medicaid application has been made, and again at certification, if found eligible by MRT. If MRT finds that the individual meets the disability requirements and SSA has not yet made a decision, the county may certify the case for Medicaid. To verify that no SSA decision has been made, the WASM screen will be checked, if appropriate, and the individual or authorized representative will be contacted by mail or telephone prior to certification.
Additional case action is indicated as follows:
If application for Social Security Disability is approved first:
. Notify MRT
Approve Medicaid application (if all other requirements have been met)
If application for SSI is approved first:
. Notify MRT
Deny Medicaid application, except for LTC, which may be approved for facility payment on WNHU (if all other requirements have been met)
If SSA determines the applicant is NOT disabled:
. Notify MRT
Deny Medicaid application
If the county certifies a case based on an MRT disability decision and later learns the individual has been denied by SSA, the Medicaid case will be closed after appropriate notice, unless theVecipient appeals the closure. If the appeal is made within the 10-day time frame, the Medicaid case will remain open pending the outcome of the DHS appeals process. In no case, will the Medicaid case remain open pending the outcome of the SSA appeals process if the recipient has appealed the SSA decision. If an approved Medicaid recipient is approved for SSI, the system will automatically convert the Medicaid case to an SSI category and no further action will be required of the county, except to notify MRT that no future reexamination is required, if appropriate.
The following procedures will be followed for verification of blindness or disability through the Medical Review Team. The disability onset date will be indicated on the
The county office worker will complete Part 1 of Form DCO-107, when the form is needed. The applicant must sign and date the form in Part 2. The form will then be given to the applicant to take to the medical practitioner of his or her choice. A stamped envelope addressed to the county office will be provided with the DCO-107. The medical practitioner will complete Part 3 of the form and return the form to the county office.
If an applicant states he or she does not have the funds for payment of a physician's examination, the applicant should be informed that MRT can arrange and pay for an examination. If the applicant wishes MRT to do this, the county office worker should report this on the DCO-108 Social Report.
The Medical Review Team (MRT) will report the decision regarding physical or mental incapacity to the county office on Form DCO-109.
If MRT finds that the medical information is not adequate to make a decision, further medical/psychiatric/psychological examinations may be recommended by MRT at the expense of the Agency.
Arrangements for such evaluations will be made by MRT only. When medical and social evidence has been resubmitted on questioned cases, the Medical Review Team will make a decision as to disability and notify the county office on Form DCO-109. This decision of MRT will be final, subject to the regular appeal process, unless a later decision by SSA finds the individual not disabled.
If a reappl ication is filed and the case has been closed within the past five years for reasons other than disability and the last Form DCO-109 stated, "Re- examination not necessary" or the date for reexamination has not yet been reached, new medical and social information will not be submitted to MRT. If the case has been closed for more than five years, new medical and social information must be submitted. In all cases of reapplication, a DCO-106 will be completed to determine the applicant's SSA disability status.
When medical and social information indicates that an individual may recover in a year or more and/or be rehabilitated to the point where he could meet substantial gainful employment, the MRT will require reexamination. Whether or not required by MRT, reexamination may be requested by the county office at any time for the aforementioned reasons.
In either case, it is the responsibility of the county office to initiate the reexam by submitting current medical and social information (DCO-106, DC0-108A, and DCO-107 and/or DHS-81) to MRT.
When indicated on the DCO-109, the county office will key the appropriate date to WALR for future action. The county office will contact the individual in a timely manner that will allow all necessary medical and social information to reach MRT by the first of the month of reexamination. When the reexamination decision is not received in the county office by the end of month in which the reexamination was required, the case will remain open pending receipt of the MRT decision.
Substantial gainful activity (SGA) is defined as the performance of significant physical and/or mental work activities for pay or profit, or in work activities generally performed for pay or profit.
Countable monthly earnings are obtained by deducting any employer subsidy and any impairment related work expense (not payroll deducts) from the gross income (gross income includes payment in-kind for the performance of work in lieu of cash). Then, if earnings are irregular, they will be averaged over the period of months being considered to obtain countable monthly earnings.
Employer subsidy is the payment of wages that is more than the value of the actual
' services performed.
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"If the work is sheltered or if there is marked discrepancy between the amount of pay and the value of services, there exists the strong possibility of a subsidy that requires development of specific evidence.
Sheltered Employment is work performed by handicapped individuals in a protected environment under an institutional program; nonsheltered employment is any work performed by individuals in an unprotected environment.
Impairment Related Work Expenses are items or services needed in order to maintain employment, such as attendant services, prostheses, or other devices. Drugs and medical services are not deductible unless it can be shown they are necessary to control the disability to enable the individual to work. Deductible expenses must be paid for by the individual, and cannot be reimbursable from any source. Legitimate expenses may include installation, repair, or maintenance; the payments may be deducted in one month or prorated over 12 months.
The expenses must be considered "reasonable," i.e. not more than Medicare would allow or than would ordinarily be charged in the individual's community.
The following SGA Earnings Guidelines provide the basis for evaluating whether an individual is engaged in SGA:
When "a." or "b." occur in a nonsheltered employment situation (or if gross earnings include a subsidy), reexam will be initiated by submitting current medical and social information to MRT.
When average countable monthly earnings from sheltered employment fall within the $300 to $500-a month range, the work is not ordinarily SGA. However, if earnings include a subsidy, the sheltered worker will also be reexamined by MRT.
* Impairment causes the individual to quit work or reduce employment within a short time (6 months or less) under circumstances that would justify the employment being termed an unsuccessful work attempt. Specific evidence must be developed for both sheltered and nonsheltered employment.
* When there is no subsidy involved in gross pay and when there is no marked discrepancy between the amount of pay and the value of the services, an assumption will be made that pay from employment is fully earned. Action will be taken to close the case as the individual no longer meets the criteria for disability (Re. 3310). Advance notice will be given on the DCO-700.
All applicants must provide proof of citizenship or qualified alien status, along with a signed declaration of citizenship or satisfactory immigration status, before a case can be certified. If an individual does not have current documents from the Immigration and Naturalization Service (INS), advise him or her to contact INS for replacement documents if it is believed that the individual is a qualified alien. The following is the INS address:
Immigration and Naturalization Service ATTN: Status Verifier/SAVE 245 Wagner Place, Suite 250 Memphis, TN 38103
845, attaching the document.
Deeming applies only to immigrants who are sponsored by individuals. Deeming will not apply to battered immigrants or to those who would be indigent (unable to obtain food and shelter without assistance) because their sponsors are not providing adequate support.
The only aliens qualified to receive SSI are refugees, asylees, and noncitizens whose deportation has been withheld (subject to a five year eligibility limit); honorably discharged veterans, active duty armed forces personnel, their spouses and dependent children; and lawfully admitted aliens who have 40 qualifying work quarters for SSA purposes.
The Social Security Administration (SSA) sent active SSI beneficiaries notice in February and March 1997, to advise them that SSA will be reviewing their citizenship or immigrant status. If the recipients were not in one of the eligibility categories, they received a second notice after a period of 90 days telling them that their benefits were terminated. If recipients appeal this action by SSA, their benefits can continue during their appeal.
If an individual whose SSI benefits and Medicaid have been terminated by SSA comes to a county office to apply, the county must look at all Medicaid categories to determine if the individual would qualify (e.g., QMB, SMB, Medically Needy, ElderChoices, etc.). If the individual can meet the alienage requirements along with the other eligibility requirements for a chosen category, the individual may be certified in that category.
The Immigration Reform and Control Act (IRCA) of 1986 ( P.L. 99-603) requires that, as a condition of an individual's Medicaid eligibility, the individual must declare in writing under penalty of perjury if he or she is a citizen or national of the United States or, if not, that he or she is an alien in satisfactory immigration status. This requirement does not affect the existing citizenship and alienage requirement nor does it affect the verification requirements for citizenship or alienage. Therefore, an allegation of U.S. citizenship must still be verified, and the immigration status of all aliens must be verified.
Each adult applying for or receiving Medicaid assistance must make his or her own declaration of citizenship or satisfactory immigration status. The parent or guardian will make the declaration for all unemancipated persons under the age of 18 or otherwise incapacitated for whom medical assistance is requested. A legal guardian may also make the declaration for minors or for individuals otherwise incapacitated.
The application form will serve as the written declaration of citizenship for the applicant and/or any unemancipated persons under the age of 18. Caseworkers should be alert to the proper completion of the question on the application regarding citizenship for each person. As the declaration of citizenship is an eligibility requirement for the individual, the citizenship question on the application form must be answered for each person who will be an eligible in a Medicaid case.
In LTC cases where the applicant/recipient or the applicant/recipient's legal guardian has completed a DCO-777, no further action is necessary. In instances where an authorized representative other than a legal guardian has signed the DCO-777, the applicant/recipient should sign the DCO-9, unless he or she is physically or mentally incompetent to do so. If the applicant/recipient is unable to sign the DCO-9, then the authorized representative's declaration on the DCO-777 will be accepted as declaration of citizenship.
Once an adult has provided declaration of citizenship or satisfactory immigration status for himself or herself or others, a declaration will not be required again unless an individual loses eligibility. If the individual later reapplies, a new declaration will be obtained. -
Resources are generally defined as those assets, including both real and personal property, which an individual, or couple, possesses. Resources include all liquid assets as well as those assets which are not presently in liquid form.
In order for assets to be considered as resources, property or an interest in property must have a cash value that is available to the individual upon disposition.
Countable resources will be determined on the first day of the month. When resource eligibility exists at the beginning of a month, it continues for the full month. A resource change that occurs during a month in which resource eligibility exists will not be considered for determination of countable resources until the first of the month following the change.
When an individual is ineligible at the beginning of a month due to excess resources, ineligibility due to resources exists for the full month.
Assets which have been received during the month and considered as income may not also be counted with resources during the same month (unless the income received is given away during the month it is received - Re. MS 3336.6). For example, if an individual had a checking account balance of $1,950 as of June 1, the receipt of a $300.00 SSA check during June would not cause the individual's $2,000 resource limit to be exceeded during June even if the entire check was deposited in the checking account. The individual's resource eligibility would not be affected by the receipt of income during the month. It would only be affected if the income was retained to the extent that it caused the $2,000 limit to be exceeded as of the beginning of July.
SSI lump sum benefits (never counted as income) will be excluded from resource consideration for 6 full months after the month of receipt (Re. MS 3332.3 #6). SSA lump sum payments also have the 6 month resource exclusion, but will count as income in the month of receipt-Re. MS 3341. Interest earned on the excluded funds will be counted as income in the month accrued and, if retained, as a resource in the month following.
Each individual must be advised of how countable resources are determined and how resource changes can affect eligibility.
Requests for legal Opinions Regarding Resources
A legal opinion from the Office of Chief Counsel (OCC), will be requested when the worker, the ES Supervisor, and the DCO Program Support Specialist are unsure of whether a resource should be considered or disregarded.
If the equity value of the questionable resource, when combined with other resources,
appears to exceed the resource -limit, OCC will be contacted if:
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. ;1. Ownership of the resource is questionable, or
016.20.97 Ark. Code R. 025