WV INCOME MAINTENANCE MANUAL. Specific Medicaid Requirements

Transcription

1 INTRODUCTION The West Virginia Medicaid Prgram prvides payment fr cvered medical services t certified medical prviders fr eligible individuals wh are aged, blind r disabled and t eligible members f families with dependent children. The determinatin f which medical services are cvered under Medicaid and which medical prviders are certified t accept Medicaid patients is the respnsibility f the Bureau fr Medical Services and is nt addressed in this Manual. Unless therwise specified, the cverage grup receives all services cvered under Medicaid. Fr eligibility fr nursing care services and HCB, TBI and I/DD Waiver cverage grups, refer t Chapter 17. This Chapter prvides an verview f the Medicaid Prgram. In additin, each cverage grup has specific requirements which must be met and prcedures t fllw that may nt apply t ther Incme Maintenance prgrams r ther Medicaid cverage grups. These are cntained in this Chapter. Certain prgrams, such as CDCS, I/DD, TBI and HCB Waiver, require a medical and/r ther determinatin by a cmmunity agency r gvernment rganizatin ther than DFA and a financial determinatin by an Incme Maintenance Wrker. When an applicant s medical eligibility fr, r enrllment in these prgrams is pending, he must nt be refused the right t apply, but must be evaluated fr any r all DFA prgrams. NOTE: Children determined eligible fr QC r PL Medicaid remain eligible fr 12 cntinuus mnths, regardless f any changes after apprval, except thse specified in Sectin 2.8. In additin t the cverage grups described in this Chapter which make up the Medicaid Prgram, the Department has special prcedures in place t pay fr certain necessary drugs fr individuals nt eligible fr Medicaid. See Chapter 28. A. ASSIGNMENT OF MEDICAL SUPPORT RIGHTS Prvided they are legally able t d s, all adult Medicaid applicants and recipients must assign t the Department any rights t medical supprt and t payments fr medical care frm any third party. When the adult receives Medicaid under any cverage grup, under any case number, the assignment f medical supprt rights is a cnditin f eligibility and he must cperate in identifying and prviding infrmatin t use in pursuing third parties, unless gd cause is established fr nt cperating. This includes 4/

2 prviding accurate health insurance infrmatin at applicatin and redeterminatin. See Sectin 4.2 fr verificatin requirements. Gd cause is determined by DFA, based n written infrmatin btained by the Wrker. NOTE: All ther adults wh have the legal ability t d s, but wh are nt Medicaid recipients, must assign medical supprt rights as well. When an therwise eligible individual cannt legally assign his wn rights, and the persn legally able t d s des nt cperate, the individual remains eligible. EXAMPLE: A mther refuses t assign benefits fr herself and her children, fr whm she can legally make an assignment. The mther is ineligible and the children remain eligible fr Medicaid. NOTE: Pverty-Level Pregnant Wmen are nt penalized fr failure t cperate with this requirement until the expiratin f the pstpartum perid. An applicant fr SSI is required t assign third-party rights t the Department as part f his applicatin fr SSI. If he refuses t assign these rights, he is ineligible fr Medicaid. B. DATA SYSTEM INTERACTION When health insurance infrmatin is entered by BCSE, RAPIDS alert 191 Ins. Inf. Check OSCAR S INSU, is sent t the Wrker. Since BCSE and BMS data systems d nt interface, the Wrker must enter the health insurance infrmatin n RAPIDS screen AFMC which will interface with BMS. The Bureau fr Medical Services must verify health insurance with the carrier befre entering it in the BMS data system. The Wrker is ntified by RAPIDS alerts when BMS updates Third-Party Liability (TPL) infrmatin, there is an insurance carrier r plicy number mismatch r the TPL infrmatin is nt verified. See the RAPIDS User Guide fr specific Wrker actins required. If the Wrker has any infrmatin which cnflicts with the BMS-verified infrmatin, he must prvide the infrmatin t the Third-Party Liability (TPL) Unit by r fax s that BMS can clear up any discrepancy. This insures accurate infrmatin is entered in bth data systems. C. CERTIFICATE OF COVERAGE WHEN MEDICAID COVERAGE ENDS All Medicaid recipients wh s request, must be issued a Certificate f Cverage DFA-HIP-1, when Medicaid benefits stp. This applies t all individuals whse Medicaid benefits stpped n r after July 1, See Sectin /

3 D. CHILD SUPPORT REQUIREMENTS AND PROCEDURES Federal law mandates that effrts be made t lcate absent parents, establish paternity and btain medical supprt fr dependent children wh receive Medicaid. The respnsible adult included in any Medicaid cverage grup must cperate with BCSE. EXCEPTION: Recipients f TM cannt lse eligibility fr failure t cperate with BCSE. Hwever, BCSE services must be explained and a vluntary referral made when apprpriate. When the respnsible adult is nt a Medicaid recipient under any cverage grup, he must be infrmed f the availability f BCSE services and prvided the pprtunity t vluntarily receive services. Vluntary BCSE referrals d nt sign the DFA-AP-1. There is n penalty when a vluntary referral subsequently fails t cperate with BCSE. The majr respnsibility fr this effrt rests with the Bureau fr Child Supprt Enfrcement (BCSE) thrugh its staff f Legal Assistants. In additin, the Wrker has the fllwing respnsibilities: - T prvide a BCSE applicatin, the App-1-interactive and an explanatin f where the applicatin is submitted, when the respnsible adult wh can legally assign rights and is nt a Medicaid recipient under any cverage grup, expresses an interest in vluntarily receiving services. Fr a child nly case, n referral is made by the Wrker and n change is made in the data system. - T explain the requirements and benefits f BCSE services, including the right t claim gd cause fr refusal t cperate - T refer apprpriate cases t the Legal Assistant. Referral is accmplished by data system exchange r DHS-1. - T evaluate evidence presented if the client claims gd cause - T determine if gd cause fr failure t cperate with BCSE exists - T apply the penalty fr refusal, withut gd cause, t cperate r prvide infrmatin abut medical supprt t adults included in any Medicaid AG wh can legally assign supprt rights. - T respnd t RAPIDS alert 191. See Sectin fr the required actin. 4/

4 a. The DFA-AP-1 must be cmpleted fr: (1) Applicants (a) AFDC Medicaid, AFDC-Related Medicaid The DFA-AP-1 must be cmpleted when at least ne f the children under age 18 wh receives Medicaid has a parent(s) wh is absent due t death, desertin, divrce r paternity nt established. See Sectin 15.3 fr exceptins. (b) SSI and SSI-Related Medicaid (2) Recipients NOTE: Newbrns are referred at birth, even thugh the parent may nt be required t cmply until the pstpartum perid ends. See Redirectin f Supprt and Incme Withhlding belw. The DFA-AP-1 must be cmpleted when there is at least ne child under age 18 included in the AG wh has a parent wh is absent due t death, desertin, divrce r paternity nt established. This includes children wh receive SSI and SSI-Related Medicaid. The DFA-AP-1 must be cmpleted fr active cases as fllws: (a) AFDC Medicaid and AFDC-Related Medicaid The DFA-AP-1 must be cmpleted when a 2-parent family becmes a 1-parent family. (b) CEN and SSI-Related Medicaid NOTE: Newbrns are referred at birth, even thugh the parent may nt be required t cmply until the pstpartum perid ends. See Redirectin f Supprt and Incme Withhlding belw. 4/ When at least ne parent f a child(ren) under age 18 wh is included in the AG is absent due t death, desertin, divrce r paternity nt established. This includes children wh receive SSI and SSI-Related Medicaid. 7

5 b. Instructins fr cmpletin: - When a child under age 18 with a parent wh is absent fr ne f the abve reasns is added t the AG. This includes children wh receive SSI and SSI-Related Medicaid. See Sectin 15.3 fr exceptins. - Cmplete in triplicate. - Enter the case name and case number in the indicated spaces n the frm. - Enter a check mark in the blck beside each paragraph number t indicate that the client understands the infrmatin. - The respnsible adult must sign the frm. If the parent is in the hme, the parent must sign the frm. - The Wrker and client must sign all cpies - Distribute cpies t the client and BCSE Child Supprt Specialist, and file ne in the case recrd. If n referral is made, the extra cpy is filed in the case recrd. c. Prcedure When the Client Refuses t Sign the DFA-AP-1 When the client refuses t sign the DFA-AP-1, the actin taken depends upn the reasn fr the refusal. When the client indicates that he will nt sign the DFA-AP-1 and, in ding s, indicates he will nt cperate with BCSE, the Wrker must determine if gd cause exists fr the refusal. If gd cause des exist, n BCSE actin is required r taken and n penalty is applied t the client. If gd cause des nt exist, the Medicaid case is referred t BCSE and the penalty described in Redirectin f Supprt and Incme Withhlding belw is applied. The Wrker must recrd in RAPIDS the circumstances invlved in the determinatin f gd cause. When the client indicates that he will nt sign the DFA-AP-1, but indicates that he will cperate with BCSE after referral, the Medicaid case is referred t BCSE and n penalty is applied. The Wrker must recrd in RAPIDS that the cntent and purpse f the frm were explained t the client, that he refused t sign, the reasn given fr the refusal, that the client has indicated that he will 4/

6 Physical r emtinal harm t the child fr whm medical supprt is being sught; r Physical r emtinal harm t the parent r ther respnsible adult with whm the child lives, which wuld reduce such persn's capacity t care fr the child adequately. A finding f gd cause fr emtinal harm may nly be based upn evidence f an emtinal impairment that substantially affects the parent r ther relative's functining. In determining gd cause based in whle r in part upn the anticipatin f emtinal harm, the Wrker must cnsider the fllwing: The present emtinal state f the individual; The emtinal health histry f the individual; The intensity and prbable duratin f the emtinal impairment; and The extent f invlvement f the child in the paternity establishment r medical supprt activity t be undertaken. 4/ b. When the Client Refuses t Cperate Prir t BCSE Referral If the client indicates t the Wrker, prir t BCSE referral, that he des nt intend t cperate in BCSE activities, the Wrker must determine if gd cause exists fr the refusal. If gd cause des exist, n BCSE actin is required r taken and n penalty is applied t the client. If gd cause des nt exist, the Medicaid case is referred t BCSE and the penalty described in Redirectin f Supprt and Incme Withhlding belw is applied. The Wrker must recrd in RAPIDS the circumstances invlved in the determinatin f gd cause. c. When the Client Claims Gd Cause fr Refusal t Cperate After BCSE Referral A client may claim gd cause fr refusal t cperate prir t r after referral t BCSE. When the client claims gd cause after the referral, the Legal Assistant refers the case back t the Wrker fr a determinatin f 9

7 - The Wrker must determine if gd cause exists within 45 days f the date gd cause is claimed. - If gd cause is established, the case is nt acted n by BCSE. Hwever, at each redeterminatin, the Wrker must determine if gd cause still exists. If gd cause n lnger exists the Wrker must ntify the client and take apprpriate actin t ntify BCSE. - If gd cause is nt established, the Wrker initiates the penalty and sends apprpriate client ntificatin. RAPIDS ntifies BCSE that gd cause was claimed, but nt established, and that the penalty fr refusal t cperate has been applied. 5. Redirectin Of Supprt And Incme Withhlding NOTE: While there is n penalty fr Medicaid recipients wh refuse t redirect supprt payments, they must be instructed that being referred t BCSE autmatically triggers incme withhlding, whenever there is an existing curt rder fr supprt and an identifiable surce f incme. When a Medicaid referral is made t BCSE, the Legal Assistant immediately implements incme withhlding fr any child supprt the child may be receiving, whenever pssible. This actin may nt be declined r terminated by the Medicaid client. Cllectin f supprt must, thereafter, be made thrugh BCSE and distributed as nn-public assistance (NPA) payments. If the client refuses t cperate in the establishment f paternity and in btaining medical supprt, the Legal Assistant ntifies the Wrker. If the client has nt claimed gd cause, r if a claim is made and gd cause is nt determined, the penalty in Penalties Fr Failure T Cperate belw is applied. 6. Penalties Fr Failure T Cperate NOTE: A Pverty-Level pregnant wman, wh fails t cperate in securing medical supprt fr children ther than the unbrn child, is nt penalized until after the expiratin f the 60-day pstpartum perid. Recipients f TM cannt lse eligibility fr failure t cperate with BCSE. Hwever, BCSE services must be explained and a vluntary referral made when apprpriate. The penalty is as fllws: 4/