MEDICAL SERVICES POLICY MANUAL, SECTION I

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1 I-310 Caseworker Responsibilities The renewal processes described below apply to all eligibility groups using the AABD eligibility requirements. See MS B-300 and Section F. For those factors of eligibility subject to change, eligibility will be redetermined during the renewal process in accordance with the applicable eligibility requirements described in MS Sections D, E, F and H. Factors which are subject to change include income, resources, disability, and medical necessity. (MS Sections E and F) A renewal form will be system generated to the individual, his or her spouse, or authorized representative requesting updated information for those factors of eligibility subject to change. The same renewal form is not used for all AABD eligibility groups. See Appendix O for the specific renewal form that is used for each of the AABD groups. The system generated form will include a date by which the form must be returned to the agency. The system will initiate the renewal process in the 10 th month following the last renewal or application so that the renewal can be completed prior to the end of the 12 th month. The system will take the following actions: 1. Generate the appropriate renewal form to the individual, his or her spouse, or authorized representative. 2. Set the due date for return of the form. This date will be the 10 th day of the 11 th month. 3. If the form has not been scanned or entered to the system as received by that date, generate a Notice of Adverse Action to the individual advising that his or her Medicaid eligibility will end at the end of the notice period for failure to return the renewal form unless the form is received prior to that date. 4. If the form has still not been scanned or entered as received in the system by the date in the Notice of Adverse Action, end the individual s Medicaid eligibility as of that date and close the case. I-310 Caseworker Responsibilities The caseworker is responsible for the following actions to complete an AABD renewal: 1. Ensure that the completed renewal form and any verification provided by the individual are scanned into the system upon receipt.

2 I-320 Alternate Renewal Processes 2. Review the information provided and request any necessary verification to validate the information. 3. Redetermine the individual s eligibility based on the information received from the individual and enter any new or changed information to the system. 4. Update the system to reflect continued eligibility, level of service, vendor payment, etc. or to end the individual s eligibility if no longer eligible. 5. Generate the appropriate notice to advise the individual of continued eligibility or of ineligibility. I-320 Alternate Renewal Processes Some AABD eligibility groups do not follow the standard renewal process as described in MS I- 300 above. These groups include: ElderChoices/AAPD Waiver, Assisted Living Facilities, PACE, DDS Waiver, TEFRA, Autism and Medicare Savings Program. The following sections describe their renewal processes. I-321 ElderChoices/AAPD Waiver ElderChoices and AAPD Waiver renewals will be conducted annually by the Long Term Care Unit (LTCU). Form DCO 7781, LTC Medicaid Annual Renewal, will be completed. After eligibility has been re-determined, the review date will be entered in the system. Reassessment of medical necessity will be completed by the DHS RN. The Office of Long Term Care will review the assessment and assign the Level of Care.

3 I-322 Assisted Living Facility I-322 Assisted Living Facility Assisted Living Facility Waiver renewals will be conducted annually by the county office. Refer to Appendix O for the list of required forms to be used in the renewal process. After eligibility has been re-determined, the review date will be keyed to the system. Reassessment of medical necessity will also be completed annually by DAAS. I-323 PACE Both financial and medical eligibility will be re-determined annually. Medical eligibility will be re-determined by the DHS RN. Financial eligibility will be conducted at each annual renewal by the county office. Form DCO-7781 and all other forms required at initial application will be completed. DAAS will complete an annual Level of Care assessment on all PACE participants using the same assessment instruments and review and approval processes as the initial assessment. DAAS may deem eligible those individuals who are determined to no longer meet the nursing facility Level of Care requirement, but who would reasonably be expected to meet nursing facility Level of Care within the next six months in the absence of continued coverage under PACE. I-324 DDS The DDS worker will be responsible for renewals. Renewals will be scheduled for completion 12 months from the date of the last approval or renewal, or at any time when a change occurs which affects eligibility. Please refer to Appendix O for a list of required renewal forms. All eligibility factors, with the possible exception of disability and medical necessity, will be redetermined. A reexamination by MRT is necessary when indicated by the DCO-109 or when a non-ssi or non-ssa client was initially accepted for Waiver Services based on a disability determination made by SSA more than one year prior to the renewal. A review by MRT is also necessary if the DDS Medicaid Eligibility worker or DDS Provider Case Manager or Specialist becomes aware of significant improvement and/or employment at or near the Substantial Gainful Activity (SGA) level (Re. MS F-120). DDS will be responsible for securing the DHS-703s for timely redetermination of medical necessity.

4 I-325 TEFRA The DDS Medicaid Eligibility worker will complete the renewal process in the system. If an income change is made, the total gross income amount must be entered in the system on the income tab. If a change is anticipated, then a task must be created. I-325 TEFRA MS Manual 05/12/17 TEFRA Waiver cases will be renewed every 12 months. To insure that renewals are completed by the end of the twelfth month, the renewal process should be started in the 9th month from the date of the last approval or renewal. If the child s SSI eligibility has fluctuated due to changing parental income since the last certification or renewal, medical necessity and appropriateness of care will not be determined until the case is in, or nearing, the 9th month since completion of the last TEFRA renewal or certification. At renewal, all eligibility factors including appropriateness of care will be redetermined. A MRT disability redetermination may or may not be necessary at the time the TEFRA case is reevaluated. A reexamination by MRT is necessary when indicated on the DCO-109, or one year after the initial certification for TEFRA when the certification was made based on a previous SSI determination of disability and there has been no SSI payment or subsequent redetermination by SSA. EXAMPLE: A child received SSI for 6 months in 2013 and then lost SSI due to increased parental income. The parent applies for TEFRA in September 2013 and the case is certified in November 2013 based on the previous SSI disability determination. The child has not received SSI benefits since certified. At the annual renewal in 2014, a MRT disability determination is required. A review by MRT is also necessary if the caseworker becomes aware of significant improvement and/or employment at or near the SGA level (Re. MS F-124). All forms completed for the initial application, including the DMS-2602 and DCO-2603, must be completed at renewal. In addition, the premium amount will be redetermined at renewal. If the premium changes, the parent will be notified of the new amount by the TEFRA Premium Unit.

5 I-326 Autism I-326 Autism Autism Waiver cases will be renewed every 12 months by the Area TEFRA Processing Unit (ATPU). ATPU will mail the parent or guardian a DCO-7779, Annual Renewal Notice, to redetermine eligibility. A MRT disability redetermination may or may not be necessary at the time of the renewal. A need for a disability redetermination by MRT will be indicated on the DCO-109 received during the initial determination and case renewals, if applicable. When approval was made based on a previous SSI determination of disability and there have been no SSI payments or subsequent redetermination by SSA, a MRT disability redetermination will be made one year after the initial approval for the Autism Waiver. All eligibility factors, except the autism diagnosis, will be redetermined at renewal. If the renewal form is not returned, a DCO-700, Notice of Action, will be sent advising that the DCO-7779 must be received within 10 days or the case will be closed after the notice expires. To insure that renewals are completed by the end of the 12 th month, the renewal process should be started in the 9 th month from the date of the last approval or renewal. I-327 Medicare Savings Program (MSP) ARSeniors, QMB, SMB and QI-1 reevaluations will be conducted on an annual basis. Form DCO- 811, SNAP/MSP Annual Review, will be used to complete the reevaluation. For MSP recipients with or without a SNAP case that has been certified for 24 months or 36 months, form DCO-811 will be system generated in the 11 th month following the last review (6 th work day from the end of the month). The recipient must complete all appropriate sections of the form and return the completed form to the address listed on the DCO-811 by the 10 th of the following month. The information on the DCO-811 will be used to determine continued eligibility for both SNAP and MSP. If the recipient has both a SNAP and a MSP case, both reviews must be completed at the same time. If the spouse has a MSP case, his/her case must be reviewed at the same time as the casehead. If an individual is in the household who is not the spouse of the SNAP or MSP casehead, his/her MSP review will be completed as appropriate, based on the date of the last case review. Self-declaration will be accepted. An interview is not required for these households. Form DCO-662 should be completed (for ARSeniors and QMB only) when there has been a change in insurance coverage. The caseworker will mail the DCO-662 to the recipient to gather information on the reported change and to request a copy of the new insurance card. If additional information is needed, a DCO-103, Request for Information, will be sent to the client.

6 I-327 Medicare Savings Program (MSP) If the DCO-811 is not returned by the due date, form DCO-93, Notice of Action, will be issued to the recipient advising that his/her case will be closed. This notice is specific to MSP and SNAP 24/36 annual reviews. The notice will explain why the case is being closed and provide instructions on how to prevent the case closure. If the DCO-811 is not returned by the date specified on the form DCO-93, the caseworker will close the case. If the SNAP case is closed and the continued eligibility for MSP can be established, the MSP review will be completed. If the MSP case is closed for failure to provide information and the requested information is returned within 30 days after closure, the MSP case will be reinstated and eligibility determined. A Medicare Savings Program Annual Review can be completed via the telephone and will not require a returned, signed DCO-811, Annual Review. The telephone review may be completed at anytime during the review process to obtain information needed to complete the review. The call can be initiated either by the worker or the client. For example, the worker may be contacting the client for another reason or calling to remind the client to return the review form. Another example is if the client initiates the call for a replacement form. However, it is the worker s discretion as to whether an interview to obtain the information should be completed. During the phone interview, the worker should review the client s information in the system and ask if there have been any changes since the last review. Workers should be alert to whether the individual has a spouse who is also receiving MSP benefits and if so be sure to obtain information and complete the spouse s review at the same time. The worker should document in the system using the narrative type Annual Telephone Review and verify information if necessary (e.g., SOLQ). The client should be advised that the annual review has been completed and that the form does not need to be returned.