Expanding Foundations MAGI

Transcription

1 Expanding Foundations MAGI Participant Guide Health Care and Economic Security Staff Development Center 7800 East Orchard Road, Suite 280 Greenwood Village, CO Participant Guide Page 1

2 Acknowledgements The Health Care and Economic Security Staff Development (SDC) would like to acknowledge all of the individuals and agencies that provided assistance during the Expanding Foundations development process. In particular, several Counties and Medical Assistance (MA) sites worked closely with the SDC, offering their time and expertise to ensure that Expanding Foundations was comprehensive and accurate. Hence, the SDC would like to extend a special thanks to: Arapahoe County Human Services Boulder County Housing and Human Services Broomfield County Health and Human Services Denver Human Services Denver Health Eagle/Pitkin Health and Human Services El Paso County Jefferson County Human Services Parkview Medical Center Introduction The Health Care and Economic Security Staff Development Center (SDC) is excited to present a guide to the framework for the precision delivery of Expanding Foundations curriculum. Expanding Foundations represents competency based training offered by the SDC, and will prepare health and human service professionals to use the Colorado Benefits Management System (CBMS) to determine eligibility. Common Terms and Phrases There are several terms and phrases found throughout this Guide that have other common names associated with them. We have chosen these terms and phrases based on accuracy, appropriateness, and general understanding in order to provide consistency. The terms and phrases used in this Guide are listed below with other associated common names. Cash Assistance: Colorado Works (CW) and Adult Financial (AF) Member: applicant, customer, recipient, household Colorado Works: Temporary Assistance for Needy Families (TANF; this is the federal program) Eligibility Worker or Public Assistance Professional: user, eligibility technician, program specialist, eligibility professional, worker Food Assistance: Supplemental Nutrition Assistance Program (SNAP; this is the federal program), food stamps Medical Assistance: Medicaid and Child Health Plan Plus (CHP+); not Medicare Public Assistance: Food, Medical, and Cash Assistance programs; human services, social services Participant Guide Page 2

3 Table of Contents Acknowledgements... 2 Introduction... 2 Common Terms and Phrases... 2 Welcome... 6 Course Modules:... 6 Group Expectations/Housekeeping... 6 Introductions... 6 Medical Assistance Overview... 7 Objectives:... 7 Brief History of Medical Assistance... 7 Medicaid Administration... 8 Who does Medical Assistance Serve?... 8 Medicaid Benefits What s Covered?... 9 Medical Assistance Review General Eligibility Requirements for Medical Assistance (MA) Objectives: Introduction to Self-Attestation and Interfaces Social Security Number Residency True or False: Citizenship and Identity True or False Deficit Reduction Act (DRA): Jigsaw Reading Deficit Reduction Act (DRA): What You Should Know Reasonable Opportunity (ROP) Good Faith Effort Other Eligibility Requirements Affordable Care Act (ACA) Objectives: Paddle Game: Fact or Fiction? Main Goals of the ACA Participant Guide Page 3

4 Medical Assistance Hierarchy Race Connect for Health Colorado Shared Eligibility System ACA Review Introduction to Modified Adjusted Gross Income (MAGI) Medical Assistance Objectives: MAGI True or False MAGI Categories Part 1: Children, Pregnant Women and Parent/Caretaker Relatives MAGI Review: Part MAGI Categories Part 2: Adults and CHP True or False: Emergency Medical Assistance Emergency Medical Assistance: True or False MAGI Review: Part Applying for Medical Assistance Objectives: No Wrong Door Processing Timeframes Real-Time Eligibility (RTE) Questions? Colorado Benefits Management System (CBMS) Objectives: Application Initiation (AI) Review Interactive Interview (II) Retroactive Medical Assistance Emergency MA: Non-Qualified Non-Citizen MAGI Pregnant: Non-Qualified Non-Citizen Interfaces - SOLQ-I Medical Assistance: Notice of Action (NOA) Objectives: Interfaces - Systematic Alien Verification for Entitlements (SAVE) Participant Guide Page 4

5 MAGI Medical Assistance Objectives: Introduction to Household Composition Relationships: Monthly Budget Units MBU: Creating Individual Monthly Budget Units Three Questions: Household Relationship: Tax Filer vs. Non-Filer Three Exceptions: MBU: Practice Makes Perfect! Paddle Game: Relationships MAGI: Income Self-Attestation: Scavenger Hunt! Income Income: Countable or Exempt? Reasonable Compatibility Verification Checklist Household Composition and Income Review: Carousel Walk CBMS Data Entry Employment History Frequency and Income Conversion CBMS: Wrap Up Adding a Needy Newborn or New Household Member Presumptive Eligibility (PE) Objectives: The Need to Know Benefits: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Child Welfare Former Foster Care Accountable Care Collaborative (ACC) Action Idea List Participant Guide Page 5

6 Breast and Cervical Cancer Program (BCCP) Objectives: The Basics The Process IRS 1095-B Health Coverage Form Members Who Won t Receive a 1095-B from HCPF CBMS Updates Closing Accessing the ILRS Resources Welcome Course Modules: Group Expectations/Housekeeping Notes: Introductions Notes: Participant Guide Page 6

7 Medical Assistance Overview Objectives: After this course, participants will: Outline the history of Medical Assistance Describe the administration of Medical Assistance programs Identify populations served by Medical Assistance programs Recognize Medical Assistance benefits Goal Participants will summarize the Medical Assistance programs. Notes: Brief History of Medical Assistance Draw a line between the following events and the date they occurred: Affordable Care Act (ACA) signed into law 1965 Deficit Reduction Act (DRA) signed into law 2013 Medicaid created 2005 State Children s Health Insurance Program (SCHIP) begins Medicaid expands to cover more adults including those without dependent children Health Insurance Marketplace open 2000 Participant Guide Page 7

8 Medicaid Administration Medicaid is a joint federal/state partnership program with federally established national guidelines At the federal level, Medicaid is administered by the Center for Medicare & Medicaid Services (CMS), which is an agency within the United States Department of Health and Human Services (DHHS) In Colorado, Medicaid is supervised by the Department of Health Care Policy and Financing (HCPF) HCPF will: Develop additional programs beyond what the federal government requires Create and maintain its plan for delivering services Set payment rates Receive matching funds from federal government; known as Federal Medical Assistance Percentage (FMAP) At the local level, Medicaid is administered by eligibility sites including County Departments of Human/Social Services and Medical Assistance (MA) sites Notes: Who does Medical Assistance Serve? Serves legally admitted qualified non-citizens (usually subject to a five year waiting period), and unqualified non-citizens facing emergency medical situations Medical Assistance for people with limited income and resources Largest source of health related funding in the United States Medicaid also supplements Medicare recipients who are aged, blind and/or disabled Note Medicare is the federal health insurance program for people who are aged, blind or disabled. Notes: Participant Guide Page 8

9 Medicaid Benefits What s Covered? List the benefits that are covered or not covered for Medicaid. COVERED Health care provider visits (primary care) Rehabilitative care Pediatric services Emergency services Maternity and newborn care Family planning Mental health care Substance abuse services Laboratory and X-ray Some vision services Physical therapy Speech therapy Prescriptions and medical equipment Preventative and wellness care Dental services NOT COVERED Acupuncture Cosmetic procedures Chiropractic services Infertility treatments Vaccines for travel Personal hygiene items Sports equipment Most over-the-counter drugs Medical marijuana Some prescriptions Note This list is not all inclusive. For additional information and details, see Medicaid Benefits form in the appendix or at If Medicaid recipients have questions about Medicaid benefits, they are encouraged to contact Medicaid Customer Service at (TDD ). Notes: Participant Guide Page 9

10 Medical Assistance Review Identify three things that you learned in Medicaid Overview: Notes: General Eligibility Requirements for Medical Assistance (MA) Objectives: After this course, participants will: Identify Social Security Number (SSN) requirements for MA Identify the residency requirements for MA Identify the citizenship requirements for MA Describe the identification requirements for MA Understand the Deficit Reduction Act (DRA) Recall the concepts of Self-Attestation and the interfaces used to verify self-attested information Goal Participants will outline the general eligibility requirements for Medical Assistance (MA). Introduction to Self-Attestation and Interfaces *Use to Public Assistance Verification Matrix for assistance What is Self-Attestation? Self-Attestation is more commonly referred to as Client Statement, this is the value that will be entered into CBMS Three things that can be verified through self-attestation: Participant Guide Page 10

11 SSN Age Residency Two things that cannot be verified through self-attestation: Citizenship Identity Information that is provided through self-attestation is verified through a third-party verification system known as an Interface. Interfaces talk-to CBMS and provide information that has been entered using a member s declaration of information. List three interfaces used to verify information that has been received through self-attestation Notes: Match the acronym to the correct interface name: SOLQ-I DMV CDLE SAVE SVES Social Security Number State Verification and Eligibility System Colorado Department of Labor and Employment State Online Query-I Colorado Department of Motor Vehicles Systematic Alien Verification for Entitlements Program Members requesting MA must supply a SSN or supply verification that they have applied for SSN, with the following exceptions: Emergency MA Needy Newborns Presumptive Eligibility (PE) SSN verified through the State Verification Eligibility System (SVES) Participant Guide Page 11

12 Residency Notes: True or False: MA applicants are not required to be a Colorado resident (True or False) Self-attestation or client statement is all that is needed to verify residency (True or False) Residency can be verified through Department of Motor Vehicle (DMV) system as long as and ID or Driver s License has been issued by Colorado (True or False) Always request a bill or lease from applicant to verify residency (True or False) Incarcerated individuals or inmates at correctional facilities who are admitted to a hospital for more than 24 hours are eligible for MA (True or False) Residents of Long-Term Care (LTC) institutions are ineligible for MA (True or False) Citizenship and Identity Citizenship: Must be a citizen or national of the United States, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa or Swain s Island, or Be a lawfully admitted non-citizen who entered the United States prior to August 22, 1996, or Be a lawfully admitted non-citizen who entered the United States on or after August 22, 1996 who has been in a qualifying status for at least five years from the date of application Note Volume 8 is the Code of Colorado Regulations used by the Department of Healthcare Policy and Financing to administer Medical Assistance programs in Colorado. In simpler terms, it s the Medical Assistance rule book Participant Guide Page 12

13 5 Year Bar Immediate Full medical coverage The 5 year waiting period will be lifted for specific non citizens. Full Medical Assistance benefits will be available immediately to these specific non-citizens as long as they meet all other eligibility requirements. Some categories of non-citizens that do not have to meet the 5 Year Bar include: Refugee Asylees Cuban or Haitian Entrants Afghan special Immigrants Iraqi Special immigrants Victim of Trafficking Verification for non-citizens must be verified through the following: Systematic Alien Verification for Entitlements (SAVE) program DACA Deferred Action for Childhood Arrivals (DACA) On June 15, 2012, are certain people who came to the United States as children and meet several guidelines may request consideration of deferred action for a period of two years, subject to renewal. They are also eligible for work authorization. Deferred action is a use of prosecutorial discretion to defer removal action against an individual for a certain period of time. Deferred action does not provide lawful status. Guidelines 1. Were under the age of 31 as of June 15, 2012; 2. Came to the United States before reaching your 16th birthday; 3. Have continuously resided in the United States since June 15, 2007, up to the present time; 4. Were physically present in the United States on June 15, 2012, and at the time of making your request for consideration of deferred action with USCIS; 5. Had no lawful status on June 15, 2012; 6. Are currently in school, have graduated or obtained a certificate of completion from high school, have obtained a general education development (GED) certificate, or are an honorably discharged veteran of the Coast Guard or Armed Forces of the United States; and 7. Have not been convicted of a felony, significant misdemeanor, or three or more other misdemeanors, and do not otherwise pose a threat to national security or public safety. Participant Guide Page 13

14 Citizenship and Identity Verification: Citizenship and identity can be verified through a third-party electronic data source, known as an Interface State Verification Exchange System(SVES) SCHIP sends requests for verification to the Social Security Administration (SSA) CBMS sends a request to SVES SCHIP twice an hour to verify citizenship and identity List the documents that serve as Primary Evidence of Citizenship and Identity US Passport Certificate of Naturalization US Certificate of Citizenship of Naturalization Document issued by a federally recognized tribe Citizenship: Notes: Identity: Identity can be verified through the following interfaces SVES/SCHIP Division of Motor Vehicles (DMV) Applicant must have a valid Colorado issued Identification for DMV interface to work within CBMS Identity can also be verified through: State Identification card School identification card US Military Card Identification card issued by the Federal, State, or local government with the same information included on driver's licenses; Certificate of Degree of Indian Blood/US American Indian or Native Tribal Document Written affidavit for children under the age of 16 Participant Guide Page 14

15 Notes: Citizenship and Identity Verification Exemptions: Notes: True or False All Foster Care Children must provide verification of Citizenship and Identity (True or False) Parents of Needy Newborns do not have to provide verification of Citizenship and Identity for the newborn (True or False) A member that is receiving payments from the SSA is not required to provide verification of Citizenship and Identity (True or False) Presumptive Eligibility members must always provide verification of Citizenship and Identity (True or False) Deficit Reduction Act (DRA): Jigsaw Reading Notes: Deficit Reduction Act (DRA): What You Should Know The Deficit Reduction Act (DRA) of 2005 requires that members provide documents to verify Citizenship and Identity Once DRA requirements have been met, the information will be stored in the CBMS Participant Guide Page 15

16 Members do not have to provide documents again, with the following exceptions: If an agency receives information that the member s citizenship and identity are questionable If there is a gap of more than five years between the ending date of the member s last period of eligibility and the subsequent application Case comments must be entered in CBMS under citizenship and identity, specifically identifying which household members have provided citizenship and identity documents Case comments will be automatically system generated when interfaces verify citizenship and identity Eligibility sites must provide a reasonable amount of assistance to members who need citizenship documents. Examples of reasonable assistance are the following: Providing contact information for the appropriate agencies that issue required documents Explaining the documentation requirements Telling the member the acceptable ways they may provide documentation Referring the member to other agencies or organizations that can provide assistance with obtaining the required documentation Eligibility Sites must provide a Reasonable Opportunity Period (ROP) for members to provide their documents; CBMS will automatically set ROP 90 days for all Medical programs Reasonable Opportunity (ROP) Eligibility sites must provide a reasonable amount of assistance to members who need citizenship documents. Examples of reasonable assistance are the following: Providing contact information for the appropriate agencies that issue required documents Explaining the documentation requirements Telling the member the acceptable ways they may provide documentation Referring the member to other agencies or organizations that can provide assistance with obtaining the required documentation Eligibility sites must provide a Reasonable Opportunity Period (ROP) for members to provide their documents CBMS will automatically set ROP 90 days for all Medical programs Note Note Eligibility sites must retain a paper or electronically scanned copy of an individual s citizenship and documentation for records at least five years from the ending date of the individuals last period of MA eligibility Initially, the member has 10 calendar days + 5 business days to provide the needed information; the ROP extends the amount of time that an applicant has to provide needed verification. Currently, CBMS is setting the due date for Citizenship and Identity to 90 days to allow for ROP. Participant Guide Page 16

17 Good Faith Effort 1) When should a Good Faith Effort extension be granted? a) If a member has provided a verbal statement describing his or her efforts to obtain required documentation b) If a member provides copies of documents to support a request to obtain required verification c) On a case-by-case basis d) All of the above Notes: Other Eligibility Requirements There are other eligibility considerations for all programs, which will be discussed in detail throughout Expanding Foundations The other eligibility requirements for MA include: Income Age Disability Resources Affordable Care Act (ACA) Objectives: After this course, participants will: Outline the history of the ACA Paraphrase the main goals of the ACA List key features of the ACA Identify the purpose of Connect for Health Colorado Goal Participants will explain how the ACA impacts Medical Assistance. Participant Guide Page 17

18 Paddle Game: Fact or Fiction? Notes: Main Goals of the ACA Provide health insurance coverage, both public and private, to reduce the number of uninsured Americans Expand Medicaid to adults without dependent children Not all states have extended eligibility to this category Financial assistance available through: Cost Sharing Reductions (CSR) Advanced Premium Tax Credits (APTC) CSR and APTC can only be accessed through Connect for Health Colorado Medical Assistance Hierarchy There is a hierarchy of MA categories that consists of 45 programs. CBMS will run eligibility through ALL 45 categories every time that eligibility is determined The MA Program Execution Order Desk Aid explains how the execution order works; the way the execution order is listed, is the same order that CBMS uses to run individuals eligibility. This ensures that every individual is placed in the highest level of care they are eligible to receive; noting that an individual may be placed in a lower level category while awaiting verification that may be required for other categories. *The desk aid can be located at TrainColorado.com Medical Assistance Hierarchy Race Notes: Participant Guide Page 18

19 Connect for Health Colorado Online Marketplace where individuals can browse and shop for private health insurance plans Estimate and apply for Advanced Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR) Enrollment Periods: Individuals can only apply for financial assistance for health insurance plans during Open Enrollment Periods, unless there is a qualifying life event Qualifying Life Events include: Loss of job Death in family Addition of a family member Marriage Separation or Divorce Special Enrollment Periods occur anytime outside of Open Enrollment Periods If an applicant is denied Medicaid, they may be eligible for subsidies offered by federal government: Two types of financial assistance: Advanced Premium Tax Credits (APTC) are used to lower monthly premiums; available for people between 133% and 400% of Federal Poverty Level (FPL) Cost Sharing Reductions (CSR) are discounts that lower the amount people have to pay out-of-pocket for deductibles, coinsurance, and copayments; available to people between 133% and 250% of FPL Individuals can apply for Medicaid/CHP+ at any time Note Certified Health Coverage Guides, located at Assistance Sites across Colorado, are available to meet with people in-person. They provide unbiased assistance in considering health plan options and applying for insurance affordability programs and enrolling in health coverage. There m be a Guide in your County to assist members. Note Plans-4-You Customer Service Center, provides help to customers over the phone, is another good resource. The number is PLANS-4-YOU ( ). Notes: Participant Guide Page 19

20 Shared Eligibility System The ACA requires that people should only need to complete one application for health coverage. Shared Eligibility System is a system that will determine eligibility for Medical Assistance (MA), Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR). SES and CBMS will determine eligibility for Medicaid and in situations where the member is not eligible, APTC will be determined. The eligibility information will be used to determine APTC and CRS eligibility with a streamlined, seamless determination process. PEAK Inbox The SES is not a system that is seen by users. SES is an eligibility system that runs behind the scenes when the PEAK User applies for Medical only. PEAK Inbox applications that show only MA in the Programs Requested column would have been passed through the SES for eligibility. The Benefits of SES: Single Sign On (SSO) is a functionality that will allow the member to log into their account regardless where they created it. EXAMPLE: When the member creates an account in PEAK their information will be shared to C4HCO therefore they will also be able to log into the C4HCO Marketplace. Single Application The SES will allow Members to apply for medical benefits with one application process and have MA, APTC, or CSR s determined SES Account Access Members will be able to add and designate individuals or agencies to their application to act on their behalf. The Authorized Representative will be able to submit applications and change reports on behalf of the Primary Account holder. When the update or change is made SES will run behind the scenes and the member will automatically have access to C4HCO using their PEAK account information. REMEMBER: This is for MEDICAL ONLY cases. ACA and SES Review Participant Guide Page 20

21 Introduction to Modified Adjusted Gross Income (MAGI) Medical Assistance Objectives: After this course, participants will: Explain MAGI List the MAGI categories Summarize the rules for each MAGI category MAGI MAGI is both a methodology used to determine eligibility for certain Medicaid programs and the name for those categories which utilizes that methodology True or False Goal Participants will understand the MAGI categories and the associated rules for eligibility determination. MAGI categories do not consider resources (True or False) MAGI methodology is not applied when members are filing taxes (True or False) MAGI methodology standardizes how income and household composition is calculated (True or False) MAGI methodology is applied even when members are not filing taxes (True or False) MA and Connect for Health Colorado utilize different income calculations for their programs (True or False) Notes: Participant Guide Page 21

22 MAGI Categories Part 1: Children, Pregnant Women and Parent/Caretaker Relatives After the ACA, there are five Medicaid categories As mentioned, the categories have now been consolidated Children: Up to 142% of the FPL Covers children under the age of 19 Certain needy persons under the age of 21 All children are eligible to receive 12 months of continuous coverage; regardless of changes in income and household size Pregnant Women: Up to 195% of FPL Covers pregnant women age 19 and over Coverage extends for 60 days past the birth of the child(ren) From the 60 th day, coverage extends further to the last day of that month Pregnancy can be verified by client-statement The pregnant mother, plus all unborn children are considered part of the household Children born to a woman on Medicaid receive 12 months of guaranteed coverage Pregnant women under the age of 19 fall into the MAGI Children category Note Note DACA (Deferred Action Childhood Arrivals) are undocumented individuals who were brought here as children. They are not considered under a legal status, they are children who have work authorizations and will not qualify for MAGI Class Code A19 in the Non-Citizen page is acceptable for an individual who is pregnant or under 19, they will be eligible based on status but must also meet other eligibility criteria. MAGI Pregnant also provides medical coverage for pregnant legal immigrants who have not met the 5 Year Bar This is also referred to as Legal Immigrant Prenatal MAGI Pregnant also provides emergency Medical Assistance to non-qualified immigrants Only labor and delivery are covered Prenatal or post-partum medical services are not covered Parent and Caretaker Relatives: Up to 68% FPL Covers biological, step, and adoptive parents of children Must have a Medicaid eligible child under the age of 19 with Minimal Essential Coverage (MEC) Note Medicaid eligible children cannot be living outside of the home Participant Guide Page 22

23 A Caretaker Relative is a person who is related to the dependent child or any adult with whom the dependent child is living and who assumes responsibility for the dependent child s care. If parent/caretaker relative income is above 68% of FPL and meet all other eligibility requirements, they will fall under the MAGI adult category The Medicaid eligible child(ren) cannot be living outside of the home; as in instances of noncustodial parents, both parents could potentially be eligible for this category of MA Transitional MA: A category of MA for members in either the MAGI Parent/Caretaker relative or MAGI Children category who would lose eligibility for MA due to earned income above the FPL for their respective category If the member no longer qualifies for this category due to being over the 68% FPL because of an income increase, the member will not be eligible for Transitional Med. Must be in parent/caretaker relative category to be eligible Must have been receiving MA in 3 of the 6 months preceding the month in which the family became ineligible Certification Period Granted for 12 months Beginning the first month of ineligibility Transitional MA is a guaranteed program RRR due month will be changed to 11 months from the Trans Med start date. Member will remain on the Trans Med for the 12 months. RRR will be due 11 month from the Trans Med Start date. The member can opt out of Trans Med at any time, new radio button in CBMS Member can opt out of Trans Med at any time Example: Mom is on Transitional Medical Assistance through 12/31 and the child is on MAGI Child until 10/31. The child would move to Transitional Medical Assistance starting 11/1 12/31 since mom is approved on transitional Med until 12/31. Newly Added Individuals If you add a spouse to the Monthly Budget Unit (MBU) during the Trans Med period of the spouse s approval, and the new individual wasn t eligible for any other program, they would be approved for Trans Med as long as all other eligibility requirements are met. (we will discuss MBU later in the training) Any dependent child or Parent/Caretaker Relative who becomes part of the Medical Assistance household after the individual has begun receiving Transitional Medical Assistance are eligible to receive medical coverage during the remaining period of the Transitional Medical Assistance approval. Participant Guide Page 23

24 Income When determining income for Trans Med: Countable: Earned/Self-employment income Exempt: Unearned and income that fluctuates increase/or decrease Four Month Extended MA: Notes: MAGI Review: Part 1 Notes: MAGI Categories Part 2: Adults and CHP + Adults: Up to 133% of FPL Covers adults age 19 through the end of the month that they turn 65 Not required to have a dependent child Cannot be a Medicare recipient Not all states have extended eligibility to this category If the Adult is a Parent or Caretaker relative, the child will need Minimal Essential Coverage in order for the adult to be approved for MAGI Adult category. A Caretaker Relative is a person who is related to the dependent child or any adult with whom the dependent child is living with and who assumes responsibility for the dependent child s care. The member will be given 1 calendar day for noticing + 10 business days + 5 business days. The notice will only show the 10 days, but the system will give the member an additional 5 days behind the scenes. Participant Guide Page 24

25 If the Verification Check List is not returned the member will be denied for Adult MAGI and the 10 day noticing will apply. If the child does have Minimal Essential Coverage, you will need to update the Case Individual page to indicate the child does have MEC. Don t forget to complete the Responsible Relative field on the House Hold Relationships page if the individual is a Caretaker Relative. Child Health Plan Plus (CHP +): True or False: Child Health Plan Plus (CHP+) is low-cost health insurance for Colorado's uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for Medicaid, but cannot afford private health insurance (True or False) CHP+ does not use MAGI methodology for eligibility and household composition (True or False) CHP +Children CHP+ Prenatal CHP+ Needy Newborn Between 143% and 260% of FPL Covers children under the age of 19 Between 143% and 260% of FPL Covers pregnant women age 19 and over If the baby is born to a mother on CHP+ Prenatal the child is considered a CHP+ Needy Newborn Enrollment fee applies between 157% and 260% of FPL Native American/Alaskan Natives are exempt from enrollment fees Cover extends for 60 days past the birth of the Child(ren) No Enrollment fee for pregnant women and their household Baby is guaranteed coverage for the first 12 months of their life, regardless of household circumstances It is possible that some children in a household will be eligible for MAGI children, while others will be eligible for CHP+ All CHP+ children are eligible to receive 12 months of continuous coverage; regardless of changes in income and household size CHP+ Enrollment Fees are also referred to as Premiums; they are entered into a specific CBMS page when received from the Member. Peak CHP+ Results and CHP+ card Notes: Participant Guide Page 25

26 Emergency Medical Assistance Notes: Emergency Medical Assistance: True or False Emergency MA available for all programs (True or False) Must meet citizenship criteria (True or False) Every emergency situation requires an application unless a second emergency occurs in the same month as a prior application (True or False) Emergency MA is available for all health conditions (True or False) A physician must provide a written statement certifying the presence of an emergency medical condition (True or False) Coverage includes prenatal or follow-up care under EMS (True or False) MAGI Review: Part 2 Applying for Medical Assistance Objectives: After this course, participants will: Discuss No Wrong Door philosophy Identify processing timeframes Identify policies for Retroactive MA Explain Real-Time Eligibility (RTE) Describe self-attestation policy Goal Participants will understand the rules and polices associated with the application process for Medical Assistance. No Wrong Door The ACA requires that people applying for Medical Assistance coverage can apply for benefits using many different methods: Phone: HCPF currently taking phone applications Note MAGI Medicaid always begins the first day of the month of application and always ends at the end of the month. Participant Guide Page 26

27 The State is currently working with counties and other partners to develop a transition plan for telephone applications. Online PEAK Connect for Health Colorado In person County Departments Medical Assistance (MA) sites Certified Application Assistance Sites (CAAS) Fax Mail The ACA also requires that people should only need to complete one application. The applications that can be used include: Single Streamlined Application (SSAp) Used for Medical Assistance and Connect for Health Colorado Single Purpose Application (SPA) Used for Medicaid, Food, and Cash assistance programs PEAK Online application used for Medical, Food, and Cash Assistance programs No Wrong Door: Processing Timeframes Use the Processing Timeframe MA Desk Aid for assistance Disability Determination Required: 90 calendar days In unusual circumstances, the eligibility site may delay its decision on the application beyond the applicable deadline at its discretion If you have an issue completing an application timely, it is recommended that you speak to your Lead Worker or Supervisor Retroactive MA A request for Retroactive MA can be made for any time during the three months prior to the date of application, or the date the person became eligible for MA, whichever is later. The member would have received medical services a any time during that period and still met all eligibility requirements Participant Guide Page 27

28 All delays in processing, should be documented clearly in case comments and in the case record Notes: Retroactive MA: An eligibility determination for Retroactive MA should be made as part of the application process An applicant does not have to be eligible in the month of application to be eligible for Retroactive MA The member can verbally request retroactive coverage at any time following the completion of an application Verification required to determine MA eligibility for the retroactive period should be obtained by the eligibility site to determine retroactive eligibility Proof of the declared medical service is not required CHP+ does not provide Retroactive MA Notes: Participant Guide Page 28

29 Real-Time Eligibility (RTE) RTE is a performance standard, not a timeliness standard Not all applications will meet the parameters for RTE PEAK Applications: When an application is submitted through PEAK, RTE can only be made for MAGI categories When an application is submitted through PEAK, applications that do not receive RTE decisions will be sent to an eligibility site for processing Paper Applications: As soon as all the information needed to make an eligibility decision is provided, there should be no delay in processing This is true for both MAGI and non-magi populations Questions? Notes: Colorado Benefits Management System (CBMS) Objectives: Discuss interfaces that are used for verification purposes Identify the pages that are always added to an MA page queue Complete Citizenship and Identity data entry Complete Retroactive MA data entry Complete emergency MA data entry Goal Participants will complete data entry for an MA case in CBMS. Application Initiation (AI) Review Reminder: On Line Help (OLH) is a great resource for CBMS data entry. Notes: Participant Guide Page 29

30 Interactive Interview (II) There are 18 pages added to the Page Queue for a MA case. Depending on the responses to case questions pages, more pages will be added to the page queue Case Questions Case Information Case Communications Individual Demographics Ethnicity Case Individual Individual Tax Information Retro Information Individual Attributes Residency Household Relationship Long-Term Care Institution Long-Term Care Level of Care Data Conflict Case Wrap Up Life Change Events APTC Expense Summary APTC Individual Information MA Application Help Participant Guide Page 30

31 Participant Guide Page 31

32 Participant Guide Page 32

33 Participant Guide Page 33

34 Participant Guide Page 34

35 Participant Guide Page 35

36 Participant Guide Page 36

37 Participant Guide Page 37

38 Participant Guide Page 38

39 Participant Guide Page 39

40 Participant Guide Page 40

41 Participant Guide Page 41

42 Participant Guide Page 42

43 Participant Guide Page 43

44 Participant Guide Page 44

45 Participant Guide Page 45

46 Participant Guide Page 46

47 Participant Guide Page 47

48 Participant Guide Page 48

49 Participant Guide Page 49

50 *Run EDBC every time a change or update is made to a case in CBMS. Participant Guide Page 50

51 Participant Guide Page 51

52 Participant Guide Page 52

53 Participant Guide Page 53

54 Participant Guide Page 54

55 Participant Guide Page 55

56 Participant Guide Page 56

57 Participant Guide Page 57

58 Participant Guide Page 58

59 Participant Guide Page 59

60 Participant Guide Page 60

61 Participant Guide Page 61

62 Participant Guide Page 62

63 Participant Guide Page 63

64 Participant Guide Page 64

65 Retroactive Medical Assistance Participant Guide Page 65

66 Participant Guide Page 66

67 Participant Guide Page 67

68 Emergency MA: Non-Qualified Non-Citizen Participant Guide Page 68

69 Participant Guide Page 69

70 MAGI Pregnant: Non-Qualified Non-Citizen Participant Guide Page 70

71 Interfaces - SOLQ-I State Online Query Internet (SOLQ-I) interface The request for information is entered into CBMS through the SVES Request page in CBMS, SVES sends the request to SOLQ-I and the returned information is populated into CBMS and can be viewed from the Search SVES Data page within CBMS SOLQ-I is used to obtain verification through the State Verification Eligibility System (SVES) Medical Assistance: Notice of Action (NOA) Objectives: Explain the NOA letters that will be sent to members Summarize appeals and additional information section Recite when NOAs are generated Goal Participants will become familiar with the MA Notice of Action Participant Guide Page 71

72 Participant Guide Page 72

73 CBMS Tip! The Search/View Client Correspondence in the Print Queue page will also show the type of NOA that was generated Correspondence # - shows the number of the correspondence Correspondence Name shows the name of the NOA Symbols in the left hand corner of all the notices: green check mark = approved red minus sign = someone in the household has been terminated triangle = a change to the case Participant Guide Page 73

74 Interfaces - Systematic Alien Verification for Entitlements (SAVE) SAVE is the interface that verifies non-citizen information as well as some sponsor information and can provide additional information for non-citizens applying for Medical Assistance. SAVE verification should be checked anytime there is a non-citizen applying for MA, that has provided an Alien Number, also known as a A Number SAVE information is entered into the Non-Citizen page in CBMS When a member applies through PEAK, the SAVE interface is called by CBMS and the following information is pulled into CBMS to allow for RTE to occur. If there are any discrepancies and SAVE cannot verify the non-citizen information, the case will exception out and be sent to the PEAK inbox for manual processing Case Number VLP Operation Name First Name Last Name Middle Name Date of Birth Gender Coverage Start Date Alien Number Document Type Code Document Type CBMS Country Code Country of Issuance Error Code Error Message Note: USCIS provides free online training webinars. at-save/save-webinars Notes: Participant Guide Page 74

75 MAGI Medical Assistance Objectives: After this course, participants will: Determine the correct Household Composition for a Medical Assistance (MA) household Identify the MBU for each individual when presented with scenarios Identify Tax-Filer, Non-Filer and Exception rules that are used to determine the MBU Demonstrate correct data entry of information in CBMS in accordance with MA policy Goal Participants will accurately identify Household Composition and the Individual Monthly Budget Units (MBU) for MAGI MA utilizing MAGI methodology *Reference the MAGI MBU flowchart for assistance Introduction to Household Composition Notes: Relationships: Tax Relationship: Biological/Legal Relationship: Mandatory Members: Couples; who is considered Married? Colorado law allows for Civil Unions as well as Marriages. As of the 10/07/2014, the State of Colorado additionally recognizes same sex marriages Participant Guide Page 75

76 Civil Union - If they don t wish to get married, but want to have some of the legal protections that marriage offers Federal Medicaid provisions do not view Civil Unions as Marriages. Because of this, Civil Unions and Marriages will be treated differently for purposes of determining Medicaid eligibility. Civil Union and Domestic Partner will not be considered Married Monthly Budget Units MAGI MBUs are determined by relationships as declared on the application These relationships are based on tax-dependency, these rules will be discussed in more detail throughout this module If the individual has been determined as a non-filer, Non-Filer rules will be followed and the rules of tax dependency (tax relationship) will not apply Multiple Choice Questions 1) MBU is the acronym for which of the following? a. Medicaid Budget Unit b. Monthly Budget Unit c. MAGI Budget Unit 2) Which of the following is true for MBUs? a. An MBU is created for every family that applies for Medical Assistance b. An MBU is created for each individual that applies for Medical Assistance c. An MBU is used to determine what individuals are eligible, counted, or exempt for each person s household composition determination d. Both B and C 3) What do Eligible Adult and Eligible Child mean? a. That the Adult and Child are eligible to receive Medical Assistance b. Eligible Adult and Eligible Child are referring to the person for whom the MBU is being created c. It means nothing important, it is just a code in CBMS Notes: Participant Guide Page 76

77 MBU: Creating Individual Monthly Budget Units Follow along with the Facilitator as they take you through creating an MBU using the following scenario. Use the space provided to diagram, draw or take notes. Scenario: 1) Jenna is pregnant. She lives alone and files her own taxes. What is Jenna s MBU? 2) Jenna s boyfriend, Rick, moves in. They each file taxes separately. What is Jenna s MBU? What is Ricks? Participant Guide Page 77

78 3) Jenna has her baby. Rick is the father. Jenna claims her baby when she files taxes. Rick files separately. What is the MBU of Jenna, Rick and the baby, Clara? 4) Jenna and Rick get married, but they still file taxes separately. Jenna claims Clara on her taxes. What is the MBU for Jenna, for Rick, for Clara? Participant Guide Page 78

79 5) Jenna and Rick decide to file taxes together. They claim Clara. Jenna is the primary tax-filer. What is the household MBU for Jenna, Rick and Clara? 6) Rick s son from another relationship, Ken moves in. He is 14. Ken is claimed by his mother (who he does not live with) on her taxes. What are the MBU s for Jenna, Rick, Clara and Ken Participant Guide Page 79

80 Three Questions: What are three questions you will ask for each individual when creating an MBU? Question 1: Question 2: Question 3: Notes: Participant Guide Page 80

81 Household Relationship: Tax Filer vs. Non-Filer Notes: Three Exceptions: 1) Expects to be claimed as a tax dependent of someone other than a spouse, biological, adoptive or step parent 2) Is a child under age 19 and living with both parents, but the parents do not expect to file a joint tax return 3) Is a child under 19 years old and expects to be claimed by a non-custodial parent Notes: Participant Guide Page 81

82 Matching Game Match the following by drawing a line from the acronym to the correct meaning: EA XA CC EC CA XC Countable Child Eligible Adult Excluded Child Eligible Child Excluded Adult Countable Adult Notes: Matching Game Match the below definitions with the correct terms which will be mentioned throughout the Household Composition introduction. Monthly Budget Unit Tax-Dependent Non-custodial parent Non-Filer Household Tax-Filer A. An individual, head of household or married couple who is required to and who files a personal income tax return B. A parent who lives outside of the home where the child resides C. Anyone expected to be claimed as a dependent by a tax filer D. Household composition for each individual in the case is determined based on tax-filer or non-filer rules E. An individual who neither files a tax return nor is claimed as a tax dependent; also someone who meets an exception to tax-filer rules F. Determined by relationships of tax dependency Participant Guide Page 82

83 MBU: Practice Makes Perfect! Scenario: Jake - 30 years old Husband to Jessica, Father to Jaylin, and Uncle to Ken Tax Filer/Jointly with Jessica. Jessica 30 years old Wife to Jake, mother to Jaylin, and Auntie to Ken Tax filer/jointly with Jake Jaylin 9 months Daughter of Jake and Jessica, and Cousin to Ken Tax Dependent of Jake and Jessica Ken 7 years old Nephew to Jake and Jessica and Cousin to Jaylin Tax Dependent of Jake and Jessica Notes: Participant Guide Page 83

84 Paddle Game: Relationships Participants write true on one side of the paddle and false on the other side. The Trainer will read a statement, and you should hold up the correct side in response to the statement. Tax Filer rules are based on biological relationships (true/false) A spouse is always a member of an individual s MBU if living together (true/false) A pregnant mother s MBU includes the number of children she is expecting (true/false) Non-Filer rules are based on tax relationships (true/false) MBU is determined at an individual level, not by family unit (true/false) A tax dependent always has a biological relationship to the tax filer (true/false) A biological or legal relationship includes step and adoptive relationships (true/false) If an individual falls under Non-Filer rules, only blood and law relationships are considered when determining his or her MBU (true/false) Solely because a parent and child live together in the same house, they are considered mandatory members for each other s MBU (true/false) A tax filer s MBU consists of the individual, their spouse and all other tax dependents (true/false) If an individual lives with both parents, but the parents do not expect to file a joint return, the child would fall under tax dependent rules (true/false) Individuals that who meet an exception have an MBU that is determined by Non-Filer rules (true/false) MAGI: Income MAGI is a methodology used to determine countable income MAGI is not a number on a tax return Connect for Health Colorado calculates the Modified Adjusted Gross Income differently, which may result in different income calculations The income of eligible and countable members of the MBU will have any countable income attributed to the eligible individual Self-Attestation is acceptable verification for earned income Annualized Income Self- Employment Continue entering monthly income and monthly expenses Seasonal Earned Income Work part of the year Ski Resort, Certain Farm Workers, or holiday retail Commission Based Earned Income Employment where part or all of the income earned is based on a percentage of sales made or a fixed amount per sale Real Estate, Car Sales, or Waiters /Waitresses Tips Participant Guide Page 84

85 Notes: Self-Attestation: Really means that members can declare information themselves. Self-Attestation is also known as: Client Statement, Client Declaration or Self-Declaration Self-Attestation is acceptable verification for earned income Income Verification: All income is self-attested. Reasonable Compatibility will trigger with any changes from PEAK Earned Income: Wages earned by the applicant Can be verified through interfaces Colorado Department of Labor and Employment (CDLE) Income and Eligibly Verification System (IEVS) Self-Employment: Income received from services provided or good sold by the individual Self-Attestation is acceptable Self-employment income includes but is not limited to: Sole proprietor Partner in a partnership Independent contractor Consultant Unearned Income: Income received without employment or work attached Self-Attestation is acceptable Income includes but is not limited to: Pensions and other regularly received payments Social Security Benefits (retirement, survivors and disability) Interface with the Social Security Administration should occur for individuals with a Social Security Number Workers Compensation payments Railroad retirement annuities Unemployment Insurance Benefits (UIB) Participant Guide Page 85

86 Scavenger Hunt! Income Volume 8 can be accessed via the HCPF website by following these steps: Click on For our Stakeholders 3. Click on Explore Our Regulatory Resource Center 4. Click on Department Program Rules and Regulations 5. Scroll down and click on Scroll down and click on the link right under Current Version Program Rules and Regulations: Name three types of countable income: 1) 2) 3) Name three types of exempt income: 1) 2) 3) Find and write down the definitions or rules for the following: Questionable: K.5 Unearned Income: K.2 Minimal Verification Participant Guide Page 86

87 C.1.c Income: Countable or Exempt? Determine whether the following types of income are considered Countable or Exempt for MAGI. Circle the correct answer. 1) Child Support 2) Earned income 3) Social Security Disability Insurance (SSDI) 4) Annual income below $5800 5) Self-employment 6) Alimony 7) Veteran s Benefits 8) Lump Sum 9) Foster Care payments 10) Education scholarships/grants Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Countable or Exempt Notes: Reasonable Compatibility Reasonable Compatibility: Reasonable Compatibility refers to an allowable difference or discrepancy between the income an applicant self attests and the amount of income reported by an electronic data source Reasonable Explanation refers to the opportunity given to an applicant to explain a discrepancy between self-attested income and income reported by the electronic source, when the discrepancy is above 10% or under by 10%. Participant Guide Page 87

88 If the difference is under 10%, the user should update the Reasonable Compatibility switch to Y, and CBMS will use the self-attested income. Income will be considered as having a discrepancy if the IEVS income is greater than 10% of the self-attested (client statement) income reported and there is no Reason for not compatible selected for the given discrepancy. If the IEVS hit is received and the discrepancy between the IEVS income and the self-attested income is greater than 10%, then a Verification Checklist will be created and sent out for Reasonable Compatibility. Reasonable Explanation: The applicant will then be given a reasonable opportunity period of 90 days to provide verification. If the applicant does not provide verification they will be denied for being over income with 10 day noticing. If the total household countable income including the IEVS income record is still within the FPL limit of the MAGI program, then it is not considered to have a discrepancy. The selfattested income will still be used to determine the MA household eligibility The following are acceptable reasonable explanations that can be provided by a member. If any of the below (other than Other) are provided, no additional documentation can be required: Change in hours Death in family Divorce or marriage Lost Job Other if other is selected in CBMS, actual verification must also be entered in order for the system to recognize this option as a reasonable explanation Ways that a member can report a reasonable explanation: Phone In-person Written either on the generated notice or in a written statement reporting the reason Mail Fax Other documentation Check Stubs Written documentation from the employer Telephone call to an employer Participant Guide Page 88

89 Notes: Verification Checklist Select the correct answer for the following: 1) What is a Verification Checklist? a) A checklist that you write before you go to the doctor b) A Verification Checklist (VCL) is a form that is generated by CBMS when additional information is required from the member to determine eligibility c) A notice that tells a member if they are eligible for Medical Assistance 2) Most MA verifications need to be provided within: a) 10 business days b) 30 calendar days c) 90 days d) 10 calendar days + 5 business days Notes: Household Composition and Income Review: Carousel Walk Notes: Participant Guide Page 89

90 CBMS Data Entry Participant Guide Page 90

91 Participant Guide Page 91

92 Participant Guide Page 92

93 Participant Guide Page 93

94 Participant Guide Page 94

95 Participant Guide Page 95

96 Participant Guide Page 96

97 Participant Guide Page 97

98 Participant Guide Page 98

99 Participant Guide Page 99

100 Participant Guide Page 100

101 Participant Guide Page 101

102 Participant Guide Page 102

103 Participant Guide Page 103

104 Participant Guide Page 104

105 Participant Guide Page 105

106 Participant Guide Page 106

107 Participant Guide Page 107

108 Participant Guide Page 108

109 Participant Guide Page 109

110 Participant Guide Page 110

111 Participant Guide Page 111

112 Participant Guide Page 112

113 Participant Guide Page 113

114 Participant Guide Page 114

115 Participant Guide Page 115

116 Participant Guide Page 116

117 Participant Guide Page 117

118 Participant Guide Page 118

119 Participant Guide Page 119

120 Participant Guide Page 120

121 Participant Guide Page 121

122 Participant Guide Page 122

123 Participant Guide Page 123

124 Participant Guide Page 124

125 Participant Guide Page 125

126 Employment History Add income for Rick and Jenna with your participants. You will return to the same case in CBMS you have been working on. If you have done more practice in CBMS, you may use another case. Data entry can vary based on the scenario used. Go back to the Case Question page, and select Yes for does anybody have income, and then navigate to the Employment History page using the Left Navigation Panel. You can access Online Help by pressing F1 and read the information at the top of the page about Medical Assistance. Income Details The Income Details page is used to enter and review all earned and unearned income information into CBMS. These pages are looked at by all program areas and will meet certain eligibility requirements based on your data entry. The Income Details Page is composed of seven different page categories that will capture a household s financial circumstances. The best practice is to always enter all income information for all household members based off the verification provided. For guidance on data entry, consult F1. Income Summary The Income Summary page displays income records that have previously been entered for all household members. You can sort the order of information displayed on this page by clicking on the title of the column below. Participant Guide Page 126

127 1) Individual Name This column displays any household member that has an income record entered on them. a) If a household member is listed as no longer living in the home, their name and income record will be listed in red. 2) Income Category - This column displays the type of income an individual has associated with them and which radio button you may select to view their existing data entry. 3) Type/Employer This column displays the name or title of any income record that has been entered for the individual on the case. Information listed here is displayed as a hyperlink that can be clicked to take you to that income record directly. a) By Default, the most current income records that do not have an Effective End Date are listed at the top of the column. In addition, if all income records have an Effective End Date it will sort the records with the most current income on top. 4) Begin Date - This column will display the Effective Begin Date entered for the income record, this indicates to CBMS when the income began to be received. 5) End Date - This column will reflect the Effective End Date entered for an income record. This indicates to CBMS when these income records should no longer be used. Earned Income Summary The Earned Income page consists of four data groups that are used to enter all earned income information into CBMS. Examples of Earned income include but are not limited to: Wages, Salaries, Commissions, Self-Employment, Training Allowances, etc. This page is looked at by all program areas based on certain fields. The best practice is to always enter all income information based on the verification provided. For guidance on data entry, consult F1. 1) Name For this scenario, select the head of household s name from the drop down menu. If updating income on an existing case, your customer s name will be populated here based on which hyperlink you selected on the Income Summary page. Participant Guide Page 127

128 2) Add Employer (button) - For existing cases with earned income, you can select this button to add new employer information to this page. This button will require you to complete fields related to earned income. This button is enabled when there are existing income records on this page. 3) Add Earned/Self-Emp Details (button) For existing cases with earned income, you can select this page to add any new self-employment records to this page. This button will only require you to complete the fields related to self-employment. This button is enabled when there is existing income records on this page. 4) Summary This data group will display any earned income that has been entered previously on an individual. Any earned income records labeled in red text are records for an individual that is not part of the household. Earned Income Employment Details 1) Effective Begin Date - This field tells CBMS when information saved or updated on this page will be used for eligibility purposes and affect the case. This field needs to be populated with a specific date. For pending applications, this field defaults to the application date for an FA-only case. For this scenario, enter your application date. Participant Guide Page 128

129 a) The field will default to the Retroactive Medical Assistance date if an MA is attached to your case. b) Consult with Online Help (F1) if you are unsure of what EBD to enter in this field. Remember to look at the Field Information section to determine what date should be used when it comes to the mode your case is in. 2) Effective End Date Much like the Effective Begin Date, this field tells CBMS when information will no longer be used for eligibility purposes and stop affecting the case. This field needs to be populated with a specific date, consult with F1 if you are unsure of what date to populate here. For this scenario, leave this field blank. 3) Self-Employed - This required field will designate if the customer s income needs to be entered as earned income or self-employment income. For this scenario, select No. a) If this field is answered Yes, the Self Employment Details data group is added to this page. b) If this field is answered No, the Earned Income Details data group is added to this page. c) For Employment First, this field will determine if the customer is exempt from the program based on the amount of hours or income they are receiving from their self-employment. d) When entering self-employment information, both income and business expenses reported by the customer can be self-attested. However, the Source must be entered as Self-employment ledger in order for CBMS to accept the information without requiring additional information. 4) Employment Begin Date - This field tells CBMS the date the customer started working. This field determines if the actual amount of income or conversion of income needs to be applied. This field is not the same as the Effective Begin Date. For this scenario, enter the date for two months prior to your application date. a) If CBMS registers that employment began in the same month of application, it will count the actual income received for the month of application. b) If the date the employment began is unknown, the first day of the month of the oldest check received should be used. 5) Employer Name - The name of the employer or company is entered here. If self-employed, use the customer s name or company name. For this scenario, enter the company name on the check stub. a) This field should not be entered in ALL CAPS. When the CDLE interface updates this page it is done in ALL CAPS, and those records should be clearly differentiated. Best practice is to check every employer record every time. b) Some employers may have a Doing Business As (DBA) name that is different from the name of the company. For example: McDonald s may interface as ABC Holdings. Make sure to check the records thoroughly to ensure an accurate account of all employers and income. 6) Employment Type - This field is used by Employment First to determine the enhanced funding the program will receive. For this scenario, enter Permanent (Over 90 days). a) For other work programs, this field acts as an informational indicator of the customer s work type. Participant Guide Page 129

130 7) Telephone Number/ Address These fields are not required fields for Food Assistance. If available, the telephone number will be used on the Employment First funding report. As always, if the customer reports this information, the data entry should mirror what has been reported on the application. For this scenario, leave these fields blank. Earned Income Employment Details (Continued) 1) Monthly Amount Earned - This field is used by Employment First to determine the enhanced funding the program will receive. When entering information into this field, use the Name of new Income Frequencies in CBMS Desk Aid to determine the monthly amount earned based on the frequency with which the customer is paid. a) Enter the converted amount, not the amount that is reported on the application. 2) Estimated Average Hrs/Week - This field is used by Employment First to determine the enhanced funding the program will receive. 3) Occupation This field is used by Medical Assistance programs. It is informational and will not impact eligibility for Food Assistance. Participant Guide Page 130

131 4) Employment End Date This field tells CBMS the date the customer stopped working. This field determines if the actual amount of income or converted amount needs to be applied. This field is not the same as the Effective End Date. For this scenario, leave this field blank. 5) Termination Reason This field is only enabled when you enter an Employment End Date. This field will capture the reason income was terminated. For Food Assistance, this can assist you in capturing voluntary quit information. For this scenario, this field is blank. 6) Verification This field will only be enabled when you enter a Termination Reason. This field tells CBMS if you received any verification of the customer s terminated income. For this scenario, this field is blank. 7) Source This field is only enabled when you enter the Verification field. This field tells CBMS how you verified the customer s terminated employment. For CDHS programs, Client Statement will trigger a Verification Check List. For this scenario, this field is blank. 8) Date Reported This is the date the customer reported the information on the application, CRF, RRR or during the interview. For this scenario, enter your application date. 9) Date Verified This field is enabled when you complete the Employment Termination data group. This field reflects the date the customer verified the information on this page. This date is not always the same as the date reported. For this scenario, this field is blank. 10) Address Information - All of the fields within this section are informational only and are not used by any HLPG for determination of eligibility. However, if the customer reports this information, the data entry should mirror what has been reported on the application. Earned Income Earned Income Details 1) Effective Begin Date This date will tell CBMS when this income should be for eligibility purposes or when it will affect a case. For this scenario, consult with F1. 2) Effective End Date This field will tell CBMS when information on this page should no longer be used for eligibility purposes. For this scenario, leave this field blank. a) If a customer reports a change in pay frequency or termination of their employment, consult with F1 for the appropriate date to enter here. b) If an Effective End Date is entered on the Earned Income Details data group, an Effective End Date should also be entered on the Employment Details data group. Participant Guide Page 131

132 3) Income Type This drop-down menu will identify what type of earned income a customer has. For this scenario, select Wages, Salaries and Tips. a) This drop down menu only has two options available. Wages, Salaries and Tips and Other b) The question mark icon next to this field provides guidance on which income types re now categories as Wages, Salaries and Tips. c) If you select Other the Earned Income Types child page will appear. This page is used to capture different types of Training Allowances, Americops/Title V/Volunteer, and Migrant Farm worker Income. 4) Frequency This drop-down menu will specify how often the customer is paid. Select the appropriate option based off the verification provided. 5) Date Reported Enter the date the customer reported this information to the office. 6) MA Specific Income Information (data group) - These fields are not used by Food Assistance, and will be collapsed on cases without MA. For this scenario, leave these fields blank. a) HCA Recipient (field cluster) These fields are not used by Food Assistance, leave them blank. These fields are utilized by Medical Assistance programs when determining if Home Care Allowance payments need to be exempted if the individual receiving the HCA payment resides in the same home as the HCA customer. Further training was provided during the March 2016 SDC Build Webinar. b) Commission-Based Income/Seasonal Income: These fields are not used by Food Assistance, leave them blank. These fields are used by Medical Assistance programs in order to indicate that a customer s income needs to calculate using annualized frequencies. Earned Income Paycheck Summary 1) Date Received - The date the income was received (e.g. pay date) 2) Total # of Hours Worked - The number hours worked during the pay period. Employment first will use this field to determine if a customer is exempt from participating with the program. Participant Guide Page 132

133 3) Gross Amount - This is the amount received before taxes or deductions are withdrawn. For this scenario, enter the amount listed on the check received. 4) Paycheck Type This field will identify the type of income a customer has received. This field will default to Representative. CDHS programs use this field to indicate if a customer s income needs to be used or excluded when prospectively budgeting a customer s income. For this scenario, leave the default option in place. a) Income is viewed as the following two types: i) Representative the regular anticipated amount of income that the customer expects to receive ii) Not Representative irregular income and not the amount that is regularly received (e.g. overtime, worked fewer hours due to illness, vacation, etc.) 5) Verification/Source a) Use the applicable information from the drop-down menus 6) Date Reported/Date Verified- For this scenario, enter the application date for both fields. a) Date Reported is enabled and used to record the date that a change was reported or became known to the agency. b) Date Verified is the date the reported information was verified Earned Income Paycheck Summary (Continued) 1) Housing Allowance for Minister/Income from AI/AN - These fields are used by Medical Assistance Programs when considering the treatment of income and housing subsidy received either by Ministers or individuals who are American Indian/Alaskan Native. 2) FA Use Month/CW Use Month These fields will automatically populate when the page is saved. a) The FA Use Month is used by Food Assistance to determine in which month the system will use the information on this page for FA eligibility. CBMS uses this field to apply the noticing requirements for households. b) The CW Use Month is used by Colorado Works to determine noticing requirements for households. c) The FA Use Month is determined by the Date Reported and Date Verified fields on this page. Participant Guide Page 133

134 Button Information: Employment History 1) Employment Info - Open Online Help (F1) to understand why the Employment Info page is not necessary for this application. 2) Voluntary Striker - If a customer applies for Food Assistance and indicates that they are a striker, speak with your lead worker, supervisor, or FA policy to determine how to data enter the information in this page 3) Transfer of Income If a customer reports income being received by a non-household member, this button will open the Transfer of Income child page which reduces the amount of income being received by a non-household member. 4) Income Expenses This page is used to capture any expenses incurred on any earned income received by an individual. 5) Tax Credit Annual Income This page is used by Medical Assistance Programs when determining annualized income. Fill in the blanks and write a reminder explaining the purpose of each highlighted section: Earned Income Notes: Frequency and Income Conversion *Reference the Income Frequencies in CBMS Desk Aid Select the correct answer: Frequency describes the following: a) How often an individual must apply for benefits b) How often an individual calls the call center c) Describes how often an individual is paid d) How many hours an individual works Participant Guide Page 134

135 Notes: CBMS: Wrap Up Wrap Up is the one of the most important tools available to ensure an accurate eligibility determination. Wrap Up review gives an opportunity to ensure that information that was data entered correctly and that eligibility has been accurately determined for each applicant. Med Span Process Participant Guide Page 135

136 1. Select the Search Medical Assistance Eligibility link from the Interfaces sub-category in the left navigation panel. 2. Enter the individual s State ID. 3. Click the Load button. 4. Click the Archived Spans button. 5. Highlight the med span for which you would like to see the detail and click the Detail button. Participant Guide Page 136

137 6. The Medical Spans Detail page displays. Adding a Needy Newborn or New Household Member If the mother is approved under ROP the baby will pass for MAGI child instead of NB. Once mother has complied with ROP and is approved for MAGI Pregnant the baby will switch to NB. Notes: Presumptive Eligibility (PE) Objectives: After this course, participants will: Identify members who are potentially eligible for the PE program Identify the program rules and eligibility requirements for PE List the process and required data entry steps to add PE The Need to Know Notes: Participant Guide Page 137

138 Participant Guide Page 138

139 Benefits: Medicaid & CHP+ PE: Pregnant Women Outpatient Services Prenatal Care Medicaid PE: Children Regular Medicaid Benefits, including: Doctor visits Hospitalization Mental health services Prescriptions Dental services CHP+ PE: Children Doctor visits Hospitalization Mental health services Glasses and hearing aids Prescriptions Inpatient (hospital) care, labor and delivery are NOT covered for pregnant women under PE. It is a covered benefit under regular Medicaid. Dental services are NOT Covered under CHP+ PE. Participant Guide Page 139

140 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Early Periodic Screening Diagnostic Treatment Assessing and identifying problems early Checking children's health at periodic, age-appropriate intervals Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems Performing diagnostic tests to follow up when a risk is identified Providing treatment to control, correct or reduce health problems found Notes: Participant Guide Page 140

141 Child Welfare Individuals who are involved with Child Welfare are entered into a system called Trails. The member will receive Medicaid and will not appear in CBMS Communication between Child Welfare and Eligibility Workers is important because of the two different systems. Having good communication will avoid duplication of effort to families and workers Notes: Former Foster Care Former Foster Care (FFC) is a Category of Medical Assistance that provides individuals who are in certain categories of Foster Care (FC) in Colorado continued Medical benefits until the last day of the month of their 26th birthday. The Former Foster Care file will now be available to CBMS weekly instead of monthly. This will ensure that youth do not have service gaps if their service date ends mid-month in trails. Participant Guide Page 141

142 When the member is actively receiving Medical Assistance in TRAILS, Special Indicators (Case and Individual) will be updated in CBMS to indicate that the member was a Former Foster Care member. The Special Indicator will show FFC. Existing Medical Assistance cases from TRAILS will interface automatically into CBMS weekly upon completion of the Service End Date in TRAILS. When a new application is created in CBMS the Application Type on the Applicant Information page will be FC Notes: Accountable Care Collaborative (ACC) ACC is a Medicaid program to improve members health and reduce costs ACC is not a managed care program. ACC members may see anyone who accepts Medicaid ACC will appear on the eligibility print out from Medicaid Notes: Action Idea List Write down any important ideas or thoughts about the concepts covered today. This list can be used for future reference, reflection or to capture any action items or topics that you would like to take back to your work place. Participant Guide Page 142

143 Ideas or Thoughts: Reflections: Action Items: Participant Guide Page 143

144 Breast and Cervical Cancer Program (BCCP) Objectives: Identify members who are potentially eligible for the BCCP program Identify the program rules and eligibility requirements for BCCP Describe BCCP processing The Basics The diagnosis must be made only at Women s Wellness Connection location and not at/by the member s doctor or clinic. BCCP is a category of Medical Assistance for women who are diagnosed with breast or cervical cancer (or a precancerous condition) at a Women s Wellness Connection (WWC) screening clinic BCCP is coordinated between the Department of Health Care Policy and Financing (HCPF) and the Department of Public Health and Environment (CDPHE) To be eligible for BCCP, a woman must: Complete a Medical Assistance application Meet Medical Assistance citizenship and identity criteria Be a Colorado resident Have income under the WWC s limit of 250% FPL Age for diagnosis values of Cervical Cancer Age for diagnosis values of Cervical Cancer and Breast & Cervical Cancer Age will be established for diagnosis value of Breast Cancer Be screened and diagnosed at a WWC site A woman must not: Have other insurance that would cover her diagnosis and treatment Be currently enrolled in Medical Assistance or Medicare BCCP members will receive full Medicaid benefits For more information on WWC sites, go to For more information on CDPHE, go to Goal or Notes Participants will understand the BCCP program s benefits, requirements, and determination process. Notes: Participant Guide Page 144

145 The Process Woman applies for BCCP at a WWC site PE Form MA Application If eligible, WWC contacts State Service Desk to process and approve PE WWC communicates with county MA Application sent to county Eligibility Site must process application for BCCP 30 days from receipt County redetermines eligibility annually When determined no longer eligible, proper noticing required Participant Guide Page 145

146 IRS 1095-B Health Coverage Form The IRS 1095-B is a federal tax form HCPF is required to send to members showing the months they had qualifying health coverage also known as minimal essential coverage (MEC) during the previous year. Medicaid and Child Health Plan Plus (CHP+) are two types of MEC. IRS Form 1095-B is a requirement per the Affordable Care Act. The individual listed as the head of household for the Medicaid or CHP+ case will receive a cover letter explaining what the IRS Form 1095-B is and where they can go for more information about the form. Note For general questions about 1095-B start by referring the member to the Colorado Health Visit m1095b/ Each form includes months of coverage for the member. The IRS follows the one day rule. This means that if a member has coverage for one day in a month, it is the same as if they had coverage every day that month. That month is marked on the 1095-B form. Participant Guide Page 146

147 Members Who Won t Receive a 1095-B from HCPF Presumptive Eligibility (PE) Members who qualified for temporary medical coverage through PE, but who do not qualify for Medicaid or CHP+ Colorado Indigent Care Program (CICP)- CICP is not Medicaid Emergency Medicaid Services Old Age Pension-Health Care Program (OAP-HCP) MSP QMB SLMB QI-I QDWI LIS CBMS Updates CBMS has been updated to include a new page and a new column in the Client Correspondence folder 1095-B Health Coverage page The form shows the members of the Medical Assistance case, Tax Year and the months of coverage for each member. A worker can reprint the form from this page and hand it or mail it to the Member. Search/View Client Correspondence in the Print Queue and the Search/View Printed Client Correspondence.. A new column has been added Name Year. Since a search in these pages will display the correspondence by Case # there can be many results. This column will allow an eligibility worker to easily identify forms for specific members because the column will display the member s first and last name and tax year. Participant Guide Page 147