Expanding Foundation: 7800 E Orchard Road, Suite 280 Greenwood Village, CO EF Non- MAGI Participant Guide

Transcription

1 Expanding Foundation: Non-MAGI Participant Guide 7800 E Orchard Road, Suite 280 Greenwood Village, CO EF: Non- EF Non- MAGI Participant Guide Version: 8.0

2 Acknowledgements The Health Care and Economic Security Staff Development (SDC) would like to acknowledge all the individuals and agencies that provided assistance during the Expanding Foundations development process. First, the SDC would like to extend its gratitude to Colorado s Departments of Human/Social Services for their support throughout the development of Expanding Foundations. Numerous county departments have hosted the SDC for site visits, shared training content, reviewed training material, and attended meetings in the support of training development. The SDC would also like to thank staff from the Colorado Department of Human Services (CDHS), the Colorado Department of Health Care Policy and Financing (HCPF), and the Governor s Office of Information Technology (OIT). Their willingness to share their program and systems knowledge with the SDC has been invaluable. To everyone who helped us bring Expanding Foundations to fruition, thank you so much! Introduction The Health Care and Economic Security Staff Development Center (SDC) presents this guide as a framework for the precision delivery of Expanding Foundations curriculum. Expanding Foundations represents the second phase of 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 for Food and Medical Assistance. In the spirit of the SDC s vision, which is to provide an efficient, non-duplicative, and responsive training array for staff that promotes an integrated and holistic service delivery system, we are offering this guide to standardize and formalize across Colorado the way county staff are trained. Standardization of Expanding Foundations and precision delivery of the curriculum will assure that all staff receives and attains the same high standard of competency through training. Common Terms and Phrases There are terms and phrases found throughout this Guide that have other common names associated with them. These terms and phrases are used based on accuracy, appropriateness, and general understanding to provide consistency. They are listed below with other associated common names. Cash Assistance: Colorado Works (CW) and Adult Financial (AF) Client: applicant, customer, recipient, household Colorado Works: Temporary Assistance for Needy Families (TANF) 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) 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 Version: 8.0 Page 2 of 101

3 Table of Contents Welcome... 8 Course Modules... 8 Group Expectations/Housekeeping... 8 Introductions... 8 Non-MAGI Overview... 9 Objectives:... 9 MAGI vs. Non-MAGI SSI vs. SSDI Non-MAGI programs Benefit Categories MA Assistance Hierarchy Review Non-MAGI Overview Re-Visit Objectives: Types of Resources and Data Entry Objectives: Estate Recovery Liquid Assets Good Faith Timely Dis-enrollments Ownership Encumbrances Vehicles Excess vehicles Intent to Sell Real Property Primary home M Secondary Property Mineral Rights Income Producing Property J2, Data Entry Version: 8.0 Page 3 of 101

4 Burials Life Insurance Policies Eligibility rules Data Entry Adult Financial Vs. Medicaid Countable Cash Surrender Value Practice Time! Types of Resources and Data Entry Re-Visit Objectives: SSI Related Programs Objectives: Program List Commonalities Benefit Category Countable Resource limits Income limits Income Disregards Coverage begins Processing guidelines Household Living in the home Marital Status Program eligibility SSI Mandatory Let s enter a case! Data Entry Unearned Income OAP Pickle Example: Data Entry Disabled Adult Child (DAC) Version: 8.0 Page 4 of 101

5 Example Eligibility Data Entry Qualified Disabled Widow(er) QDW Example Eligibility Data Entry SSI Related Programs Objectives: Buy-In Programs Objectives: Disability Benefit Category WAwD Household Requirements Age Disabled Income and resources Disregards Resources Coverage Begins Premiums CBwD Requirements Unique Rules CBMS Buy-In Programs Re-Visit Objectives: Disability Overview Objectives: Disability Definition Version: 8.0 Page 5 of 101

6 Meeting Disability Requirement SSA Determinations Title XVI SSI Details Title II Social Security Title II benefits could be either disability or retirement. To make the determination look for the disability onset date State Contractor Determinations Disability Application: Comments Page Medical Releases ARG Contact CBMS will mail the application for you! Pending for Disability Determination Pending for Disability Determination Full vs Limited Disability Full Disability Determination Limited Disability Determination Rationale and Data Entry Info Data Entry Practice ARG Approval Data Entry Practice Disability Wrap-Up Re-Visit Objectives Case Data Entry Medicare Based Programs Objectives: Medicare Savings Programs Program list QMB SLMB and QI QDWI Version: 8.0 Page 6 of 101

7 Income and Resource Limits MSP Income Deeming LIS Income Limit Resource limit Medicare Data Entry Other Notes Case Data Entry Medicare Based Programs Re-Visit Objectives: Version: 8.0 Page 7 of 101

8 Welcome Course Modules Group Expectations/Housekeeping Notes: Introductions Notes: Version: 8.0 Page 8 of 101

9 Non-MAGI Overview Objectives: After this module, Participants will be able to: Goal: To gain further understanding of Medical Assistance programs, Social Security programs and how they relate. Identify eligibility differences between MAGI and Non-MAGI. Associate SSI, SSDI and SSA with Medicaid or Medicare appropriately Recognize how CBMS applies the hierarchy for eligibility determinations for MA programs. Version: 8.0 Page 9 of 101

10 MAGI vs. Non-MAGI Non-MAGI programs exist to extend Medicaid coverage to individuals who are Aged, Blind and/or Disabled. While Citizenship, Identity, and Residency procedures still apply, all other criteria vary by program. Specific criteria will be addressed throughout the course, but it is important to note the population group, household composition, and the introduction of resource limits require actions above and beyond that of MAGI case processing. MAGI Non-MAGI Household Tax Filing Status Marital Status and in the home Financial Income Income and Resources Target Population Age 0-64 Aged (65+), Blind or Disabled Version: 8.0 Page 10 of 101

11 SSI vs. SSDI Being that aged and/or disabled is the primary criteria for Non-MAGI, most Non-MAGI Medicaid members will may qualify for an SSA (Social Security Administration) benefit. This may be SSI (Supplemental Security Income), SSDI (Social Security Disability Insurance), or SSA retirement. Non-MAGI Medicaid program rules build off the benefit(s) associated with SSA. SSI SSDI/SSA Work History Not enough work quarters or expired coverage. Typically at least 40 work quarters. Financial Income and Resource limits No Income and Resource Limit Medical Coverage Medicaid Medicare Cash Benefit Max benefit $750 in 2018 Benefit based on work history Population 65+ or Disabled Disabled or Retired (62+) Some Widows and Survivors Version: 8.0 Page 11 of 101

12 Non-MAGI programs SSI eligibility Disabled Adult Child (DAC) Qualified Disabled Widow(er) (QDW) Pickle Medicare (SSDI or SSA) eligibility Qualified Medicare Beneficiary (QMB) Special Low-income Medicare Beneficiary (SLMB) Qualified Individual-1 (QI-1) Qualified Disabled Working Individual (QDWI) Low Income Subsidy (LIS) Qualification Based on: Any Disability Determination Working Adults with Disabilities (WAwD) Childrens Buy-in with Disabilities (CBwD) Age Old Age Pension A and B (OAP-A OAP-B) Old Age Pension Health Care Plan A and B (OAP-HCP-A OAP-HCP-B) ***The application question: Does this person Need Help with Self-Care Activities is intended to filter Long Term Care cases. Applications marked yes should be re-directed to a Long- Term Care worker. Version: 8.0 Page 12 of 101

13 Benefit Categories Medical Assistance categories vary in total coverage or cost to the member. Category 02 is the basic State plan Medicaid. The higher the program is on the chart, the more beneficial the program is to the member. 01 LTC programs include additional services, 03 has a premium, 04 has less coverages etc. CBMS will attempt to place the member in the highest benefit category at each eligibility determination. 01 NF/300% hospital HCBS programs, PACE SSI Mandatory, FFC, Pickle, DAC, QDW, OAP Med-A, OAP Med-B, OAP-A Med>65, Trans Med, 4-month Extended, Refugee, BCCP MAGI Pregnant, Legal Immigrant Newborn, Psych <21, Eligible Needy Newborn, MAGI Child, MAGI Parent/Caretaker, MAGI Adult WAwD CBwD QMB Benefit decreases with each benefit category downgrade 05 SLIMB, QI-1, QDWI 06 OAP HCP-A, OAP HCP-B 07 LIS 08 CHP+ Children, CHP+ Newborn, CHP+ Prenatal CHP+ is separate Version: 8.0 Page 13 of 101

14 MA Assistance Hierarchy The MA assistance hierarchy shows the order that CBMS will an eligibility approval in CBMS. Version: 8.0 Page 14 of 101

15 A case that has been approved for #40 SLMB, has already been denied for programs CBMS uses this order to ensure the highest benefit category the member is eligible for. Review Which category is the last program listed on the hierarchy and what are the benefits associated with this category? Answer: LIS Medicare Part D premium + co-pays and deductible Which two main SSA programs come with Medicare? Answer: SSDI and Retirement are Medicare. Remember that customer who are 65 and receiving SSA retirement will receive Medicare on their 65th birthday. Customers who are receiving SSDI may have to wait two years before being eligible. Which SSA program comes with Medicaid? Answer: SSI Is Medicaid What are three eligibility differences between MAGI and Non-MAGI programs. A. Resource limits, Aged, blind/disabled, income limits, no MBU for Non-MAGI Version: 8.0 Page 15 of 101

16 Non-MAGI Overview Re-Visit Objectives: Can You? Goal: To gain further understanding of Medical Assistance programs, Social Security programs and how they relate. Identify eligibility differences between MAGI and Non-MAGI. Associate SSI, SSDI and SSA with Medicaid or Medicare appropriately. Recognize what approval for a MA program means in regard to other MA programs. Version: 8.0 Page 16 of 101

17 Types of Resources and Data Entry Objectives: After the module participants will be able to: Data enter different types of resources. Identify exempt resources. List references to aid in data entry. Goal: To understand resource eligibility rules and processes Version: 8.0 Page 17 of 101

18 Estate Recovery Medicaid Estate Recovery became a federal requirement for states as part of the Omnibus Budget Reconciliation Act of The goal of the program is to help cover the cost of providing services to Medicaid beneficiaries from the estates of medical assistance recipients. Medicaid.Recovery@state.co.us is the unit . The Department may recover payments made for all medical assistance paid on behalf of an individual who was institutionalized at the time he/she received medical assistance; OR, For persons age 55 at the time they received medical assistance, the Department may recover medical assistance provided for nursing facility care, home and community-based services, and related hospital and prescription drug services. 10 C.C.R , Section Estate recovery applies to clients regardless of their category of eligibility and may apply to MAGI clients under the circumstances noted above. Version: 8.0 Page 18 of 101

19 Bank accounts, retirement accounts etc. are rather straight forward and, in most cases, can be verified through AVP. We are not going to go into specific details on AVP today but there is a web-based training on CoLearn that you are urged to take to learn about this process. For our training and data entry we will demonstrate how to manually enter resources. Items held for investment may not be as clear. Personal property is exempt, so workers may need to establish intent. An antique passed down as a family heirloom would be personal property and exempt if one intends to keep it as a family heirloom. If someone intends to sell that item one day, it would be an item held for investment and countable. Any personal property that has been declared by the customer should be entered in CBMS as other personal property on the liquid assets page. Liquid Assets Cash, bank accounts, retirement accounts, investments accounts, etc. are countable. Note on bank accounts: Entering the last 4 digits of the account number and the name of the bank is recommended so that the resource can be easily identified Important for the name of the resource to be the bank name. Version: 8.0 Page 19 of 101

20 FYI - The Achieving Better Life Experience (ABLE) Act has created a tax free saving account for members with disabilities. One of the resource types will be ABLE Account. This asset is exempt for all Medical Assistance programs. The Source and the verification must read ABLE Account. An original verification must be received by the Eligibility Site. Good Faith When creating a verification checklist, customers will receive 1 calendar day+10 business day+5 calendar days to provide the information. In some instances, they may be given a Good Faith Extension to provide the documentation if they are not able to obtain the verification within that timeframe. This is typically for Citizenship but can be for resources etc. as well. Once you run EDBC and the VCL is generated, the Good Faith Screen will be enabled at the bottom half of the wrap up screen. You must now enter an EED no longer than six months. Discuss with class that you do not have to always give 6 months, have a conversation with the client and determine how long they think it may take to get the information. If the verification is not provided by the EED, batch will run and discontinue/deny the case. There is a report that was created to manage these cases and can be found in Cognos. It is they MA Good Faith Report Timely Dis-enrollments When a customer provides verification or a change, County users/ma sites will have 15 calendar days to process the change and re-determine eligibility based on the information provided. There are also two reports that have been created to monitor this within Cognos. They are the MA Dis-enrollment Processing Times Report and the MA Timely Dis-enrollment report Version: 8.0 Page 20 of 101

21 Ownership Example: If a customer co-owns a bank account with his daughter and the total available in the account is $15,000 CBMS will calculate that the customer owns 100% of this resource instead of 50%. The total $15,000 will be attributed to the customer instead of $7,500 potentially putting the customer over the resource limit Version: 8.0 Page 21 of 101

22 Encumbrances Used for loans and liabilities against an asset. The encumbrance entry should be case commented and reviewed/updated at each RRR. This isn t a regularly used field and may be skipped over by future workers when updating. Version: 8.0 Page 22 of 101

23 Vehicles One vehicle (regardless of the value) is exempt if it used for the transportation of the individual or household member ( M2c). CBMS will automatically exempt the vehicle with the greater value. All other vehicles will be a countable resource. Version: 8.0 Page 23 of 101

24 Excess vehicles Fair market value is obtained by requesting NADA/KBB etc. If the customer has a loan against any of the vehicles you would enter this into the encumbrances field (as we reviewed a few moments ago) Version: 8.0 Page 24 of 101

25 Intent to Sell M2b Excess properties (vehicles, homes, land etc.) may be exempted if there is an ongoing reasonable effort to sell. Reasonable effort means: Listed at current market value Reasonable offers must be accepted Reasonable offers are defined as at least two-thirds of the current market value Verification of reasonable efforts are required every 3 months until the property sells. At that time those funds are countable, and the client is ineligible until they are below the resource limit. Version: 8.0 Page 25 of 101

26 Real Property Equity (Value total amount owed on loans) is countable. Formal appraisals, E-appraisals can be used as a guideline. Verify loans against the property for encumbrances. Conditional exemptions for intent to sell can be applied: Primary home Is exempt so long as: Or The home is in Colorado and, Equity is $572,000 or less (2018) and, M2 The individual lives in the home or is institutionalized but intends to return to the home. A spouse or dependent relative lives in the home. -No limit on equity Estate Recovery *The home will eventually be subject to Estate Recovery. In the meantime, it provides potential for an alternative to institutionalization Secondary Property Equity is countable. Check for loans as well as fair market value Intent to sell can be applied. Use appraisals as guideline. For eappraisals check multiple sites due to volatility and use best judgement. Applicant can dispute with a 3 rd party appraisal. Version: 8.0 Page 26 of 101

27 Mineral Rights Mineral Rights are the ownership interest in natural resources that can be extracted from the ground (i.e. oil, natural gas, coal, precious metals, gemstones etc.). These rights are generally leased to an extraction company for a percentage of the profits. The value of the Mineral rights are a countable resource. If the applicant owns the land, the value is generally included in the assessed land value If the applicant does not own the land an estimate of the value can be obtained by a reputable and knowledgeable source (extraction company, Bureau of Land Management, US Geological survey) This may be low or even $0 if the land has not been prospected Income from mineral rights are countable as income If income producing, the value may be exemptible as a resource Evaluate under J2,3 Example: I own the oil under the land, but not the land. The oil or mineral rights would be entered into CBMS and would be included as part of the countable resource limit. Income Producing Property Exempt up to $6000 of value for: J2,3 Non-business producing income, goods or services essential to self-support Business property as long as it produces a 6% return (per year) on the excluded value Can apply to any property Mineral Rights, Land, rental property, vehicles etc. Income is countable Income Version: 8.0 Page 27 of 101

28 Data Entry Version: 8.0 Page 28 of 101

29 Burials Pre-paying burial/cremation expenses ensures Medicaid will not need to pick up the cost and therefore are looked upon favorably. Burial plots and irrevocable policies are exempt as are revocable policies with a face value up to $1500 (per person). HCPF must be the remainder beneficiary on all pre-paid policies. Funeral homes should be sending excess funds to: HCPF- Recoveries 1570 Grant St. Denver, CO Medicaid.Recovery@state.co.us Version: 8.0 Page 29 of 101

30 Life Insurance Policies Treatment of life insurance policies varies by the type of policy. Terms you will need to know: Face Value: The amount of the death benefit Cash Value: The amount of the investment component of a policy. Cash Surrender Value: The amount of money that a beneficiary would receive to terminate or cash out their policy. This amount may increase as a client gets older to mitigate risk from the life insurance company. The amount also decreases if clients borrow from the cash value of the policy. Term Life: These policies have a face value (benefit) that only pays out upon death. The client pays a monthly premium to provide coverage, the premium price is usually based upon age. Whole Life: May be called Universal life or Variable life depending on the exact details. These policies contain an investment component. Part of the monthly premium is contributed towards the investment component and earns a return. The policy will contain a face, cash and cash surrender value. Eligibility rules If the total face value of all policies is $1500 or less (per person), then all policies are exempt. If the total combined face value is over $1500 (per person) then all policies are countable using the cash surrender value. Term life insurance policies have no cash surrender value so will ultimately not count against the resource limit in any event. If total face value of all policies are over $1500, all are countable. If total face value of all policies are under $1500 all are not countable. Version: 8.0 Page 30 of 101

31 Data Entry The cash surrender value is the countable value on a life insurance policy. It is important to review the policy carefully. The owner, the insured and the beneficiary are very different things. The owner is the person who is paying the premiums and owns the policy. The insured is the person who is covered by the policy and the beneficiary is the person who will receive a payout when the customer passes away. The owner and the insured are most often the same person. Ensure that the radio button is the insured person different form the owner is selected with yes or no. Your customer may own the policy but is not the insured and if there is a cash surrender value this could potentially count toward the resource limit. The cash surrender value is the countable value on a life insurance policy. Version: 8.0 Page 31 of 101

32 Adult Financial Vs. Medicaid Adult Financial and Medicaid have different rules for counting Life insurance policies. This sometimes leads to situations in which an individual meets the AF resource limit but is over the Medicaid Resource limit (even when it is the same limit!) Countable for Both Face Value over $100,000 and Purchased within 48 months Counts for Medicaid only Face Value greater than $1500 but less than $100,000 Or >$100,000 and purchased more than 48 months ago Exempt for both Total Face Value $1500 or less Version: 8.0 Page 32 of 101

33 Countable Cash Surrender Value The Cash Surrender Value is always the countable value. It is possible an individual has a life insurance that has a CSV that puts them over the Medicaid limit, but is exempt for AF. Consider a policy with e $30,000 face value and $5,000 Cash Surrender Value: Face Value $30,000 is exempt for AF. AF -OAP can be approved Face Value makes the CSV countable. $5000 is over the OAP Medicaid Resource limit This will approve the AF-OAP but deny the OAP-Medicaid. This is one of the primary reasons a case will end up on HCP. OAP-HCP Version: 8.0 Page 33 of 101

34 Practice Time! Example: Client provides the below Checking Account Verification. Version: 8.0 Page 34 of 101

35 Version: 8.0 Page 35 of 101

36 Example: Client states ownership of a 2012 Chevy Malibu LT. NADA or KBB is used and printout is below. Customer owes $2,000 Version: 8.0 Page 36 of 101

37 Version: 8.0 Page 37 of 101

38 Example: Client has a Primary Home. Client still owes $200k Version: 8.0 Page 38 of 101

39 Version: 8.0 Page 39 of 101

40 Version: 8.0 Page 40 of 101

41 Example: Client provides you a Burial Policy. 030 Version: 8.0 Page 41 of 101

42 Version: 8.0 Page 42 of 101

43 Example: Client provides verification of a Term Life Insurance Policy Version: 8.0 Page 43 of 101

44 Version: 8.0 Page 44 of 101

45 Example: Client provides verification of a Whole Life Insurance Policy. Version: 8.0 Page 45 of 101

46 Version: 8.0 Page 46 of 101

47 CBMS will request a spouse s income and resources for some of the Non-MAGI categories. If the spouse s income and/or resources are not received the case will deny. Members will be given 1 calendar day + 10 business days + 5 business days to provide verifications. Keep in mind the notice will not show the extra 5 days, this is behind the scenes. Types of Resources and Data Entry Re-Visit Objectives: Goal: To understand resource eligibility rules and processes Can you? Data enter diverse types of resources. Identify exempt resources. List references to aid in data entry. Version: 8.0 Page 47 of 101

48 SSI Related Programs Goal: To understand a group of Non-MAGI programs, and their eligibility rules. Objectives: After this module, Participants will be able to: Identify program resource limits Identify Household requirements and data entry for SSI related Non-MAGI programs Data Enter an SSI mandatory case Version: 8.0 Page 48 of 101

49 Program List SSI Mandatory OAP Pickle DAC QDW Commonalities Benefit Category 2 State-Plan Medicaid Countable Resource limits $2000 for an individual $3000 for a couple (consistent with SSI) Income limits $750 for an individual $1125 for a couple ***OAP exception $771 for individual (no couple limit) Income Disregards $20 off unearned income $65 + ½ of remaining earned income. Coverage begins 1st of the month of application, 90-day retro can be applied. **OAP is the exception as it begins the day OAP AF begins (day of application). Processing guidelines 45 days, 90 if disability determination is needed. Version: 8.0 Page 49 of 101

50 Household A household consists of an applicant and spouse if they are living in the home and married. Living in the home This is a required field asking if each individual is residing in the head of household s home Version: 8.0 Page 50 of 101

51 Marital Status CBMS determines if a couple is married based on 2 pieces of data entry. Marital information must be entered. Client statement is acceptable unless questionable. Married, Common Law, and Common Law Registered are considered Married. Domestic Partner and Civil Union are not. AND Version: 8.0 Page 51 of 101

52 Household relationships must be entered and consistent with the Individual Demographics data entry (husband/wife, husband/husband, wife/wife). Again, client statement is acceptable unless questionable. *Income and resources of spouse is only included if the spouse is living in the home. Program eligibility SSI Mandatory Individuals receiving SSI are automatically Medicaid eligible. They do not need to submit a separate application. The application date is the date they were first eligible for SSI. This could be years in the past! Many times, these individuals don t know to apply for the program or assume they already have coverage. The population is typically discovered when medical coverage is needed. Case eligibility is whether or not the individual is receiving SSI. Social Security Administration has already verified citizenship, identity, income, and resources. These individuals also receive financial RRRs through SSA. Because of this, no Medicaid application or RRR is needed. Eligibility will continue via the interface until the member is no longer eligible for an SSI benefit. Let s enter a case! You receive notification that an unmarried member has been receiving $300 in SSI benefits since January 14, 20XX. AI a case from xx/01/20xx This individual is born between 1955 and Make up a name and SSN. Assume we have an SSN card and Birth Cert SSI Income is verified through SDX Version: 8.0 Page 52 of 101

53 Data Entry Select the SSI button at the bottom of the Individual Demographics page This may interface, but if you are entering a new client, you will need to fill out the just a few fields. Guidance for entering SSI income. The individual must be in pay status, so entering income is required. This would typically come from the SDX interface but if it doesn t you will have to request the information from SDX/Bendex. Be sure to back date the income to the application date in this scenario. CBMS will determine SSI MA eligibility based on data that has been entered on the SSI details page and the unearned income page. Effective Begin Date: The date the SSI benefit was approved. Receiving: Yes, if they were/are receiving benefits for this time period. Verification: Received, SSA statement. Version: 8.0 Page 53 of 101

54 Unearned Income Because CBMS also looks for active Income, you will need to enter an income record back to the date of approval (even if the received a lump sum later). This will also apply to the Income Received Details page. Version: 8.0 Page 54 of 101

55 Run EDBC and take a look! Version: 8.0 Page 55 of 101

56 The case will run back to the 1 st month of SSI eligibility and approve. This is because receiving SSI is the only criteria. OAP Old Age Pension is primarily covered in Expanding Foundations Adult Financial. Whenever an individual is approved for AF OAP they will receive a Medical assistance benefit (Must be AI ed separately). This is likely OAP Medicaid or OAP HCP, but could be other categories. This is because HCP is a very low benefit category, only covering limited services. CBMS will place the member in the highest benefit medical assistance category they are eligible for. (Removed AF Flow chart) Coverage for OAP Medicaid and OAP-HCP will begin the same day the AF benefit begins. Pickle The Pickle amendment got its name from its congressional sponsor. It protects people who were eligible for both SSI and some other type of Social Security benefits and/or OAP but lost their benefit (and their SSI Medicaid) due to a Cost of Living Adjustment (COLA). The amendment states that those who would have been eligible for SSI/Medicaid if not for the COLA raises, don t have to include the COLA for Medicaid eligibility. As long as the original SSA payment amount, along with any other income and resources is within the income/resource limits for SSI, the person can continue to receive SSI for Medicaid purposes only. Example: You retired at age 65 in March 2007 and began collecting Social Security payments. You had very limited resources and almost no other income, so you were also eligible for SSI with Medicaid. In January 2009, there was a 5.8% COLA increase to your Social Security payment. This increase made your income too high for SSI eligibility, and consequently Medicaid. By using the Pickle Amendment, you can use your original Social Security payment amount (identified in March 2007) without any subsequent COLA increases, for your income. Provided your other income and resources do not disqualify you, you will be able to re-qualify for SSI for Medicaid purposes only. You can do this any time after you lost coverage in January SSA is no longer checking income and resource eligibility. This leaves us to verify the otherwise eligible portion for pickle people. These individuals: Cannot be SSI eligible Must: Be eligible for and receiving a Title II benefit Have countable income and assets below current SSI limits ($2000/$3000) Submit an application Version: 8.0 Page 56 of 101

57 These individuals also have annual RRRs. Because a resource check is required, you should not allow these cases to auto-reenroll! CBMS will collect information to verify that the member is over the income only because of COLAs. It tracks this by identifying the amount of the initial entitlement and year. It the initial entitlement was frozen; would they still be eligible? The initial entitlement is often called the frozen amount to represent this question. The Title 2 Frozen amount + Other income must be less than the SSI or OAP amount (after disregards). Title II Frozen Amount Other Income Applicable Disregards Equal or Less Than SSI or OAP Limit Version: 8.0 Page 57 of 101

58 Data Entry (The individual will not be receiving SSI) Use Med Spans to identify Pickle Details Collect Pickle Information: Yes, will open the other fields. 1. Was SSI or OAP Med lost? Check Med Spans or SVES to identify the date for new cases. 2. COLA or Initial 3. Was this Initial title II under their own SSN? Enter initial (frozen) amount. 4. Was this Initial Title II under another person s SSN? This would be a DAC or QDW amount. 5. Likely Yes Verification: Received Source: SSA Version: 8.0 Page 58 of 101

59 Disabled Adult Child (DAC) A DAC benefit is an SSA benefit for individuals who were became disabled prior to age 22. These individuals often had no opportunity to earn significant work quarters because of their disability. The DAC benefit allows them to draw based on their parent s benefit when their parent retires or becomes disabled. Because the individual may be well into adulthood when their parents retire, the sudden receipt of the DAC benefit may jeopardize their SSI Medicaid eligibility. Example Terra was diagnosed with a childhood disability and was found disabled by SSA at age 14 Terra was unable to work as a result but was ineligible to collect SSI due to her parent s income At age 18 Terra started receiving an SSI benefit and Medicaid. In 2018 Terra s parents retire, Terra qualifies for a DAC payment of $800 based on her parent s work history. SSA uses this income change to re-evaluate SSI eligibility. $800-$20 disregard= $780 which is over income for SSI. Terra loses SSI and SSI Mandatory Medicaid. The DAC Medicaid category exists to prevent this loss. Similar to Pickle, the individual would need to be otherwise eligible for SSI. This means checking resources ($2000/$3000), conducting RRRs (do not let them auto re-enroll), and ensuring that the DAC benefit is the only reason the individual is over the SSI income limit. Eligibility CBMS will check to see if this individual would have been eligible if they were not receiving the DAC benefit. Total Income DAC Benefit Applicable Disregards Equal or Less Than SSI Limit Version: 8.0 Page 59 of 101

60 Data Entry DAC benefits are an income type from SSA. This income may interface for existing cases. CBMS uses the income type and BIC number to identify potential DAC eligibility. If the income does not interface, you will have to request the information form SVES or Bendex and verify the correct BIC code or claim number as it will be different from the customer s SSN. Income Type: Social Security Disabled Adult Child Version: 8.0 Page 60 of 101

61 Qualified Disabled Widow(er) QDW Similar to the DAC benefit, the QDW Medicaid benefit seeks to maintain Medicaid eligibility to individuals whose SSA widow(er) benefit puts them over the SSI income limit. These individuals are disabled, widowed, and would be otherwise SSI eligible. Example Valerie is 52 years old, disabled and receives SSI. She is married to Rob. Rob passes away. The widow s benefit she receives from Rob totals $920/month She is no longer eligible for SSI due to being over income Valerie will be eligible for QDW if she meets all other MA requirements. QDW Medical assistance will extend the Medicaid benefit is Valerie would have been otherwise SSI eligible. CBMS checks for Medicare eligibility (disabled), the existence of a widow benefit, the SSI resource limit $2000/$3000, and that the Widow s benefit from SSA is the sole reason she is over the income limit. Again, an application and RRRs are required. The resource check means auto re-enroll should not be allowed. Eligibility CBMS will verify that the QDW benefit is the reason the individual is over the SSI limit. Total Income QDW Benefit Applicable Disregards Equal or Less Than SSI Limit Version: 8.0 Page 61 of 101

62 Data Entry Like DAC, this is an income type. CBMS will view the income type and BIC code to identify this population. Additionally, a Medicare benefit is needed. Income Type: Social Security Survivor Adult, this income should interface but if not, you will have to request from SVES/Bendex and pay attention to the BIC number Version: 8.0 Page 62 of 101

63 SSI Related Programs Goal: To understand a group of Non-MAGI programs, and their eligibility rules. Objectives: After this module, Participants will be able to: Identify program resource limits Identify Household requirements and data entry for SSI related Non-MAGI programs Data Enter an SSI mandatory case Version: 8.0 Page 63 of 101

64 Buy-In Programs Goal: To understand a group of Non-MAGI programs, and their eligibility rules. Objectives: After this module, Participants will be able to: Explain the coverage difference between Buy-in Programs and State plan Medicaid. Identify acceptable sources of disability determination for WAwD Disability Medicaid uses the Social Security Definition of Disability. This determination can only be made by Social Security Administration, or our current State Disability Contractor. Version: 8.0 Page 64 of 101

65 Benefit Category 3 State plan Medicaid with premium. Working Adults with Disabilities (WAwD) WAwD Working Adults with Disabilities is a program designed to allow people who are between 16 and 64, working and disabled to purchase Medicaid coverage. We will discuss the disability criteria in the next module Household Always the individual only. Requirements Age Between Disabled The individual must be disabled. This would be SSA and ARG determinations (individuals over 65 aren t eligible) Disability criteria will be discussed in the next module. Income and resources Must be employed, self-employed or job attached. No minimum hours or wages. Income limit is 450% FPL ($4553/mo.) after disregards. The income limit is extremely high and it is after all disregards have been applied. Disregards $20 unearned income disregard $65 + ½ (earned income) earned income disregard Resources No resource limits Version: 8.0 Page 65 of 101

66 Coverage Begins 1 st day of application month when all criteria have been met. 0-day retro can be applied. Premiums Premiums are on a sliding scale based on countable income CBwD Children s Buy-in with Disabilities. The program exists to extend MA coverage to children who are disabled, but their family makes too much money to qualify for another program. Like WAwD this category has a premium and requires a disability determination. Requirements Under the age of % FPL after disregards 33% of total income is disregarded An additional $90 earned income disregard No resource limits Unique Rules HH composition still uses MAGI rules Tax filer status Everything else is Non-MAGI rules Individuals who are between 16 and 18 and are working are not eligible for CBwD They should be on the WAwD Program Version: 8.0 Page 66 of 101

67 Again, this is after all disregards, but includes the household income. The household is defined the same way as MAGI programs. The disregards and FPL limit extend the coverage threshold to additional families, but only covers the child with a disability. CBMS CBMS will only consider eligibility if it knows the child is disabled. This typically requires manual data entry as the family income has made the child SSI ineligible. Version: 8.0 Page 67 of 101

68 Buy-In Programs Goal: To understand a group of Non-MAGI programs, and their eligibility rules. Re-Visit Objectives: Can you? Explain the coverage difference between Buy-in Programs and State plan Medicaid. Identify acceptable sources of disability determination for WAwD Version: 8.0 Page 68 of 101

69 Disability Overview Objectives: After this module, Participants will be able to: Perform data entry on the Disability Determination screen in CBMS Identify when the disability requirement is met, and when the disability app is necessary Gather, complete and submit a disability application to the State Contractor Disability Definition *****Note: This is supplemental (and non-required) information only. Disability determinations are not made by the eligibility worker! Goal: To gain further understanding of Medical Assistance programs, Social Security programs and how they relate. Medically Determinable Impairment, Must be more than not severe (causes limitations) Medically determinable as in meeting a diagnostic criterion Lasting 12 months or more, Can be expected to last 12 months or more Resulting in death or expected to result in death negates the 12 months requirement Adults Children Resulting in an Inability to perform substantial gainful activity Resulting in multiple markedly or at least one severely limited functional domain Assessed based on actual limitations Looks at all jobs in the country Work history is increasingly considered from age 50 to 64 On a scale of: not, mildly, moderately, markedly, severely (limited) Limitations compared to average child of the same age 6 broad domains used by SSA to describe childhood functioning Version: 8.0 Page 69 of 101

70 Meeting Disability Requirement Disability can be met in three ways Disability Age 65+ Social Security State Contractor 1) Being Aged 65 or older 2) Determined disabled by Social Security Administration (SSA) 3) Determined disabled by the state disability contractor (Arbor ARG) What do I do? Upon receipt of an application, you should check for age 65+ and existing SSA disability determinations (via SDX interface). If either of these are established no further action is required! If a determination is needed, you will request that the applicant complete a disability application packet, you will then send that application to the state contractor for disability determination. Notes: Version: 8.0 Page 70 of 101

71 SSA Determinations Title XVI All Title 16 (SSI) approvals will be either age 65+ or disabled. CBMS will read SSI income as meeting disability for LTC. The screen should still be pulled in the absence of a payment though: The window indicates that the client moved to Colorado on 10/01/2014 and applied for SSI benefits on 12/17/2014. On 02/18/2015 the disability office established that the applicant has been disabled since 06/23/2009. H80 indicates a final decision is pending other eligibility criteria. Using your code sheet you may find situations where disability is established, yet the client is financially ineligible for a payment (N01 for example). This is especially common with child cases. *If disability is established but payments have been suspended, check the reason for suspension of payments. They may still be considered disabled. **If the claim has an onset date but is later denied for a reason other than cessation of disability, you may still use the determination if you can verify that the diary date has not expired. *** Colorado Disability Determination Services phone number is A threeway phone call will allow you to verify the missing diary date. This number is much faster than calling SSA. Notes: Version: 8.0 Page 71 of 101

72 SSI Details Eligibility workers should check/complete the screen. This page typically interfaces! tab on the Individual Demographics The help document (F1) is up to date and provides a walkthrough. The SSI screen determines eligbility for SSI Mandatory and other adult med programs. Version: 8.0 Page 72 of 101

73 Title II Social Security Do not assume Title 2 benefits mean disability has been established. Title 2 could be disability (SSDI) or retirement (SSA)! For Medicaid, this creates a problem for year old. Up to age 62= only for disabled Age Early retirement or disability? Age 65+ Considered disabled for MA regardless The BENDEX screen can be used to clarify which benefit is being received. Title II benefits could be either disability or retirement. To make the determination look for the disability onset date. The problem with Title 2 is that it can be retirement or disability. If they are over 65 the individual meets disability criteria, if they are it could be disability or early retirement. Disability Onset Date in BENDEX identifies if this is Retirement or Disability. Again, CBMS is looking for SSDI pay status. A blank field is retirement, a populated field is disability. When approved for SSDI, applicants have their checks held for 5 months, receiving a lump sum in the 6 th month. An individual in the 5 months Version: 8.0 Page 73 of 101

74 wait period can have their Onset date honored though. It would require manual entry of disability determination only. You do not enter a SSDI payment. Vice Versa applies. An individual receiving SSI or SSDI payment does not need the Medical Conditions and Disability Determination screen entered. Notes: Version: 8.0 Page 74 of 101

75 State Contractor Determinations If the customer is not 65, is not receiving disability benefits from SSA or has no disability determination you will need a Medicaid Disability Application If a determination is needed from the state contractor, it could take up to 90 days to receive a determination. Any time you can request medical records from the customer to send with the Disability packet you will get a much quicker determination Disability Application: under Apply by mail This is a 15-page application PLUS medical release forms (same website different link). The claimant will need to complete in full. Statements are considered, and medical records will be requested from their providers. Version: 8.0 Page 75 of 101

76 Comments Page You will need to check for completion, medical release signatures and complete this page: Required info: 1. Your application date- Arbor can backdate the disability onset date to match your needs if medically supported. 2. Any known Earned income $ /mo. Sheltered/Subsidized? Yes/No 3. Medical records attached or No Medical Records provided Helpful info: Your observations about the conditions they listed in the app (if you saw them). Using a walker, cane, hard of hearing, could or could not read application, missing limbs, attention span, comprehension, cleanliness etc. These help those in need and can eliminate fraud later! (Did they walk, sit and stand unaided for you but bring a walker to the Doctors office?) Required, this is how you will be notified of the results! Notes: Version: 8.0 Page 76 of 101

77 Medical Releases The medical release forms are used to request medical records. Arbor now only requires 1 release and can make copies as needed. Please ensure you are using the 8/18/2014 dated medical release. Applicant s Signature Notes Version: 8.0 Page 77 of 101

78 ARG Contact Complete applications will be mailed or faxed to: Arbor E&T, Action Review Group P.O. Box 340 Olyphant, PA Other contacts, Status updates, delivery receipts, change of address etc. Phone (877) Fax (877) Notes: Version: 8.0 Page 78 of 101

79 Earlier we talked about the definition of disability. There is an MA category that ignores the work component. SSA will not view this case, because the person is working. ARG will categorize these individuals as limited disability. Medically these are the same, but limited disability ignores the work aspect of disability. Full disability determination can be used for any program that requires disability. Limited disability can additionally be used for the WAwD program. LTC waivers are covered in the LTC course, but it is worth noting that WAwD eligibility can receive 2 of the LTC waivers under the WAwD program, using WAwD financial rules. Version: 8.0 Page 79 of 101

80 Version: 8.0 Page 80 of 101

81 Version: 8.0 Page 81 of 101

82 To have the Medical Conditions screen populate in the queue you will need to select disabled on the Case Questions screen. Version: 8.0 Page 82 of 101

83 The next screen to complete is the Medical Condition Screen. You will only need to complete 4 fields on this screen. They are the EBD, begin date (Date the disability began), the disability type (will be undetermined until the disability decision has been received) and date reported Version: 8.0 Page 83 of 101

84 CBMS will mail the application for you! The 4 highlighted entries are extremely specific to add. This will generate a VCL that will deny the case for failure to return disability information if it is unreturned. Currently CBMS will mail-out and pend for disability using the Disability Determination screen. Entering: Status- Pending Result- Undetermined Verification- Received Source- Client statement Will mail the disability application to the client and add it to the verification checklist. Notes: Version: 8.0 Page 84 of 101

85 Pending for Disability Determination Pending for Disability Determination The source field should be updated when the applicant returns the disability application. The worker then needs to complete the comments page and forward it to ARG. Update the Source field to State Authorized Disability Contractor If the field is not updated the case will deny as CBMS does not realize that this application has been returned. Once updated the case will pend indefinitely for disability determination. If this is the only item outstanding the case will be removed from the EPG report. CBMS will look at the hierarchy and could approve the individual for another MA program if all other eligibility requirements are met. Once the disability determination has been received and entered into CBMS, the customer may roll up the MA chain if they meet the disability criteria. If the customer does not return the ARG packet and doesn t meet the requirements for any other program, their application will be denied. The ARG packet must be returned within the same VCL timeline. Version: 8.0 Page 85 of 101

86 Results SSA s decision will overrule! Notes: Version: 8.0 Page 86 of 101

87 Full vs Limited Disability All SSA determinations will be full disability. The state contractor will specify full or limited. Full vs. Limited Disability Full Disability (All programs) Limited Disability (WAwD) Meets the SSA disability criteria Meets the SSA disability criteria without consideration of substantial gainful activity All LTC waivers WAwD clients: CMHS and EBD waivers only Full Disability Determination Notes: Version: 8.0 Page 87 of 101

88 Notes: Limited Disability Determination Notes: Version: 8.0 Page 88 of 101

89 Rationale and Data Entry Info Results Onset date: Date disability can be established Retroactive Date: Disability Onset Date Diary Date: Date Disability will be re-evaluated for improvement. Considered disabled through completion of reevaluation. (Also used by SSA) Decision Date: Date decision was made (status date in CBMS) Notes: Version: 8.0 Page 89 of 101

90 Data Entry Practice Example: Application Date 12/24/ /24/ /01/ /24/ /01/2016 Version: 8.0 Page 90 of 101

91 ARG Approval When an ARG decision has been received, you must update the information in CBMS. It is important that you enter the dates correctly EBD is the retro date Onset date is the retro date for ARG, onset date for SSA Status date is the date the status last changed Result date is the date the last decision on a disability was made Diary date is the date that the customer s disability information will be reviewed to determine if disability criteria is still met. Version: 8.0 Page 91 of 101

92 Data Entry Practice Effective Begin Date 1/1/2018 Onset Date 3/1/2018 Status Date 5/1/2018 Result Date 5/1/2018 Diary Date 5/1/2028 Note: The Diary Date will be set by ARG and is typically 1-10 years after the determination date. Version: 8.0 Page 92 of 101

93 Disability Wrap-Up Re-Visit Objectives Can you? Perform data entry on the Disability Determination screen in CBMS Goal: To gain further understanding of Disability, and the associated business processes to meet this requirement Identify when the disability requirement is met, and when the disability app is necessary Gather, complete and submit a disability application to the State Contractor Version: 8.0 Page 93 of 101

94 Case Data Entry Change your SSI case to WAwD by adding earned income, what steps must you take? Version: 8.0 Page 94 of 101

95 Medicare Based Programs Objectives: Goal: To understand a group of Non-MAGI programs, and their eligibility rules. After this module, Participants will be able to: Perform accurate data entry on the Medicare Expense Page. Explain the coverage difference between MSP programs and State-plan Medicaid. Version: 8.0 Page 95 of 101

96 Medicare Savings Programs Benefit categories 4, 5 and 7. The Medicare based programs do not grant state plan Medicaid benefits. Individuals on these programs are Medicare recipients with low income. The programs help pay Medicare costs for individuals based on which income bracket they fall into. All individuals on one of these programs must be entitled to Medicare Part A. Program list QMB Qualified Medicare Beneficiary, benefit category 4. The program pays for Medicare premiums, deductibles, co-pays, and coinsurance. SLMB and QI-1 Special Low-Income Medicare Beneficiary and Qualified Individual 1 are both benefit category 5 programs. They are similar to QMB, except cover less Medicare expenses (only Part B premiums). The primary difference between the programs is that QI-1 must be re-authorized by the Congress every year. SLMB and QI1 are eligible for up to 90 days retroactive coverage. QDWI Qualified Disabled Working Individual also benefit category 5. Medical Assistance coverage is limited to the monthly payment of Medicare Part A premiums and any other Medicare cost sharing expenses. Some individuals receiving SSDI benefits do attempt to return to work. If their earned income goes above the Substantial Gainful Activity threshold, they can lose their SSDI benefit. To be eligible for QDWI the individual must have exhausted the SSA s allowable extension of premium free Medicare coverage, has resources below $6,000 and has income below ($2,044 for an individual or $2,764 for a couple) Medicare part A is still made available to them, but at a cost. If these individuals meet the income and resource criteria for QDWI, their part A costs can be covered. Coverage can be backdated 90 days. Version: 8.0 Page 96 of 101

97 Income and Resource Limits *These Income limits include the $20 unearned income disregard. MSP Income Deeming In addition to the standard $20 and earned income disregard ($65 + ½), there are also disregards related to children and child support. The Income of the spouse and children in the household towards the income limits. Children are defined as: Under 18 and in the household, or Under 21, in the household, and attending school, college, or technical training. Child support has a 33% disregard. Each child allows a disregard equal to ½ SSI ($ in 2017). Disabled children receive disregard = SSI ($750 in 2018). Each child s first $400/mo. Income (up to $1620/yr.) is not countable. Income from any child receiving SSI or OAP does not count, nor does the disregard apply. Version: 8.0 Page 97 of 101

98 LIS Low Income Subsidy for Part D is a program managed by SSA for Medicare. This provides a partial credit towards Part D expenses. This benefit is included in the other MSP programs. Individuals approved or denied for LIS in CBMS has been denied for all other programs. Info collected for LIS is forwarded and administered by SSA. Income Limit $1,518 Individual $2,058 Couple Resource limit $14,100 Individual $28,150 Couple Version: 8.0 Page 98 of 101

99 Medicare Data Entry The Medicare Expense page will interface for ongoing cases but must be completed for new applications. The page has separate sections for Part A and B. You must complete the Approval Date, Payment Method, Buy-in status, and Monthly Premium for both sections. Payment Method will be: Other for Free Part A Monthly Deduction for Paid by Beneficiary State Payment for Paid by State Buy-in. ***Currently Enrolled should be a Yes. This causes major issues for APTC when left blank*** Version: 8.0 Page 99 of 101

100 Other Notes Client Pays: Yes affects FA and LTC. Eligible to Enroll : This is an actual form that the member may provide indicating they are eligible for QDWI. Again, these individuals will probably be eligible for WAwD and are extremely rare. The Billing and Payment screens should be complete if the member is on FA. It may grant a medical expense until the Medicaid picks up the premium(s). Enter part D expenses in the Part D tab. It will also affect LTC and FA programs. Version: 8.0 Page 100 of 101