016.20.98 Ark. Code R. 024
Section 301 of Public Law 100-360, the Medicare Catastrophic Coverage Act of 1988, requires Medicaid buy-in of Medicare premiums and coverage of deductibles and coinsurance for Qualified Medicare Beneficiaries (QMBs) with income at or below specified percentages of the poverty level and resources at or below twice the SSI limit.
Qualified Medicare Beneficiaries under the Medicare Catastrophic Coverage Act are not eligible for the full range of Medicaid Services. QMBs are eligible only for payment of all Medicare premiums, deductibles, and coinsurance.
QMBs will not be eligible for any retroactive coverage as QMBs. Coverage of Medicare premiums, deductibles, and coinsurance will begin on the first of the month following the month of approval, where an individual is found eligible as a QMB. Individuals who apply for coverage as QMBs and who have medical expenses in prior
months may be considered in other Medicaid categories (including spend-down categories) for the retroactive coverage.
With the exception of spend-down categories, an individual may not be certified in a QMB category and in another Medicaid category for simultaneous periods. If an individual is eligible in a category other than QMB, he will be eligible for and receive the QMB benefits along with the other Medicaid benefits (Re MS 2047.8). If an individual could be eligible in either a QMB category or a non-QMB category, the individual should be approved in the non-QMB category. Example: An individual is eligible in both categories 41 and 48; the individual will be certified in category 41, but will receive full QMB benefits.
An individual may be approved for a spend-down and as a QMB for simultaneous periods. Example: An individual applies for QMB coverage and for other Medicaid categories on March 1 and has sufficient non-coverable medical bills for a spend-down period of March, April, and May. QMB coverage is approved on March 30. QMB coverage will begin April 1. For any concurrent months of QMB and spend-down eligibility, Medicare premiums may not be considered as a non-coverable medical expense.
QMBs must meet the following eligibility requirements:
Individual | $4,000 |
Couple | $6,000 |
Countable Resources are determined according to LTC guidelines (Re. MS 3330-3337). There will be no penalty imposed for transfer of resources.
Effective 4/1/98, the monthly income limits are as follows:
Individual | $670.83 |
Couple | $904.17 |
Countable Income is determined according to LTC guidelines (Re. MS 3340-3348). In-Kind Support and Maintenance is considered in QMB determinations. For a couple, total monthly countable income will be compared to the couple's standard in each case. If only one spouse can be a QMB, then the procedures for deeming of income in MS 2111-2111.5 will apply.
Individuals applying for QMB coverage only will not be required to apply for SSI if their income is less than the SSI SPA. If an individual does not wish to be referred to SSA and does not want to be certified for full Medicaid benefits in a non-QMB category, he may be certified for QMB coverage only.
A QMB must be entitled to or conditionally eligible for hospital insurance benefits under Medicare Part A. Medicare Part A beneficiaries include the following groups:
Effective 4/1/98, the QDWI countable income limit will be:
Individual | $1,341.66 |
Couple | $1,808.34 |
Individual | $4,000 |
Couple | $6,000 |
Resources wi 11 be determined according to LTC guidelines (RE. MS 3330-3337). There will be no penalty imposed for transfer of resources.
Each eligibility factor will be verified by the Service Representative and documented in the case narrative.
The income of an ineligible spouse will be deemed to the QDWI applicant (Re. MS 2111-2111.5) and the net income compared to the couple's QDWI limit.
The income of an eligible couple will be totaled, and SSI exclusions will be given (only one $20 exclusion). The net income for the couple will be compared to the couple's QDWI income limit.
The income of QDWI's may vary monthly due to their income from employment. MS 3343 will be utilized in the determination and verification of earnings from employment.
A QDWI applicant must reenroll for Medicare Part A, if he/she has not previously reenrolled prior to making application.
The Social Security Administration will send notices to those individuals who lost or will lose Medicare Part A solely due to SGA, advising them to contact the SSA office. Once reapplication has been made for Medicare Part A, SSA will refer potentially eligible individuals to the County Office to make a QDWI application.
If an individual applies at the County Office prior to reenrolling for Medicare Part A, the individual will be instructed to go to the SSA Office to reenroll for Medicare Part A and provide verification of reenrollment and the effective date of coverage.
The Individual Enrollment Period begins with the month in which the individual receives notice from SSA that his/her entitlement to Disability and Medicare will end solely due to SGA. The enrollment period ends 7 months later.
There will also be a General Enrollment Period each year from January 1 - March 31.
Approval:
If all eligibility factors have been met, and the case is approved, the Service Representative will perform the following tasks:
For example, an individual applies for QDWI benefits on September 1, 1994, and the effective month of Medicare Part A is August. This individual's QDWI benefits could begin August 1, 1994.
If, however, the individual has not reenrolled for Medicare Part A prior to making application, and his Medicare Part A entitlement will not be effective until October 1, 1994, QDWI benefits cannot be effective prior to 10/01/94.
Individual | $4,000 |
Couple | $6,000 |
Resources are determined according to Long Term Care guidelines (MS 3330 - 3337). No penalty will be imposed for transfer of resources.
Effective 4/1/98 these levels are:
100% | 120% | |
Individual | $670.83 | $ 805.00 |
Couple | $904.17 | $1,085.00 |
The LTC guidelines at MS 3340-3348 will be applied when determining countable income. The Supplemental Security Income Exclusions at MS 3348 will be given. Inkind Support and Maintenance will be considered, if applicable.
For couples, their combined net countable income, after all disregards and exclusions, will be compared to the couple's standard in determining the eligibility of each member of the couple. In determining eligibility for only one member of a couple, the procedures for deeming of income at MS 2111 - 2111.5 will apply.
Note: In determining eligibility each year between January 1st and April 1st for SMB applicants, the Social Security Cost of Living Adjustment (COLA) for the year will be disregarded until April 1st, i.e., an individual's or couple's SSA amount to be considered in the budget will be the amount for the previous year. The current year's SSA amounts will not be considered until April first when the new Federal Poverty Level Income limits become effective (Re. MS 2051.5).
The beginning date of eligibility for payment of the Medicare Part B Premium will be the first day of the month following the month of SMB certification (i.e. completion of the DC0-57). For example, if an SMB application is certified on August 15th, the effective date of eligibility will be September 1st. Date specific eligibility will not change the effective begin date for SMB recipients.
Medicaid eligibility for SMBs cannot begin earlier than the first day of the month following the month of certification. Retroactive coverage will not be authorized for SMBs. If eligibility is to be established retroactively in another category, all eligibility requirements for that category must be met.
185% Federal Poverty Level (4/1/98)
Number in Standard | Monthly Standard |
1 | $1,241.03 |
2 | 1,672.71 |
3 | 2,104.37 |
4 | 2,536.03 |
5 | 2,967.71 |
6 | 3,399.37 |
7 | 3,831.03 |
8 | 4,262.71 |
Add $431.68/month for each additional member.
Note: The FPL is adjusted annually due to changes in the Consumer Price Index. For continuing eligibility, the average monthly gross income, as computed above, will be compared to the FPL in effect during the report month, if different from the preceding months.
If the family's average gross monthly earnings (less paid child care) do not exceed 185% of Federal Poverty Level, the family will remain eligible. The case will be documented.
If the family's average gross monthly earnings (less paid child care) exceed 185% of the FPL, the County will send a notice of closure to the family, and will key a closure to the Transitional Medicaid case on WATM and WACE with a Medicaid End Date effective the last day of the report month. Earnings that resulted in Transitional Medicaid closure will be entered in the budget section. Night Edit will convert all open members in category 25 to closed status.
Minor children entering the household, who were not in the budget group at the time the group became AFDC ineligible, will not be eligible for Transitional Medicaid and will not be added to the case. If an excluded child has earnings, they will not be considered in computing the family's average gross monthly earnings. The Service Representative will determine eligibility for this child in another category, counting only the child and the child's parent(s) in the unit, and considering only their income.
Minor children, who were in the home and included in the AFDC grant during the last month of AFDC eligibility, who later leave the home, will be dropped (a 10 day notice will be given). If he/she subsequently reenters the home while the family is receiving TM, he/she will be added to the Transitional Medicaid case. Any earnings that this child may have will be considered in computing the family's average gross monthly earnings.
The return of an absent parent to the home during Transitional Medicaid is not, in itself, a reason for closure (i.e., deprivation is not an eligibility factor for Transitional Medicaid). The absent parent who returns, if he/she was not in the budget group at the time of AFDC case closure, will not be eligible for Transitional Medicaid and will not be added to the case. Any earnings of the absent parent, however, will be used in computing the family's average gross monthly earnings.
If the only child in the home becomes eligible for SSI, the parent(s) (or non-parent specified relative) will remain eligible for Transitional Medicaid as long as the SSI child is under age 18. However, the County will receive a Systems Action Report notifying them that the case has been closed. The Service Representative will reopen the Transitional Medicaid case for the adults(s) by using a "B" action type and "096" action reason. The Transitional Medicaid Status on WATM will be changed to open status. The adult(s) must continue to meet all other eligibility requirements in order to remain eligible for Transitional Medicaid.
On the first workday of each month the system will search all Transitional Medicaid records for children who will reach the age of 18 that month. If the only child in the home is reaching age 18, the system will close the case and send a notice of case closure to the family. If there are other children under 18 in the home, the system will close only the 18 year old and leave the remaining individuals open.
The Counties will receive a Systems Action Report that will inform them of Transitional Medicaid 18 year olds and cases closed by the system.
When the system has closed an 18 year old, or at any time a member or a case is found ineligible for Transitional Medicaid, the County Office will make a determination and document the case record as to whether or not the ineligible member(s) meets the eligibility criteria in any other Medicaid Category (e.g., PW, MN-SD, etc.). If it appears that a member or the case would be eligible in another category, an application and notice of potential benefits will be sent to the individual(s).
The system will continue to close cases becoming AFDC ineligible due to the loss of the 1/3, or $30 earned income exclusions. A system notice will be generated to inform the individuals of Transitional Medicaid eligibility, and these cases will be converted by the system to Category 25 for Transitional Medicaid. These cases will also be listed on the Systems Action Report.
During the Additional 6 Months TM Extension Period (Second Six Months), a monthly report titled "Transitional Medicaid Cases" will be generated to the Counties to assist them in tracking the Transitional Medicaid cases. This report will list the Case Number, Casehead Name, Worker Number, Transitional Medicaid Begin Date, Current Month of Transitional Medicaid and the next month in which a Transitional. Medicaid Report (DCO-124) is due.
At the end of the 12th month, the system will send a notice and close all Transitional Medicaid cases which remained open throughout both 6 month periods.
Form DCO-123 manually issued to family.
Initial 6 months Extension Period 1st Month
1st month of AFDC ineligibility.
The County Office is responsible for investigation and follow-up on each referral received from the State Hospital. An initial investigation will be made on all referrals to determine whether the patient is already eligible for Medicaid.
When it is determined that the patient is Medicaid eligible, a notice of the patient's eligibility status will be forwarded to the State Hospital by interagency memorandum. The notice will include the following items (if known): the recipient's name, his ten digit Medicaid ID Number, his aid category, date of birth, SSN, and Medicare Claim Number and/or other health insurer information. Correspondence will be mailed to: Director, Social Work Dept., State Hospital, 4313 W. Markham, Little Rock, AR 72201. No other action will be required for known Medicaid eligibles.
If a referred patient is not Medicaid eligible, the County Office will take steps necessary to secure and process an application for assistance in accordance with the requirements specified in MS 2071.
The State Hospital will be responsible for reporting when the patient is discharged. Discharge from the State Hospital by itself may not make the patient ineligible for Medicaid. The County Office will treat reported actions in accordance with the policies applicable to the category.
Section 4732 of the Balanced Budget Act of 1997 (Public Law 105-33) created the Qualifying Individuals-1 group of Medicaid eligibles. These are individuals who would be QMBs except that their income exceeds the QMB income level, and is at least 120% but less than 135% of the Federal Poverty Level.
QI-ls will not be eligible for the full range of Medicaid benefits. QI-ls will be eligible for payment of their Medicare Part B premium only. No other Medicare cost sharing charges will be covered.
Unlike QMBs and SMBs, a QI-1 may not be certified in another Medicaid category for simultaneous periods. A QI-1 may not be approved for a spend down and as a QI-1 for simultaneous periods. An individual who is eligible for both QI-1 and. spend down will have to choose which coverage is wanted for a particular period of time.
Individuals eligible for the QI-1 program will not receive a Medicaid card.
Application will be made on Form DCO-777 by the individual requesting assistance, his/her authorized representative, or a person acting responsibly on the applicant's behalf.
When both members of a couple apply, separate applications will be completed and registered for each individual.
Other forms to be completed during the application process are the DCO-86, DCO-662, DCO-707, and DCO-769.
Applications will be registered on WIMA in Category 58.
The county office worker will have a maximum of 45 days to dispose of the application by approval, denial, or withdrawal.
To be certified as a QI-1, an individual must meet the same requirements as a Qualified Medicare Beneficiary (with the exception of income). Each eligibility requirement will be verified and documented in the case record.
Individual | $4,000 |
Couple | $6,000 |
Resources are determined according to Long Term Care guidelines (MS 3330 -3337). No penalty will be imposed for transfer of resources.
Effective 4/1/98 these levels are:
120% | 135% | |
Individual | $ 805.00 | $ 905.62 |
Couple | $1,085,00 | $1,220.63 |
The LTC guidelines at MS 3340 - 3348 will be applied when determining countable income. The Supplemental Security Income exclusions at MS 3348 will be given. Inkind Support and Maintenance will be considered.
For couples, their combined net countable income, after all disregards and exclusions, will be compared to the couple's standard in determining the eligibility of each member of the couple. In determining eligibility for only one member of a couple, the procedures for deeming of income at MS 2111 - 2111.5 will apply.
Individuals eligible for the QI-2 program will not receive a Medicaid card.
Application will be made on Form DCO-777 by the individual requesting assistance, his/her authorized representative, or a person acting responsibly on the applicant's behalf.
When both members of a couple apply, separate applications will be completed and registered for each individual.
Other forms to be completed during the application process are the DCO-86, DC0-662, DC0-707, and DC0-769.
Applications will be registered on WIMA in Category 78.
The county office worker will have a maximum of 45 days to dispose of the application by approval, denial, or withdrawal.
To be certified as a QI-2, an individual must meet the same requirements as a Qualified Medicare Beneficiary (with the exception of income). Each eligibility requirement will be verified and documented in the case record.
Individual | $4,000 |
Couple | $6,000 |
Resources are determined according to Long Term Care guidelines (MS 3330 -3337). No penalty will be imposed for transfer of resources.
Effective 4/1/98 these levels are:
135% | 175% | |
Individual | $ 905.62 | $1,173.95 |
Couple | $1,220.63 | $1,582.30 |
The LTC guidelines at MS 3340 - 3348 will be applied when determining countable income. The Supplemental Security Income exclusions at MS 3348 will be given. Inkind Support and Maintenance will be considered.
For couples, their combined net countable income, after all disregards and exclusions, will be compared to the couple's standard in determining the eligibility of each member of the couple. In determining eligibility for only one member of a couple, the procedures for deeming of income at MS 2111 - 2111.5 will apply.
Note: In determining eligibility each year between January 1 and April 1, the Social Security Cost of Living Adjustment (COLA) for the year will be disregarded until April 1; i.e., the SSA amount to be considered in the QI-2 budget will be the amount for the previous. year. The current year's SSA amounts will not be considered until April 1 when the new Federal Poverty Level income limits become effective.
The beginning date of eligibility will be the first day of the month following the month of QI-2 certification (i.e., completion of the DCO-57). For example, if a QI-2 application is certified on June 15, the effective date of eligibility will be July 1.
QI-2 eligibility cannot begin earlier that the first day of the month following the month of certification. Retroactive coverage will not be authorized for QI-2's. If retroactive coverage is needed, eligibility will need to be determined in another category.
The ARKids First category was established by Act 407 of 1997 (the ARKids First Program Act), and it was implemented by Arkansas on September 1, 1997. It is designed to provide Medicaid eligibility for uninsured children age 18 and under whose family's gross income is at or below 200% of the federal poverty level. Persons who are already eligible for Medicaid under another category cannot be eligible concurrently in the ARKids First category.
Participants in the ARKids First category are not eligible for the full range of Medicaid services. Copayments and coinsurance will apply, as appropriate, for all services with the exception of immunizations, preventive health screenings, family planning, and prenatal care. Child Health Services (EPSDT) will not be offered. For a list of services provided, please refer to "[LESS THAN]Insert Title of Brochure[GREATER THAN]."
No person will be prevented from participation, denied benefits, or subjected to discrimination on the basis of race, color, national origin, age, religion, disability, sex, veteran status, or political affiliation. The Agency will be in compliance with the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and regulations issued by the Department of Health and Human Services.
The Agency has the rsponsibility for informing applicants and recipients that assistance and services are provided on a nondiscriminatory basis and that they have a right to file a complaint with the Agency or federal government if it is thought that discrimination has occurred on the basis of race, color, national origin, age, religion, disability, sex, veteran status, or political affiliation.
To be eligible for services in the ARKids First category, the following criteria must be met:
If a minor who is pregnant is living with her parent(s), then the gross income of the parent(s) will be counted in full to the pregnant participant.
In minor parent (MP) households, the income of the parent(s) of the minor parent is counted in full in the MP's need determination, but is totally disregarded in the need determination of the MP's child.
The income of an alien sponsor is disregarded.
Lump sums are considered income in the month received when determining eligibility for each of the three months in the retroactive eligibility period up through the date of certification. Lump sums and other income changes which occur after the date of certification will be disregarded.
* Monthly Standards (4/1/98)
Number in Standard | 2005S |
1 | 1,341.66 |
2 | 1,808.34 |
3 | 2,275.00 |
4 | 2,741.66 |
5 | 3,208.34 |
6 | 3,675.00 |
7 | 4,141.66 |
8 | 4,608.34 |
9 | 5,075.00 |
10 | 5,541.66 |
For each additional person, add $466.66.
Monthly Standards (4/1/98)
Number in Standard | 133% - PW/Children Under aae 6 | 100% - Children ages 6 and ud |
1 | $ 892.20 | $ 670.83 |
2 | 1,202.55 | 904.17 |
3 | 1,512.88 | 1,137.50 |
4 | 1,823.20 | 1,370.83 |
5 | 2,133.55 | 1,604.17 |
6 | 2,443.88 | 1,837.50 |
7 | 2,754.20 | 2,070.83 |
8 | 3,064.55 | 2,304.17 |
9 | 3,374.88 | 2,537.50 |
10 | 3,685.20 | 2,770.83 |
. For each additional person add, $310.32 | $233.00 |
S0BRA eligibility for a pregnant woman may begin at any time during a medically verified pregnancy, and will be extended through the end of the month in which the 60th day postpartum falls. A PW who applies postpartum and is found S0BRA eligible in the month of delivery will be given the full postpartum coverage.
In determining eligibility for the PW, the worker must inquire if the PW had any medical bills of her own (paid or unpaid) in the 3 months prior to the date of application and, if so, determine retroactive eligibility for the retroactive period (there must be medical bills to give retroactive coverage and the medical bills must be verified - the bills must be for the PW - medical bills for other family members will not qualify the PW for retroactive PW coverage); if retroactive coverage is not given, the case record should be clearly documented to show that coverage was considered and why it was not given.
In conjunction with consideration of the retroactive coverage, if an applicant is found eligible in any of the 3 retroactive months, certify the case effective the earliest retroactive month of eligibility; there will be a "No Look Back" at later income increases, throughout the pregnancy and the postpartum period, even if the applicant is not income eligible in the month of application or in the month in which the 45th dav of the application falls.
Example: Mrs. Smith applies for S0BRA coverage on November 1, and is not income eligible in November or in December (the month, in which the worker is ready to dispose of the application). However, Mrs. Smith was income eligible and had incurred medical bills in August, September and October. The County will certify Mrs. Smith for SOBRA coverage effective on the date of the earliest bill incurred during the retroactive period (but not more than 3 months prior to the date of application), and will not "look back" at her eligibility again (i:e., disregard ' the income increase that made her ineligible in November, the month of application).
When the PW is eligible, the full postpartum coverage must be provided, as mandated by law. Based on the expected date of delivery given by the PW, begin counting 60 days on the calendar, with the delivery date as day one; the end of Medicaid coverage will be the last day of the month in which the 60th day falls.
Example: Mrs. Jones' expected delivery date is November 15, and the 60th day after November 15th is January 13th. Coverage will be given through January 31st.
The client will be given the responsibility of reporting a premature delivery or delayed delivery.
SOBRA eligible infants/children born after September 30, 1983, will remain eligible through the end of the month of their birthday, as specified below, as long as they remain income and resource eligible and as long as they reside with their parent(s), or other specified relatives (Re. FA 2250 - 2252). Children born prior to October 1, 1983, are not eligible under SOBRA.
If an infant/child is an inpatient on his/her birthday, as specified below, eligibility will continue until the end of the inpatient stay, provided the infant/child remains income and resource eligible. (Infants/children with severe disabilities will be referred to Social Security for SSI determination).
Application made after termination of a pregnancy does not prohibit coverage for the infant/child, i.e., a mother need not be a certified Medicaid recipient at the infant's birth in order for the infant/child to receive SOBRA coverage, as specified below. A mother need not remain Medicaid eligible in-order for the infant/child to qualify for continuing coverage.
October 1,1990-Eligibility may continue up to the eighth birthday;
October 1,1991-Eligibility may continue up to the ninth birthday;
October 1,1992-Eligibility may continue up to the tenth birthday;
October 1,1993-Eligibility may continue up to the eleventh birthday;
October 1,1994-Eligibility may continue up to the twelfth birthday;
October 1,1995-Eligibility may continue up to the thirteenth birthday;
October 1,1996-Eligibility may continue up to the fourteenth birthday;
October 1,1997-Eligibility may continue up to the fifteenth birthday;
October 1,1998-Eligibility may continue up to the sixteenth birthday;
October 1,1999-Eligibility may continue up to the seventeenth birthday;
016.20.98 Ark. Code R. 024