016.20.98 Ark. Code R. 029
The following categories of Individuals are eligible for Medicaid:
If a hearing is not requested during the advance notice period, the planned termination will be completed. If a hearing is requested during the advance notice period, the County Office will forward a copy of the DCO-700 (if applicable) along with the DCO-1200 to Appeals and Hearings and delay action pending the hearing.
Assistance will be terminated without advance notice when:
Changes other than termination will not require recipient notification. When the agency becomes aware of changes (e.g. address) appropriate verification will be secured and case and member information will be updated. When the change involves only member information, the DCO-56 will be completed for input showing only member items changed. When the change requires update of case information, the DCO-56 will be completed to show an "0" (Other) action type with appropriate case field changes.
All changes will be evaluated in regard to their impact on recipient eligibility before update.
The Sixth Omnibus Budget Reconciliation Act of 1986 (SOBRA) allowed states to provide medical services to indigent pregnant women, infants and children. Medicaid coverage for pregnant women could be continued through the end of the 60 day period beginning on the last day of a pregnancy, and coverage for infants/children could be gradually extended through the end of the month of the fifth birthday. Arkansas elected to take this option, effective April 1, 1987.
The Omnibus Budget Reconciliation Act (OBRA) of 1987 allowed states to extend SOBRA coverage. Postpartum coverage of pregnant women was extended through the end of the month in which the 60th day post parturn falls, (Re. MS 5740.1). This change was effective August 1, 1988. OBRA 1987 also allowed states the option of accelerating the extension of coverage of children, born after September 30, 1983, up to age 5 and the option of gradually extending coverage up to age 8. Arkansas implemented both of these options, extending coverage for children up to age 5, effective July 1, 1988, and gradually extending coverage up to age 8 (Re. MS 5740.2) by October 1, 1990.
The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandated states to cover pregnant women and children under age 6 at 133% of Federal Poverty, effective April 1, 1990.
The Omnibus Budget Reconciliation Act of 1990 mandated states to provide Medicaid coverage to children born after September 30, 1983, who have reached age 6, and to extend coverage yearly until they reach the age of 19, with family income at 100% of the Federal Poverty Income Guidelines. This provision was effective July 1, 1991, in Arkansas.
*Titles XIX and XXI of the Social Security Act allow states the option of providing Medicaid coverage to children born earlier than September 30, 1983. Effective October 1, 1998, Arkansas has elected to expand Medicaid coverage to children born after September 30, 1982, and before October 1, 1983, with family income at or below 100% of the Federal Poverty Level. Medicaid coverage will continue to be extended yearly to these children until they reach the age of 19.
*Medicaid eligibility under SOBRA is limited to pregnant women and infants/ children whose family income does not exceed the specified Federal Poverty Level income limits. Net income for pregnant women and children under age 6 cannot exceed 133% of the Federal Poverty Income Guidelines. Net income for children age 6 and up, born after September 30, 1982, cannot exceed 100% of Federal Poverty Income Guidelines. Countable resources will be compared to the Medically Needy Resource Levels for the number of individuals 1n the unit.
The pregnancy must be medically verified by a documenting statement, or by a birth/death certificate.
SOBRA allows the provision of Medicaid for ambulatory prenatal care during a period of presumptive eligibility (PE). The P£ period precedes the eligibility determination made by the County Office, and the PE period begins on the date that a Qualified Provider determines on the basis of preliminary Information that the net family income of the pregnant woman does not exceed 133% of the Federal Poverty Income Guidelines. No resource test will be imposed for presumptive eligibility. When a Qualified Provider has made this determination, the provider is required to notify the County Office in the pregnant woman's residence county within 5 working days after the date of determination.
additional time, the County Office Worker will acknowledge the request by sending a second DCO-002 that clearly specifies what information is needed by the end of the extended time period and will assist the applicant in obtaining information, if possible. If the information has not been provided by the end of the extended time period, a DCO-700 or system notice will be sent and, the application will be denied.
If a pregnant woman under the age of 18 is living with her parent(s), the parental income will be deemed to the PU (Re. FA 2377 - 2377.2).
Lump sum payments will be considered income in the month received and, if retained, will be a resource in the month(s) following.
Income changes which occur after the first month of eligibility will be disregarded for the PU throughout the woman's pregnancy and the postpartum period of eligibility, (Re. MS 5740.1 for retroactive coverage and "No Look Back").
If the PU is not eligible for retroactive coverage and it is known prior to disposition of her application that income will increase in the month of planned certification, the increase in income will be verified to determine eligibility before certification is made for that month.
If It is known prior to certification of an eligible P\i that income will increase in the month(s) following the month of planned certification, the certification may be completed in the month of PU eligibility, with disregard of the future income increases.
SOBRA infant(s)/chi1d(ren) must be income eligible in each month of the certification period. If family income changes during a month, closure may be indicated. If family income fluctuates frequently, determine an average based on best information available, document the average, and leave the infant/child(ren) in SOBRA. However, the casehead must continue to report income changes.
NOTE: Actual income will be used in the month of eligibility determination for SOBRA pregnant women. Prospective eligibility for SOBRA children will be determined using the FA multipliers (Re. FA 2361).
If a pregnant woman under the age of 18 is living with her parent(s), the parent(s) will not be included in the need standard.
An OCSE referral is not required for a SOBRA pregnant woman, during her pregnancy or postpartum period, on children for whom she is receiving Medicaid. (Re. MS 1355).
Note: This provision applies to SOBRA pregnant women only.
The Federal Poverty Income Guidelines are the basis of income eligibility for SOBRA. Net income for the appropriate number of persons included in the need standard may not exceed the percent of the Federal Guidelines as indicated below. In order to achieve eligibility, net family income must be equal to or less than the standards shown below; if net family income is greater than the standard, the applicant is not eligible.
Monthly Standards (4/1/98)
Number in Standard | 13396 - PW/Children Under aae 6 | 100% - Children aaes 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 SOBRA 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 SOBRA 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, 1982, may remain eligible up to their ninetheenth birthday 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, 1982, 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.
Eligibility for infants and children may be established for the 3 month period prior to the date of application. Application made after termination of the PW's pregnancy does not affect coverage for infants or children.
When retroactive eligibility is determined, the infant/child budget unit must meet the income and resources requirements for each of the retroactive months, i.e., the "No Look Back" consideration of income changes given to the PW does NOT apply to Infants and children.
The County Office Worker will complete the following tasks when approving an application:
Begin date will be the date of application, unless retroactive coverage is given. The begin date may overlap or precede the begin date of the category 62 presumptive case.
When certifying SOBRA cases where the pregnant woman is the only eligible member, the case will be certified in fixed eligibility ("AF" or "BF" action type, action reason "101") giving the PW coverage from the beginning date through the end of the month in which the 60th day postpartum falls, basing the postpartum end date on the expected date of delivery, and entering the end date in the "Med End Date" field. The PW will be entered in closed status with a "Y" in the budget indicator. A member close code of 34 (PW eligibility expired) will be entered in the woman's reason of close field. Entries of the date of close and close reason (34) will allow the system to terminate Medicaid eligibility on the last day of the month in which the 60th day postpartum falls.
If certification is made after termination of a pregnancy, the period of eligibility will be known to the worker, and the case should be certified in a fixed period of eligibility.
When certifying SOBRA cases where the pregnant woman is included with eligible children, the case will not be certified in fixed eligibility ("A" or "B" action type will be used), but the PW will be certified in closed status (following instructions above).
NOTE: Though the pregnant woman and child are budgeted separately, both will be included on the DCO-56 with the child's prospective income.
The infant may be added to the mother's case (if open) with eligibility effective the birth month, if application has been made and if the infant is found eligible. If the mother's case is in closed status, the case must be reopened to add the infant, but the mother should remain in closed status and her Med End Date unchanged. If application for the infant/child is made after the mother's category 61 case has been closed and if eligibility is established, use the mother's category 61 closed case number as the case number for the infant/child. If there has never been a category 61 case for the mother, obtain a new case number for the infant/child in category 61, unless the infant/child has a previous family category case number.
When Newborn coverage (MS 2080) is given, the Newborn case may remain open for 1 year, and the newborn infant need not be opened in, or added to, a category 61 case. A reevaluation need not be scheduled as the system will close the case when the infant reaches one year of age.
NOTE: A PW "Minor Parent" (Under age 18) will always be given a "101" suffix.
The County Office Worker will complete the following tasks when denying an application.
If certification is made after termination of a pregnancy, the period of eligibility will be known to the worker, and the case should be certified in a fixed period of eligibility.
When certifying SOBRA cases where the pregnant woman is included with eligible children, the case will not be certified in fixed eligibility ("A" or "B" action type will be used), but the PW will be certified in closed status (following instructions above).
NOTE: Though the pregnant woman and child are budgeted separately, both will be included on the DCO-56 with the child's prospective income.
The infant may be added to the mother's case (if open) with eligibility effective the birth month, if application has been made and if the infant is found eligible. If the mother's case is in closed status, the case must be reopened to add the infant, but the mother should remain in closed status and her Med End Date unchanged. If application for the infant/child is made after the mother's category 61 case has been closed and if eligibility is established, use the mother's category 61 closed case number as the case number for the infant/child. If there has never been a category 61 case for the mother, obtain a new case number for the infant/child in category 61, unless the infant/child has a previous family category case number.
When Newborn coverage (MS 2080) is given, the Newborn case may remain open for 1 year, and the newborn infant need not be opened in, or added to, a category 61 case. A reevaluation need not be scheduled as the system will close the case when the infant reaches one year of age.
NOTE: A PW "Minor Parent" (Under age 18) will always be given a "101" suffix.
The County Office Worker will complete the following tasks when denying an application.
that she wishes to withdraw her application.
016.20.98 Ark. Code R. 029