Medicaid (MA)

1.   DHS will review FIP-related Medicaid cases for evidence of disabilities before closing those cases.  As part of ongoing efforts to settle the Crawley lawsuit, DHS has issued new policy on pre-termination reviews (review of Medicaid eligibility before ending a person’s Medicaid eligibility).   It also has added definitions for some of the terms used in the pretermination policy.  In addition, DHS has inserted in most of the Bridges Eligibility Manual items reminders to caseworkers about the need for pre-termination reviews, and  describing the criteria for the various Medicaid eligibility categories. See Bridges Policy Bulletin 2010-013.   

When FIP-related Medicaid eligibility is ending because of an actual or anticipated change,  (e.g. a parent’s only child is 18 and graduating from high school)  the ex parte review must include a review of whether the individual scheduled to lose Medicaid has “ indicated or demonstrated a disability”, which is defined in the Glossary as follows:

“Information in the recipient’s current Medicaid eligibility case file shows the recipient has alleged a serious mental or physical impairment or injury. A condition, impairment, or injury will not be considered serious if information in the case file shows it is so minor it cannot reasonably be expected to interfere with the individual’s mental or physical functioning, or cannot reasonably be expected to last more than a year, or to result in death. An individual who has indicated or demonstrated a disability may or may not, following a disability review, be determined to meet the defini­tion of disability used to determine eligibility for Medicaid under SSI-related disability based Medicaid [categories].“

2.   The ex parte review process  - Pre-termination Medicaid reviews begin with an ex parte review of the information in the individual’s  current Medicaid eligibility file.  BAM 210 p. 1 and BAM 220 p. 14-15.  Ex parte review is defined the glossary as “A determination made by the department without the involvement of the recipient, the recipient’s parents, spouse, authorized representative, guardian, or other members of the recipient’s household. It is based on a review of all materials available to the specialist that may be found in the recipient’s current Medicaid eligibility case file.”

“Current Medicaid eligibility case file” also is defined in the glossary and includes at least  “All written information received or maintained electronically in the eligi­bility determination system or in hard copy by the worker at any time in the last 24 months, including all information available regarding all SSI or SSDI claims and including any information in the MRT packet.” 

DHS policy instructs caseworkers to begin the pre-termination review 90 days before the case is due to close due to an anticipated change, such as the end of the 12-month TMA eligibility period or a young adult’s 21^st birthday.    This reduces the number of months in which eligibility is continued because of the need for a pre-termination review even though the person turns out to not be eligible ANY Medicaid eligibility category.   Bridges is supposed to alert caseworkers about cases in which an ex parte review should be started.

 2.  Evaluating evidence of disabilities  - If the ex parte review shows that the client is eligible under another category, the caseworker must transfer the case to the new category instead of ending Medicaid eligibility.

If the ex parte review shows the recipient may be eligible to continue receiving Medicaid under a different category, but there is not sufficient information to make a full eligibility determination, DHS must request from the client any additional information that is needed.  If the information is not provided timely or if that information indicates that the person is not eligible under the other categories, the Medicaid case will be closed.

If the Social Security Administration or the DHS Medical Review Team (MRT) has already determined that the person losing FIP Medicaid is “disabled”,  then the caseworker must transfer that individual to a disability-related category,   if they are otherwise eligible.

If the individual has not already been determined disabled, the caseworker must request the information needed for an MRT review of disability.   If the client returns the requested information, the review must be completed and eligibility for disability-related Medicaid categories must be established or ruled out.  The Medicaid case cannot be closed until the review has been completed, even if the individual’s eligibility under the other category has ended.

DHS has created a Powerpoint Training for caseworkers, which is posted on the www.mplp.org  website.  The training provides more details about the information that caseworkers must review when determining whether an individual has indicated or demonstrated a disability.

 3.   If the MRT review finds the client is not disabled  - When the review is complete, if the person is not eligible for ALL Medicaid categories, DHS will send a negative action notice, which the individual can appeal.    If an MRT review has been conducted, the notice must tell the recipient that DHS has determined they are not disabled.  Individuals who disagree with the DHS decision about their Medicaid eligibility and who submit timely hearing requests will be eligible for continued Medicaid until a hearing decision is issued and implemented.  To be timely, a hearing request must be received by DHS before the deadline stated in the negative action notice, usually 12 days after the date of the notice.

1.    Monitor DHS compliance with the new policy

2.    Contact CCJ if you become aware of problems with the new policy or if Medicaid is terminated without an ex parte review (contact information is at the top of this alert)

3.    Contact CCJ if you have clients with disabilities who were terminated from FIP-related Medicaid without a pre-termination review of disability.