Worker responsibilities

Ex parte review and redetermination

For every redetermination for individuals who lose coverage under a CN medical coverage group, review available records of each individual within a terminated AU by checking:

1. The electronic case record for the last review form, application or other documents;
2. The notes in ACES or EJAS (if applicable); and
3. SOLQ for a current SSI application or social security disability.

Instructions for common ex parte review scenarios

Below are instructions for handling common ex parte review findings.

No indication of disability or pregnancy

1. Terminate the individual's CN coverage, and
2. Document in ACES the actions taken and that the redetermination process has been completed.

Individual may be pregnant

1. Refer the individual to Washington Healthplanfinder to apply for Apple Health for Pregnant Women;
2. Set a 10-day tickler for follow-up;
3. Terminate the individual's prior CN coverage only after the individual has been given 10 days to apply for Apple Health for Pregnant Women; and
4. Document in ACES the actions taken and that the redetermination process has been completed

Individual claims to be disabled or there is an indication of disability in the record

1. Screen in SSI-related medical (S02) coverage so that medical coverage can be continued while gathering the medical documentation needed to do a disability referral;
2. Pend for verification of disability;
3. Set a 20-day tickler for follow-up;
   1. If the individual does not respond within 20 days:
      1. Terminate the individual's prior CN coverage; and
      2. Send termination letter with Reason Code 552 and insert appropriate free-form text.
      3. Document in ACES the actions taken and that the redetermination process has been completed.
   2. If the individual responds within 20 days:
      1. Terminate the individual's prior CN coverage;
      2. Send termination letter with the appropriate Reason Code and insert appropriate free-form text;
      3. Finalize the pending S02 AU, including entering any new income;
         1. If there is income, the S02 may trickle to S99. If this happens, insert appropriate free-form text
      4. Set 4-month tickler for follow-up; and
      5. Add remarks behind the DEM2 screen explaining that the disability coding is a workaround to continue medical coverage under S02 while waiting for the NGMA determination due to redetermination.
      6. Document in ACES the actions taken and that the redetermination process has been completed.
      7. If the NGMA referral is returned indicating the individual is not disabled, remove the disability coding on the DEM2 screen to terminate the S02/S99 coverage.

Individual has pending SSI application

Follow instructions above for "Individual Claims to Be Disabled or There Is an Indication of Disability in the Record" except:

1. Do not do a NGMA referral; and
2. Notify the Division of Disability Determination Services (DDDS) that the agency has continued the individual's medical coverage and ask them to notify you when a decision is made on the individual's SSI application.

Individual may be eligible for Apple Health for Workers with Disabilities (HWD)

If the individual is over age 16 and working and is not otherwise eligible for S02 coverage (and meets disability requirements) send a referral to the specialized medical unit to consider eligibility for the Health Care for Workers with Disabilities (HWD) program. Allow the termination under the original program to proceed (allowing advance and adequate notice).

Note: If an individual is working and has monthly gross earnings at or above the Substantial Gainful Activity (SGA) level and does not receive Title 2 (SSDI, DAC, DWB), then HWD is the only Medicaid program that may provide coverage for them. An individual who is working at SGA is not eligible for S02/S95/S99 coverage, unless their Title 2 cash benefit continues. If their Title 2 has not ended, then HWD staff will explain their options to either enroll in HWD for CN coverage or meet their spenddown for MN coverage.

Set a barcode tickler to the HWD unit in DMS for @HWD in CSO 017 to contact the individual and determine if they wish to pursue HWD. Since HWD is a premium based program, CN coverage should not be authorized under this program until the individual has approved the premium requirement and amount.

For HCS individuals, set a barcode tickler to the HCS Regional HWD specialist to contact the individual and determine if they wish to pursue HWD.

Note: A working individual who is eligible under a Home and Community Based CN waiver program (L22 in ACES) whose income goes over the Special Income Limit (SIL) or who accumulates excess resources should always be referred to the HWD unit prior to terminating CN medical coverage. Both Home and Community Services (HCS) and the Division of Developmental Disabilities (DDD) have included the HWD program as an available coverage group in the CN waivers. An ADSA individual may transition from the L22 program to the S08 program and remain eligible for long-term care funding for waiver services.

System-generated alerts

The ACES system helps with the medical redetermination process by sending alerts when CN coverage ends for an individual or for all members in an assistance unit (AU), however staff should not rely solely on system generated alerts to determine when a medical redetermination is required.

The following alerts require the department to follow up, make a redetermination decision and document that decision in the narrative.

• Alert 416 - Case closed in batch
• Alert 322 - New MAU created for certain members of the closed AU
• Alert 248 - SSI terminated, redetermine medical eligibility

When signed applications or review forms are not required

Signed application or eligibility review forms are NOT needed for:

• Redeterminations of CN medical coverage for the same program (including MSP programs) with the same individuals in the assistance unit, either prior to the end of the certification period or within 30 days after the case closed. 
• Changing to a medical program which has a more stringent eligibility requirement (such as changing from HWD, with no resource test to CN SSI-related, which does have a resource test). However, we do need to document in ACES that we asked the necessary questions for the more stringent requirements and what the answers to those questions were. 

Continuous eligibility

Redetermination does not apply to individuals who receive continuous eligibility, since their coverage continues through the end of their certification period. The following two programs provide continuous eligibility:

1. Children terminated from any CN medical program are eligible through the end of their original 12-month certification period.
   1. Children whose coverage was approved under the family institutional medical program are eligible to receive one full year of coverage. When a child discharges from a medical facility and is no longer eligible for K01 coverage, open F06 for the balance of the certification period without requiring an application or review from the parents.
2. Pregnant women terminated from any CN medical program are eligible for CN medical to continue through the end of the post partum period.

Note: A pregnant woman who applies for retroactive medical coverage and is found eligible for CN medical in any month of the retroactive period also remains continuously eligible for CN through the end of the post partum period.

SSI redetermination

When an individual loses eligibility for Supplemental Security Income (SSI) cash assistance, the department must redetermine their eligibility for Medicaid. The State Data Exchange (SDX) interfaces with ACES and provides us with information regarding the termination or suspension of SSI cash assistance. (The ACES automated redetermination process does not apply to any individual where the SDX medical eligibility code shows as A, C, G, N, or Y on the SDX1 screen. These individuals are considered SSI cash recipients and remain eligible under the S01 medical coverage group).

When the medical eligibility code is 'R' (Referred to State), the ACES system takes the following steps, depending on whether the SSI is in nonpay status or is in suspended status.

Suspended Status

ACES checks the SDX to determine the individual's payment status code. If the code is a payment suspense code (S01, S04, S05, S06, S07, S08, S09 or S10) ACES waits and does not generate the 22-05 Redetermination letter and Alert 248 - SSI Terminated, Redetermine Medical Eligibility for 60 days. Social Security uses the suspense codes when updating an individual's address, changing a payee or budgeting fluctuating income and in many cases the SSI cash starts again within a short period of time.

If the individual's status changes again from suspended status to nonpay status at any time during the 60 day wait period, the 22-05 Redetermination letter is generated, along with the 248 Alert.

If the individual's status changes from suspended back to a pay status, then all tracking is stopped and no 22-05 Redetermination letter is sent. ACES automatically removes the SSI closure information from the bottom of the UNER screen when this happens.

After 60 days, if the status on the SDX has not changed, ACES generates the 248 Alert and 22-05 Redetermination letter to the individual.

Nonpay status

When the SSI closes for an individual who is not in a suspended status with Social Security Administration, ACES populates the bottom of the UNER screen with the SSI closure date and generates the 22-05 Redetermination letter and Alert 248.

Both suspended and terminated individuals have 60 days from the review is sent to return the form. At the end of 60 days, if the S01 AU is still active, ACES will check for 'Y' (Yes) in the ELIG RVW RCVD field on the MISC screen to indicate the review has been received. A barcode to ACES interface automatically populates this field if an eligibility review form is received in the Document Management System (DMS).

If there is a 'Y' on the MISC screen, Alert 251-SSI TERM'D 60 DAYS AGO, COMPLETE MED REDETERMINATION generates and the AU remains active until the review is initiated in the system.

If there is not a 'Y' on the MISC screen, the S01, L01 or L21 AU's will automatically close with reason code 235 - Review Not Complete and ACES generates the correct termination letter allowing advance notice. At this point, the redetermination process is complete. The ACES tracking process automatically stops if an SDX record is sent indicating the individual has started receiving SSI again.

Note: When SSI closes, a redetermination of the individual's disability status is also required, in addition to reviewing income and resource criteria. If SSI closed because the individual began receiving Title II Social Security Disability benefits, a new disability determination is not required. However, a referral needs to be made to DDDS to determine the disability review date if the individual is under the age of 65.

Disability review date

If SSI closed for some other reason, a new referral to DDDS for a disability determination may need to be made, unless you are able to contact the local SSA field office for the disability review date, or 'diary' date which is the term used by SSA. DDDS does not keep information about the disability review date once it sends the disability decision to the SSA field office, but SSA staff do have access to the information. Unfortunately, the diary date information is not available through any of the department interfaces with SSA, so if you are unable to obtain the diary date, or if it is time for the individual's disability status to be reviewed, a new DDDS referral for NGMA needs to be initiated. Follow directions under the Ex-Parte review process by screening in an S02. Then set the end date 4 months out to allow time for the disability decision to come back. Set a barcode tickler to review the case again at that time if no disability decision was received within that time frame.

Note: When approving the S02 (or S95/S99) coverage group, remember to change the Approval Source code on the DEM2 screen from "SI" to "SA" if the individual starts receiving Title II benefits.

If the individual receives long-term care services under a Home and Community Waiver (HCBS) program (COPES or DDD waiver), it is important to coordinate closely with the social worker or case manager during this process to ensure Apple Health coverage is not closed for these vulnerable individuals. If the individual has an Equal Access representative, guardian or designated authorized representative, ensure copies of all letters are sent to them so they can respond on behalf of the individual. See WAC 182-503-0120 for more information on Equal Access Services.

If the individual receives services through HCS or DDD, attach a copy of the latest individual CARE assessment to the NGMA referral packet (or ensure DDDS receives a copy if an electronic NGMA referral is initiated through barcode).

SSI-Related Special Income Disregards discusses the ACES redetermination process for individuals who lose eligibility under the SSI program but who remain eligible for CN Medicaid due to the SSI-related special income disregards: Pickle, Disabled Adult Child or the Disabled Widow(er) provisions.

Redetermination for Individuals Who Might Be Eligible for Apple Health.