Apple Health phone lines down Thursday, April 18
The Apple Health customer service phone lines will be down Thursday, April 18, from 11:30 a.m. to 2:30 p.m. We apologize for the inconvenience. View other ways to contact Apple Health.
The Apple Health customer service phone lines will be down Thursday, April 18, from 11:30 a.m. to 2:30 p.m. We apologize for the inconvenience. View other ways to contact Apple Health.
To define medical redetermination, describe when a medical redetermination is required, and to provide step by step directions through the process.
Definition: When eligibility ends for a CN Apple Health program during the certification period, federal law requires the agency (or its designee) to look at eligibility for other Apple Health programs before terminating CN coverage. Redetermination is completed at the point the agency considers eligibility for other Apple Health programs and documents in ACES that the reconsideration has been completed.
Without documentation of the redetermination process, the case will be found in error even if the correct action has been taken.
Note: CN coverage may end at the point of redetermination, even while waiting on a final disability determination, for example if the individual's income causes the CN medical (S02) to trickle to medically needy (MN) medical (S95/S99).
Effective October 1, 2017.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
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:
Below are instructions for handling common ex parte review findings.
Follow instructions above for "Individual Claims to Be Disabled or There Is an Indication of Disability in the Record" except:
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 157 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.
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.
Signed application or eligibility review forms are NOT needed for:
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:
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.
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, Q 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.
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.
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.
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.