Medical

Created on: 
Aug 11 2017

Alien Emergency Medical (AEM)

Created on: 
Aug 11 2017

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Alien Emergency Medical (AEM)?

Undocumented aliens ineligible for any other medical program due to citizenship or alien status, may be eligible for AEM programs. Eligibility criteria can be found in  Apple Health eligibility manual - Apple Health Alien Medical Programs.

How long is the certification period for Alien Emergency Medical (AEM)?

The certification periods for AEM:

  • Are set so that coverage begin and end dates match the exact date of the Specialized Medical Consultant's (SMC) approved date span. 
  • Cannot be more than 12 months for non-spenddown Assistance Units (AU).
  • Cannot be less than 1 month and no more than 6 months for spenddown AUs.
  • Are not synchronized with other related AUs.
  • Are not continued beyond the end date when a review is initiated or received but not completed 
NOTE:  If the SMC AEM approval date span includes a date for coverage to end in the future month, the system sets the certification end date to the last day of the month that the AEM End Date is approved for.  Example:  An application is processed on 5/10/17 and the Specialized Medical Consultant’s (SMC) approval span is 05/10/2017 to 08/21/2017.  In this scenario, the certification start date is set to 5/10/2017 and the certification end date is set to 8/31/2017.

 

For more information, see Apple Health eligibility manual - Apple Health Alien Medical Programs.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

 

Related Chapters

Modified Adjusted Gross Income (MAGI) Alien Emergency Medical (N21, N25)

Created on: 
Nov 13 2019

Online Processing 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What are the Modified Adjusted Gross Income (MAGI) Alien Medical coverage groups?

As a result of the implementation of the Affordable Care Act (ACA), the following MAGI Alien Medical Coverage groups are in effect with applications received starting 10/1/2013:

  • Parent/Caretaker Alien Emergency Medical (N21)
  • New Adult Alien Emergency Medical (N25)

Who processes the Modified Adjusted Gross Income (MAGI) Alien Medical programs?

MAGI Alien Medical Assistance Units (AU) belong to Health Care Authority (HCA) and can only be processed by HCA or Home and Community Services (HCS) staff.

MAGI AUs are in Region 9 and are assigned to one of the following Community Service Offices (CSO).

  • CSO 181 - MAGI AUs that belong to Region 1 geographical/zip catchment.
  • CSO 182 - MAGI AUs that belong to Region 2 geographical/zip catchment.
  • CSO 183 - MAGI AUs that belong to Region 3 geographical/zip catchment.

Online Processing

How do I process a pending Modified Adjusted Gross Income (MAGI) Alien Medical program?

To process a pending MAGI Alien Medical program, Health Care Authority (HCA)/Home and Community Service (HCS) staff need to take the following steps:

  1. From the Welcome back page in ACES.online, enter the [client id] in the Enter an ID field.
  2. From the Client Summary page, hover over Details and select Demographics from the drop down menu.
  3. At the bottom of the Client Demographics page in the Citizenship and Alien Medical section, update the following fields by clicking the Update link:
  • Alien Medical Emergency Indicator field - Select Yes (Y) from the drop down menu.
  • Alien Medical Approval Source Code field - Select one of the following from the drop down menu:
    • HCA Medical Consultant Approved (H)
    • ADSA Approved (A)
    • Referral Not Approved (N)
  • Approval Begin Date field - Enter the [approval begin date].
  • Approval End Date field - Enter the [approval end date].

Once the fields have been updated, HCA/HCS staff must access the application for Alien Emergency Medical (AEM) in Healthplanfinder to initiate a call to the Eligibility Service (EServ) to either approve or deny the Assistance Unit (AU).

NOTE: If AEM is pending in the ongoing and retroactive benefit months, users must finalize the ongoing months first before finalizing the pending retroactive months.

How do I process a Retroactive Modified Adjusted Gross Income (MAGI) Alien Emergency Medical (AEM) request?

To process a Retroactive MAGI Alien Emergency Medical (AEM) request, see Retroactive Medical.

NOTE: For AEM cases, users must update the AEM approval information in ACES.online to process the retro benefit months. Retro AEM approval information should be within the retro months in which the AEM was requested.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Non-Citizen Categorically Needy SSI Related (S07)

Created on: 
Jan 16 2019

Online Processing 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible for Non-Citizen CN SSI Related (S07) medical?

Undocumented aliens with a medical emergency who are SSI-related (aged, blind, or disabled), may be eligible to receive S07 medical coverage. See Apple Health eligibility manual - Apple Health Alien Medical Programs for more information.

What happens when a Non-Citizen client active on Medically Needy (MN) medical (S95) or Long Term Care MN No Spenddown (L95) becomes eligible for Non-Citizen CN SSI Related (S07) medical?

When a client is active on Medically Needy (L95/S95) and becomes eligible for S07, AUTO changes the medical coverage group to S07.

Online Processing

How do I screen Non-Citizen CN SSI Related (S07) medical?

S07 is screened initially as a SSI Related Categorically Needy (S02) Assistance Unit (AU). For instructions, see SSI Related Medical - How do I screen S02 medical?. When coded correctly, the S02 trickles to S07 when the AU is finalized.

NOTE: When screening the S02 AU, include all immediate family members in the household/AU to ensure proper allocation/deeming of income.

How do I process a pending Non-Citizen CN SSI Related (S07) medical Assistance Unit (AU)?

To process a pending SSI Related Categorically Needy (S02)/S07 AU, take the following steps:

  1. Go to the Case Actions page. For more information, see How do I access the Case Actions page in ACES 3G?
  2. Complete the interview following the steps in Online Processing - How do I initiate and complete an intake interview?
  3. On the AU Details page choose the following Financial Responsibility codes:
  • Applicant (PN) for the applicant.
  • Ineligible Spouse (SP) for an ineligible or non-applying spouse.
  • Child - SSI/Of SSI-related Parent/Used for HH Size (SC) for non-applying children of the applicant(s).
  1. On the Client page update the following fields:
  • In the Citizenship / Alien section:
    • Citizenship Status field - Select Undocumented Alien (U) using the drop down menu.
    • Other Federally Qualifying Status field - Select No Federal Qualified Status (NQ) using the drop down menu.
    • Alien medical Approval Source field - Select ADSA Headquarters Approved (A) or HCA Med Consultant Approved (H) using the drop down menu
    • Alien medical approval begin date field - Enter the [approval begin date].
    • Alien medical approval end date field - Enter the [approval end date].
  • In the Disability / Incapacitated / Psychiatric section:
    • Disability/Incapacity Type field - Select the appropriate disability or incapacity type using the drop down menu.
    • Approval Source field - Select the appropriate approval source using the drop down menu.
    • Approval Date field - Enter the [disability or incapacity approval date].
    • Established Date field - Enter the [date the disability or incapacity was established].
    • End Date [MM/YYYY] field - Enter the [end date if appropriate].
  1. On the Expense page, click the Add icon to add a Shelter Expense page for the applicant, if applicable.  Enter the applicant's shelter expense information in the appropriate fields.
  1. Complete all other screens as needed following the instructions in How do initiate and complete an intake interview?.
  2. After committing the interview data, follow the instructions in How do I complete Process Application Months? for all pending months.
  3. After all pending months have been processed, follow the instructions in How do I complete Finalize Application? to complete the S07 eligibility determination.

How do I open coverage for a non-citizen receiving Long Term Care (LTC) services in a residential setting?

To open coverage for a non-citizen receiving LTC services in a residential setting, follow the steps in State Funded LTC - SSI Related for Non-Citizens at Home or Alternate Living Facility (L24) - Online Processing.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Breast and Cervical Cancer Treatment Program (BCCTP) for Women (S30)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women) medical?

Women who meet the criteria listed in the Apple Health eligibility manual - WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility may be eligible for S30 medical coverage.

How long is the S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women) certification period?

S30 medical is certified for 12 months and is not subject to reporting requirements. However, S30 may be manually terminated prior to the end of the certification period using Reason Code 530 - Termination-Cancer Treatment Ends Prior to Cert Period if the client completes treatment before the certification period ends.  Also, S30 has retroactive medical coverage up to three months prior to the date of application.

Approximately 45-50 days prior to the end of the certification, ACES generates Alert 100 BREAST/CERV CANCER E/R DUE, CALL DOH. When this alert is received, the worker needs to contact the Department of Health (DOH) in order to determine continued eligibility. Letter 022-09 (Re-determination for Medical - BCCTP) can be sent to the client if necessary. An Eligibility Review form DSHS 14-78 is included with this letter when centrally printed.

How is eligibility determined for S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women)?

The Department of Health (DOH) completes the S30 eligibility determination and screening for breast and/or cervical cancer under the CDC Breast and Cervical Cancer Early Detection Program (BCCED) program.

How is S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women) opened?

The Medical Eligibility Determination Services unit (MEDS) Community Services Office (CSO) 076 administers the S30 program and open cases based on medical information received from the Department of Health (DOH). An active S30 cannot be transferred out of CSO 076.

Financial eligibility tests cannot be performed on S30 Assistance Units.

Can a client receive S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

Online Processing

How do I screen S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women) medical?

To screen an S30 medical Assistance Unit, follow the steps in the Screening an Application chapter. 

  1. On the Programs page click the checkbox next to Breast/Cervical Cancer.

How do I process a pending S30 (Breast and Cervical Cancer Treatment Program (BCCTP) for Women) Assistance Unit (AU)?

To process a pending S30 AU take the following steps:

  1. On the Assistance Units page, update the following fields:

  • BHP Plus field - Click the radio button next to Yes or No.
    • If Yes is selected, enter an [ACES User ID] in the User field.  
  • Financial Responsibility field: 
    • For the applicant - Applicant (PN).
    • For all other household members - Non-Member (NM).
  1. Complete the interview following the steps in How do I initiate and complete intake interview?.
  2. Complete processing following steps in How do I complete Process Application Months?.
  3. Finalize the case following the steps in How do I complete Finalize Application?.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Categorically Needy Foster Care / Adoption Support / Juvenile Rehabilitation Medical (D01/D02/D26)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive FC/AS/JRA/SSI CN (D01) medical?

A child in foster care, foster care relative placement, adoption support, or juvenile rehabilitation, who is an SSI recipient and age 0 - 21.  

See Apple Health eligibility manual - Foster Care Relative Placement Adoption Support Juvenile Rehabilitation Unaccompanied Minor Program and EAZ Manual - Foster Care/Relative Placement/Adoption Support/Juvenile Rehabilitation/Unaccompanied Minor Program.

Who is eligible to receive FC/AS/JR Medical (D02)?

A child in foster care, foster care relative placement, adoption support, or juvenile rehabilitation, who doesn't receive SSI and is age 0 - 18.

See Apple Health eligibility manual - Foster Care Relative Placement Adoption Support Juvenile Rehabilitation Unaccompanied Minor Program and EAZ Manual - Foster Care/Relative Placement/Adoption Support/Juvenile Rehabilitation/Unaccompanied Minor Program.

Can a client receive FC/AS/JRA/SSI CN (D01), FC/AS/JR Medical (D02), or Washington Apple Health Post-Foster Care Coverage (D26) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

Who is eligible to receive Washington Apple Health Post-Foster Care Coverage (D26) medical? 

Adults who were in foster care on their 18th birthday (on or after July 22, 2007) that aren't receiving SSI and are age 18 - 26.

See Apple Health eligibility manual - Foster Care Relative Placement Adoption Support Juvenile Rehabilitation Unaccompanied Minor Program and EAZ Manual - Foster Care/Relative Placement/Adoption Support/Juvenile Rehabilitation/Unaccompanied Minor Program.

Who can open and close a FC/AS/JRA/SSI CN (D01); FC/AS/JR Medical (D02) or Washington Apple Health Post-Foster Care Coverage (D26) Medical AU?

Only users on the Health Care Authority (HCA) Foster Care Medical Team (FCMT) and the Juvenile Rehabilitation Administration (JRA) Case manager who belong to the Office of Medicare, Medicaid, Eligibility and Policy (OMMEP) section can open or update a D01, D02 and D26 Assistance Units(AUs). Workers assigned to this unit are designated as unit type 17 in CSO 076.

Other users have read-only access to D01, D02 and D26 AUs.

NOTE:  For read-only users, the address for any Authorized Representative or child(ren) active on D01 and D02 appears as asterisks.

What happens before opening a FC/AS/JRA CN SSI (D01) or FC/AS/JR Medical (D02) AU?

The Children’s Administration Case Management System (FAMLINK) sends notifications to the Foster Care Medical Team (FCMT) for every child placed in foster care or adoption support.

Juvenile Rehabilitation Administration (JRA) Group Homes notify the JRA case manager when a child is placed in a juvenile rehabilitation group home.

If a child who is placed in foster care is active on an ACES Assistance Unit (AU), an interface between ACES and FAMLINK generates Alert 190 - ACES CHILD IN FOSTER CARE - CONTACT FOSTER CARE UNIT to the Community Services Office (CSO) user of record for the active AU.

As soon as possible, before month end, the CSO user contacts the FCMT to determine the child’s status. If appropriate, the child is closed off all other active medical AUs so the FCMT can open the child on D01 or D02 medical.

The CSO user also processes all benefit changes for the active ACES AUs from which the child was removed. See Change of Circumstances and EAZ Manual - Change of Circumstances - TOC.

For instructions about removing a child from an active ACES AUs, see Close an Assistance Unit/Client.

What do I do when a child leaves foster care, adoption support, or juvenile rehabilitation?

Foster Care Medical Team (FCMT) receives a tickle from the Children's Administration Case Management System (FAMLINK) that the child has left the placement.

FCMT users redetermine the child’s medical eligibility for any medical program and closes D01 or D02 Assistance Unit (AU).  

If the Foster Care Placement has ended, the D-track medical closes with Reason Code 166 - No Longer in Foster Care

If the child returns to a household that has an active ACES AU, the head of household reports this change. See EAZ Manual - WAC 388-418-0005 How will I know what changes to report?

When notified that the child has returned to the household, the Community Services Office (CSO) user adds the child back to the active AU(s) according to the eligibility requirements for the program(s). See EAZ Manual - WAC 388-418-0020 How does the department determine the date a change affects my cash and Basic Food benefits?

For instructions on adding a child to an active AU, see Add a Person.

Online Processing

NOTE:  Only FCMT staff can screen D01, D02 and D26 cases.

How do I screen FC/AS/JRA/SSI CN (D01)/FC/AS/JR Medical (D02)/Washington Apple Health Post-Foster Care Coverage (D26) medical?

To screen a D01, D02 or D26 AU, take the following steps:

  1. From the Welcome Back page in ACES.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.
  2. On the Applicant page, using the child as the Head-of-Household (HOH), enter the HOH's [Name], [Residential], and [Mailing Addresses].
  3. If the child is in a Child Placing Agency foster or adoptive home, click the checkbox next to AREP/Payee so the Child Placing Agency and the foster parent(s) can both be entered as authorized representatives.
  • Child Placing Agencies are licensed organizations allowed to recruit, train, and license foster homes; recruit and train adoptive parents; place children, including children referred by the department, for foster care or adoption. Both the Agency and the foster parents may need to obtain medical services for the same child during the same month.
  1. To add the authorized representatives, see How do I add an authorized representative (AREP) during screening?
  • Use AREP type Foster Care Agency (FC)  for the Child Placing Agency and type Other-Receives Letters, ER, Warrants/EFT, and Medical Services Card (NA) for the foster parents.
  1. Continue with the screening process until you reach the Programs page.
  1. On the Programs page, click the checkbox next to Foster Care/Adoption Support.
NOTE:  If you are not in the Foster Care Medical Team (FCMT), this option is grayed-out and cannot be checked.
  1. Complete the screening process. See Screening an Application.
  1. On the Finalize page, ACES.online defaults to the D01 coverage group. If the child does not receive SSI benefits, the program trickles to D02 when the AU is processed and finalized.
  • For D26 coverage, click the Specify Program button.
  • The Medical Coverage Group: field defaults to Washington Apple Health Post-Foster Care Coverage (D26).
  • Click Next to select this program and return to the Finalize page.

How do I process a pending FC/AS/JRA CN SSI (D01)/FC/AS/JR Medical (D02)/Washington Apple Health Post-Foster Care Coverage (D26) AU?

To process a D01, D02 or D26 AU, take the following steps:

  1. From the Commit Status page when screening has been completed, click on Interview
  2. On the Pending Application page, check the Begin Intake Box
  3. On the Client page, update the following fields:
  • Living arrangement code using the drop down list.​
    • Foster Care Non-Title IV-E (FC)
    • Foster Care Title IV-E (FE)
    • Adoption Support Non IV-E (AD)
    • Adoption Support IV-E (AE)
    • Juvenile Rehabilitation (JR)
  • Placement code using the drop down list
    • Only placement code Foster Care Expansion (E) is valid for D26 medical. 
  • Temporary Placement End date (if appropriate)
  • Placement Begin date 
  1. On the Programs page, click the checkbox next to Foster Care/Adoption Support.
NOTE:  If you are not in the Foster Care Medical Team (FCMT), this option will be grayed-out and cannot be checked.
  1. If the child receives SSI benefits, add unearned income type SI – SSI Benefits.  
NOTE: Only FCMT staff and Juvenile Rehabilitation Administration (JRA) case managers should use Foster Care related living arrangement codes.
 
  1. Complete the interview following the instructions in the Interview chapter.  
  2. From the Case Actions Page, Process the current/historical months if the client's data is different in those month.  
  3. From the Case Actions Page, click on Finalize to finalize the application. 

When does a D-Track medical AU trickle/spawn/close?

A D02 medical trickles to D26 the month following the child’s 18th birthday when the placement code is auto-changed to Foster Care Expansion (E) or when the placement code is one following:

  • Foster Care Placement (F)
  • Relative Placement (R)
  • Tribal Foster Care Placement (T)
  • Interstate Compact on Placement of Children (ICPC) (P)

When D02 trickles to D26:

  • During the automated batch process, any Authorized Representatives (AREP) is removed.  
  • As a result of worker actions, the worker determines if the AREP should be retained or deleted.
  • The Address Confidentiality security function is removed making the client address viewable for users with read-only access.

A D02 medical spawns to D01 medical if  SSI is approved for Foster Care clients under age 18 who are eligible for SSI.

A D26 medical spawns to D02 in the ongoing month, through the month a client turns age 21, when the Placement Code Foster Care Expansion - E is changed to one of the following codes:

  • Adoption Support Client in Relative Placement (A)
  • DDD Client in Relative Placement (D)
  • Foster Care Higher Education (H)
  • Juvenile Rehabilitation Placement (J)
  • Interstate Compact on Placement of Adoption & Medical Assistance (ICAMA) Placement (M)
  • Special Immigration Juvenile Status in Foster Care (S)
  • Unaccompanied Minor Program (U)
  • Voluntary Placement Program (V)

ACES automatically terminates D26 Assistance Units (AUs) at the end of the month the child turns age 26 with Reason Code 220 – Failed Age Requirement.

When Foster Care Placement has ended, the D-track medical is closed with Reason Code 166 - No Longer in Foster Care 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Categorically Needy Non-Institutional Medical in an Alternate Living Facility (G03)

Created on: 
Nov 13 2019

Online Processing 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible for Categorically Needy Non-Institutional Medical in an Alternate Living Facility (G03)?

This program is used for SSI-related individuals receiving Long-Term Service and Support (LTSS) under Medicaid Personal Care (MPC) or Community First Choice (CFC).  It is also used for Regional Support Network (RSN) placements in Alternate Living Facilities (ALF).

The individual income test is performed for all G03 clients. They are income eligible if their countable income is over the Categorically Needy Income Level (CNIL), but under the Special Income Level (SIL) and the state-contracted rate (x) number of days.  The state contracted daily rate drives the eligibility for G03.

  • The income calculation for G03 AUs follows the same path as SSI Related Categorically Needy (S02) AUs. When a G03 recipient’s own net income is less than or equal to the one person Categorically Needy Income Level (CNIL), the following edit message displays on the Eligibility and Eligibility Details pages: Client is eligible for S02. Screen in S02 and Close G03.
  • If the G03 applicant or recipient's own countable Net Income is less than or equal to the calculated Group C income standard, they are eligible for G03.
  • If the G03 applicant or recipient's own countable Net Income is greater than the calculated Group C income standard, they are not eligible for G03 and the system trickles to MN and performs tests for G95 or G99.  SSI-related individuals paying privately in a state-contracted Alternate Living Facilities (ALF) can be considered for this program under Medically Needy Non-Institutional Medical in an Alternate Living Facility – No Spenddown (G95) or Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown (G99).     

For more information, see Apple Health eligibility manual - WAC 182-513-1205 Determining eligibility for non-institutional coverage in an alternate living facility.

How long is Categorically Needy Non-Institutional Medical in an Alternate Living Facility (G03) certified?

G03 is certified for 12 months.

For more information, see Apple Health eligibility manual - WAC 182-504-0015 Washington apple health -- Certification periods for categorically needy programs.

Online Processing

How do I screen G03 (Categorically Needy Non-Institutional Medical in an Alternate Living Facility)?

To screen a G03 Assistance Unit, take the following steps:

  1.  Follow the instructions in Screening an Application - How do I screen an application for a client? 
  2.  On the Programs page, click the checkmark next to Medical.       
  3.  On the Finalize page, take the following steps in the Specify Program Section:​ ​
  • Program field – Select Medical Assistance (MA) from the drop down list.
  • Medical Coverage Group field – Select Alternate Living Facility (G03) from the drop down list.  
  • Program Type field – Select the appropriate program type from the drop down field.

How do I process a pending G03 (Categorically Needy Non-Institutional Medical in an Alternate Living Facility) Assistance Unit (AU)?

  1. Follow the steps in Interview - How do I initiate and complete an intake interview?
  1. Follow the steps in Finalize Application - How do I complete Finalize Application?
NOTE:  If the AU exceeds the income standard for G03, it may trickle to Medically Needy Non-Institutional Medical in an Alternate Living Facility – No Spenddown (G95)  or Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown (G99) during finalize.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Children's Medical

Created on: 
Aug 11 2017

Modified Adjusted Gross Income (MAGI) - Newborn Medical (N10)

Created on: 
Jan 18 2020

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive N10 (MAGI Newborn Medical)?

A child under the age of one is eligible for categorically needy (CN) Newborn Medical assistance when:

  • The child's mother was eligible for and receiving coverage under a medical program at the time of the child's birth; and
  • The child is a Washington state resident.

For more information on N10 medical eligibility, see Apple Health eligibility manual - WAC 182-505-0210 Washington apple health - Eligibility for children.

Can a client receive N10 (MAGI Newborn Medical) coverage while incarcerated? 

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

How long is the N10 (MAGI Newborn Medical) certification period?

The N10 medical program may be certified up to 12 months, through the end of the month of the child’s first birthday.

How long is a newborn covered under their mother’s medical?

Newborns are covered under their mother’s medical Services Card:

  • Through the month in which the 21st day of life occurs if mom was on managed care, or
  • Through the month that includes the baby's 60th day of life if mom was on fee-for-service medical benefits.

For more information on how long a newborn is covered under their mother's medical, see Apple Health eligibility manual - WAC 182-505-0210 Washington apple health - Eligibility for children - Clarifying Information.

Who can process N10 (MAGI Newborn Medical) in ACES?

Users with Enhanced Secured Group Newborn N10 Update in their ACES.online profile can screen new N10 AUs in ACES.online/ACES 3G. If the N10 AUs were screened in ACES.online/ACES 3g, users in this group can also:

  • Process and finalize N10 
  • Make changes to N10 AUs 
  • Reinstate N10 AUs 

Online Processing

How do I screen N10 (MAGI Newborn Medical) in ACES?

To screen N10 MAGI medical, take the following steps in ACES.online:

  1. Follow the instructions in Screening an Application.
  2. On the ACES Screening – Finalize page, click Specify Program to go to the ACES Screening – Finalize Details page.
  3. On the ACES Screening – Finalize Details page, complete the following fields:
  • Program dropdown – Select Medical Assistance (MA).
  • Medical Coverage Group dropdown – Select Newborn (N10).
  1. Click Next to return to the ACES Screening – Finalize page.
  2. In the Application Date field, enter [the newborn’s Birth Date].
  3. Click Commit.

How do I process and finalize N10 (MAGI Newborn Medical) in ACES?

To process and finalize N10 (Newborn) MAGI medical AUs screened in ACES.online, follow the steps in the InterviewProcess Application Months, and Finalize chapters.

NOTE: N10 AUs screened and processed in ACES.online/ACES 3G are always denied in the ongoing month.

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Modified Adjusted Gross Income (MAGI) - Children's Medical (N11/N31)

Created on: 
Jul 12 2017

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive N11 (MAGI - Children's Medical - Federal) and N31 (MAGI - Children's State) medical?

Children under the age of 19 may be eligible for N11 or N31 medical when they meet the requirements described in Apple Health eligibility manual - WAC 188-505-0210 Washington apple health - Eligibility for children.

For income standards, see Apple Health eligibility manual - WAC 182-505-0100 Washington apple health - Monthly income standards based on the federal poverty level (FPL).

Can a client receive N11 (MAGI - Children's Medical - Federal) or N11 (MAGI - Children's State) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

Can a child be eligible for N11 (MAGI - Children's Medical - Federal) or N31 (MAGI - Children's State) if the household’s income exceeds the N11/N31 income standards?

Children may be eligible for N11/N31 as a separate Medical Assistance Unit (MAU) when certain conditions exist. For more information, see Apple Health eligibility manual - WAC 182-506-0010 Medical assistance units (MAU) for MAGI-based Washington apple health programs.

Children not eligible to receive N11/N31 medical, may be eligible under another program:

Children who were previously approved for certain medical benefits within the last 12 months may be eligible for continuous eligibility. See Continuous Eligibility for Categorically Needy Children's Medical.

How long is the N11 (MAGI - Children's Medical - Federal) or N31 (MAGI - Children's State) certification period?

The certification period for N11/N31 medical is 12 months. When the child turns 19, the certification ends even if the 12 months are not over. For additional information, see Apple Health eligibility manual – WAC 182-504-0015 Washington apple health - Certification periods for categorically needy programs.

Changes during the certification period that affect eligibility should be processed according to Apple Health eligibility manual – WAC 182-504-0125 Washington apple health - Effect of reported changes.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Modified Adjusted Gross Income (MAGI) - Children's Health Insurance Programs (CHIP) (N13/N33)

Created on: 
Dec 04 2019

Online Processing

Mainframe Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) medical?

Children under the age of 19 may be eligible for N13 or N33 medical when they meet the requirements described in Apple Health eligibility manual – WAC 182-505-0210 Washington apple health - Eligibility for children.

For income standards, see Apple Health eligibility manual - WAC 182-505-0100 Washington apple health - Monthly income standards based on the federal poverty level (FPL).

Can a client receive N13 (MAGI - CHIP Federal) or N33 (MAGI -  CHIP State) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

How long is the N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) certification period?

The certification period for N13/N33 medical is 12 months. When the child turns 19, the certification period ends even if the 12 month period is not over.

The certification may extend beyond the end of the month of the child’s 19th birthday when certain conditions exist. For more information, see Apple Health eligibility manual - WAC 182-504-0015 Washington apple health - Certification periods for categorically needy programs.

What are the premium requirements for N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) medical?

Children receiving N13 or N33 medical are required to pay premiums and enroll in managed care. For more information, see Apple Health eligibility manual - WAC 182-505-0225 Premium requirements for premium-based health care coverage under programs included in apple health for kids.

Do all N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) recipients pay a monthly premium?

For more information on whether all N13/N33 recipients pay a monthly premium, see Apple Health eligibility manual - WAC 182-505-0225 - Premium requirements for premium-based health care coverage under programs included in apple health for kids.

How are N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) premiums calculated?

Premium amounts are based on the household’s net countable income.

  • Tier 1 Premiums - Households with income greater than 200% and up to 250% of the Federal Poverty Level (FPL) are required to pay $20 per child with a maximum of two premiums for households with two or more children.
  • Tier 2 Premiums - Households with income greater that 250% and up to 300% of the FPL are required to pay $30 per child with a maximum of two premiums for households with two or more children.

Premium amounts for non-citizen children who are not lawfully present qualified or nonqualified (NQ) alien children in households with income above the 200% FPL have a higher premium amount which is no greater than the average of the state-share of the per capita cost for state-funded children's health coverage.

The orders in which premiums are determined are as follows:

  • Federally Qualified children with Tier 1 premiums.
  • Federally Qualified children with Tier 2 premiums.
  • Non-Qualified/Non-Federally Qualified children.
EXAMPLE:
1. If a household has three children, two which are citizens and the other is NQ or non-federally qualified, the household is billed for the two citizen children first. Since the cap is 2 children there is no billing for the NQ child.
2. If a household has two children, one child is a citizen and the other child is NQ or non-federally qualified. The household is billed for the citizen child and for the NQ child.

For more information, see Apple Health eligibility manual - WAC 182-505-0225 - Premium requirements for premium-based health care coverage under programs included in apple health for kids.

How do clients pay their N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) premiums?

For more information on how clients pay their premiums, see Apple Health eligibility manual - WAC 182-505-0225 - Premium requirements for premium-based health care coverage under programs included in apple health for kids.

What is a "Locked-In" premium tier?

A "Locked-In" premium tier is the lowest tier level that a child active on N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) is eligible for during the child’s Continuous Eligibility tracking period.

EXAMPLE: A child is living with his mother, active on N13, and "Locked-in" to $20.00 Tier 1 monthly Premium. The child leaves mom's home to go live with dad and his two other children. Dad's income is over 250% Federal Poverty Level so the 2 kids living with him are "locked-in" to Tier 2 premiums of $30.00 each, for a household premium of $60.00. When the Tier 1 child is added to dad's household the household's total premium changes from $60.00 to $50.00, because the system uses the lowest "locked-in" premiums for the two premium cap.

Online Processing

Where does premium tier information display?

Premium tier information displays in ACES.online on the Premium Payment Status and Premium Amount - Children's Medical pages.

How do I remove a "Locked-In" premium tier?

To remove a "locked-in" premium tier, enter Reason Code 536 - Fail with no Tier Tracking in the Reasons field on the Assistance Unit Details page of the ongoing month to reset the "locked-in" tier level from 1 to 2.

How can I tell what a family's premium amount is?

The Premium Payment Status and Premium Amount - Children's Medical page is AUTO updated when an optional child, not exempt from premiums, is found eligible for N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP Premium) medical prior to ACES deadline.

Two days after ACES deadline, during the monthly issuance run, ACES sends an interface to Financial Services Administration (FSA) who begins billing for medical coverage received the following month. The Premium Payment Status and Premium Amount - Children's Medical page displays the household’s premium amount after FSA has successfully interface with ACES.

The amount of the premium is determined by the amount of income in the Net Income field in the Net Income section on the Eligibility Details page.

A household’s premium amount and any delinquent payment information can be viewed on the Premium Payment Status and Premium Amount - Children's Medical page.

The Premium Payment Status and Premium Amount - Children's Medical page is not benefit-month driven. The page displays the latest premium that the Head of Household must pay per month.

What happens if a Children's Health Insurance (CHIP) premium is not paid?

If the N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) premiums are not paid for three consecutive months, the child is disenrolled from the program. The family must then pay all past-due premiums before the child can be re-enrolled. 

When notification is received from Financial Services Administration (FSA) that a household has delinquent premiums, the following actions take place:

  • ACES reviews each active N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) Assistance Unit (AU) for Optional Children.
  • Each non-exempt optional child’s Financial Responsibility code on the Assistance Unit Details page is changed to Ineligible Child (IC) with Reason Code 342 - Termination/Denial Due to Non-Payment of Premium.
  • AUs without any mandatory or optional children close with Reason Code 342.
  • Sanction Reason field entry 200 - Delinquent Payment Amount is added to each non-exempt optional child. The sanction Eff Start Dt is set to the ongoing benefit month. The sanction End Date on the Sanctions Summary page is set at 90 days.  The "Locked-Out" period of 90 days starts the first of the month following the notice of adverse action. For more information on adverse action, see Adverse Action (10 day notice).
  • The Premium Amount field on the Premium Amount - Children's Medical page is changed to zero and the Premium Effective Date lists the current date.
  • The Delinquent Amount field on the Premium Amount - Children's Medical page and Notification Date field is updated from the FSA interface.

What happens when a delinquent payment is received late?

When notification is received from the Financial Services Administration (FSA) interface that a delinquent premium amount has been paid in full, the following automated process occurs for all N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) Assistance Units (AUs):

  • The Delinquent Amount field on the Premium Amount - Children's Medical page is updated to zero.
  • The Notification Full Payment Received Date field on the Premium Amount - Children's Medical page is updated with information received from FSA.
  • A Narrative entry is AUTO added to the Head of Household indicating the premium payment has been paid in full with the date payment was received.
  • When the AU is re-opened or reinstated, the Sanctions page data is kept or deleted depending on the receipt timeframe of the delinquent payment.
  • There are two valid reasons to enter a sanction exemption code: continuous medical eligibility pending a fair hearing or department error.
  • For all active AUs, recalculation of eligibility re-determines the household premium amount for the next premium interface with FSA.

Mainframe Processing

Where does premium tier Information display?

Premium tier information displays in the OP field on the STAT and ELIG screens, and on the CTCN screen in the Prem Tier Level field.

How can I tell what a family’s premium amount is?

The PREM screen is AUTO updated when an optional child, not exempt from premiums, is found eligible for N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP Premium) medical prior to ACES deadline.

Two days after ACES deadline, during the monthly issuance run, ACES sends an interface to Financial Services Administration (FSA) who begins billing for medical coverage received the following month. After FSA has successfully interfaced with ACES, the PREM screen displays the household’s premium amount.

The amount of the premium is determined by the amount of income in the Net Income field on the MAFI screen.

A household’s premium amount and any delinquent payment information can be viewed on the PREM screen. You can also find the PREM information by selecting <F20> from the MAFI screen.

The PREM screen is not benefit-month driven. The PREM screen displays the latest premium that the Head of Household must pay per month. Historical data can be viewed by using the As Of Date field on the AMEN screen, Option B - AU/Client Inquiry.

What happens if a Children's Health Insurance (CHIP) premium is not paid?

If the N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) premiums are not paid for three consecutive months, the child is disenrolled from the program. The family must then pay all past due premiums before the child can be re-enrolled.

When notification is received from Financial Services Administration (FSA) that a household has delinquent premiums, the following actions take place:

  • ACES reviews each active N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) Assistance Unit (AU) for Optional Children.
  • Each non-exempt optional child’s Finl Resp code on the STAT screen is changed to [IC] - Ineligible Child with Reason Code 342 - Termination/Denial Due to Non-Payment of Premium.
  • AUs without any mandatory or optional children close with Reason Code 342.
  • Sanction Reason field entry 200 - Delinquent Payment Amount on the SANC screen is added to each non-exempt optional child. The sanction Eff Start Dt is set to the ongoing benefit month. The sanction End Dt is set at 90 days.  The "Locked-Out" period of 90 days starts the first of the month following the notice of adverse action. For more information on adverse action, see Adverse Action (10 day notice).
  • The Premium Amount field on the PREM screen is changed to zero and the Premium Effective Date lists the current date.
  • The Delinquent Amount field on the PREM screen and Notification Date field is updated from the FSA interface.

What happens when a delinquent payment is received late?

When notification is received from the Financial Services Administration (FSA) interface that a delinquent premium amount has been paid in full, the following automated process occurs for all N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) Assistance Units (AUs):

  • The Delinquent Amount field on the PREM screen is updated to zero.
  • The Full Payment Received Date field on the PREM screen is updated with information received from FSA.
  • A Narrative entry is AUTO added to the Head of Household indicating the premium payment has been paid in full with the date payment was received. The entry appears in “pink” when displayed on the NARR screen.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Children's Medically Needy Program (F99)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who processes F99 (Medically Needy (MN) Children with Spenddown) Assistance Units (AUs)?

F99 AUs are processed by Health Care Authority (HCA) users assigned to Region 9 in one of the following Modified Adjusted Gross Income (MAGI) Community Service Offices:

  • 181 - Houses MAGI AUs that belong to Region 1 geographical/zip catchment.
  • 182 - Houses MAGI AUs that belong to Region 2 geographical/zip catchment.
  • 183 - Houses MAGI AUs that belong to Region 3 geographical/zip catchment.

HCA users have the ability to screen in or reinstate F99 AUs if needed.

Who is eligible for F99 (Medically Needy (MN) Children with Spenddown) Medical?

Individuals who meet the criteria in the following WAC may be eligible for F99 medical coverage: Apple Health eligibility manual - WAC 182-505-0210 - Washington apple health - Eligibility for children.

Can a client receive F99 (Medically Needy (MN) Children with Spenddown) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

How long is the F99 (Medically Needy (MN) Children with Spenddown) certification period?

F99 assistance units default to a six-month certification period but can be shortened. For more information, see Apple Health eligibility manual – WAC 182-519-0110 Spenddown of excess income for the medically needy program.

Online Processing

How do I screen F99 (Medically Needy Children with Spenddown) medical?

To screen in a F99 Assistance Unit (AU) take the following steps:

  1. Follow the instructions in How do I screen an application for a client?    

How do I process a pending F99 (Medically Needy Children with Spenddown) Assistance Unit (AU)?

To process a pending F99, take the following steps:

  1. Go to the Case Actions page. For more information, see How do I access the Case Actions page in ACES 3G?
  2. Complete the interview following the steps in How do I initiate and complete an intake interview?
  3. Complete all other screens as needed following the instructions in the Interview chapter.
  4. After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months.
  5. After all pending months have been processed; follow the instructions in the Finalize Application chapter to complete the F99 eligibility determination.

For more information on the spenddown process, see Apple Health for the Medically Needy and Spenddown.

How do I add a person to a F99 (Medically Needy Children with Spenddown) Assistance Unit (AU) when it's at M status?

Additional household members cannot be added to a spenddown AU at M status.

A new AU is needed for the change in household composition.

To add a person to an F99 AU, take the following steps:

  1. Manually close the current F99 AU following the instruction in the Online Processing - How do I manually close an Assistance Unit (AU) or client?
NOTE: Before manually closing the current F99 AU, review the base period and shorten if necessary. For more information, see Online Processing - How do I shorten a spenddown Assistance Unit (AU) base period?.
  1. Screen in a new F99 AU including the new AU member(s) and following the instructions in Online Processing - How do I screen F99 (Medically Needy Children with Spenddown) medical?
  2. Process the pending F99 AU following the instructions in Online Processing - How do I process a pending F99 (Medically Needy Children with Spenddown) Assistance Unit (AU)? 

How do I enter spenddown medical expenses for an F99 (Medically Needy Children with Spenddown) Assistance Unit (AU) in M status?

To enter medical expenses to meet the client’s spenddown liability on an F99 AU in M status, take the following steps:

  1. Follow the instructions in Spenddown - How do I enter medical expenses?
  2. After expenses have been added, follow the steps in Spenddown - How do I assign medical expenses and authorize spenddown?

How do I initiate an Eligibility Review on an F99 (Medically Needy Children with Spenddown) Assistance Unit (AU)?

To complete the eligibility review on an F99 AU take the following steps:

  1. Follow the instructions in the Eligibility Review chapter.

Eligibility reviews can be initiated on spenddown AUs in A - Active or M - MA Spenddown status. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Continuous Eligibility for Categorically Needy Children's Medical

Created on: 
Nov 13 2019

Online Processing

Mainframe Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Categorically Needy (CN) Children's Medical?

Children who have been determined eligible for CN medical are eligible to receive a full 12 months of CN medical coverage regardless of changes in the circumstances or the household the child is associated with.

For more information see the following:

What Categorically Needy (CN) medical coverage groups are tracked?

ACES tracks each child's certification in the following CN medical coverage groups:

  • K01 - CN Long Term Care (LTC) - Family
  • L01 - CN LTC in a Medical Facility - Supplemental Security Income (SSI) Recipient
  • L02 - CN LTC in a Medical Facility - SSI Related
  • N11 - Modified Adjusted Gross Income (MAGI) Children's Medical - Federal
  • N13 - MAGI Children's Health Insurance Program (CHIP) - Federal
  • N31 - MAGI Children's Medical - State
  • N33 - MAGI CHIP - State
  • S01 - SSI Categorically Needy

Each recipient child in the above medical coverage groups are tracked for a 12-month potential continuous range which is based on the begin date of the certification period. The potential range end date is the child's begin date plus 11 months, it is not based on the number of months the client received coverage.

When is Modified Adjusted Gross Income (MAGI) Children's Health Insurance Program (CHIP) - Federal (N13) and MAGI CHIP - State (N33) coverage automatically authorized?

When a child is closed off an N13 or N33 Assistance Unit (AU) that does not result in continuous eligibility, the system continues to track continuous N13/N33 eligibility. If the child is reopened on medical during the 12 month tracking period, and the household's income exceeds 200% of the Federal Poverty Level, the MAGI Children's - Federal (N11) or MAGI Children's - State (N31) AU trickles to an active N13/N33 AU.

What happens to a child's continuous range when they are added to a Modified Adjusted Gross Income (MAGI) household?

When a child is added to a MAGI household and becomes an active recipient, the begin date of the tracking is the begin date on the new certification period for that child. A new potential continuous range is created for the added client(s) only and each added recipient child gets their own complete 12-month potential range.

Online Processing

How is Categorically Needy (CN) continuous medical eligibility tracked in ACES?

The system automatically tracks a child's 12-month continuous CN Medicaid coverage based on the begin date of the Assistance Units (AUs) certification period on the Children's Tracking CN Medicaid page.

How do I access the Children's Tracking CN Medicaid page?

The Children's Tracking CN Medicaid page can be accessed in the following ways in ACES.online:

  1. On the Welcome Back page in ACES.online, complete the following fields in the Quick Navigation section:
  • Select a Type of ID field - Select Client from the drop down menu.
  • Enter an ID field - Enter a [Client ID number].
  • Select a Page field - Select Children's Tracking CN Medicaid from the drop down menu and click Go.
  1. From the Summary page, select Children's Tracking CN Medicaid from the Details submenu.

What information is displayed on the Children's Tracking CN Medicaid page?

The Children's Tracking CN Medicaid page displays the following information:

  • AU ID field - The Assistance Unit (AU) number under which the client is receiving, or has received Categorically Needy (CN) Medicaid Coverage.
  • Range Start and Range End fields - The range start date plus 11 months calculates the range end date. Continuous range is 12 months regardless of the original AU certification period.
  • Premium Tier field - The premium Tier level a recipient is “locked” into.
  • Premium Tier End Date field - The date the Tier level is anticipated to end.
  • Cancelled Date field - The date the CN Medicaid range is no longer tracked and is not considered for continuous coverage.
NOTE: If no Children's Tracking data exists for that client the following message will display: No Tracking Record For The Child's Continuous Eligibility Found. 

How do I invalidate Continuous Eligibility Tracking (CTCN) in ACES.online?

For more information on invalidating the CTCN for children's medical, see How do I invalidate Continuous Eligibility Tracking (CTCN) for Children's Washington Apple Health (WAH) Modified Adjusted Gross Income (MAGI) in ACES.online?

Mainframe Processing

How is Categorically Needy (CN) continuous medical eligibility tracked in ACES?

The system automatically tracks a child's 12-month continuous CN Medicaid coverage based on the begin date of the Assistance Units (AUs) certification period on the CTCN screen.

How do I access the CTCN screen?

The CTCN screen can be accessed in the following ways:

  1. On the AMEN screen, complete the following fields:
  • Selection field - Enter [2] - Children's Tracking CN
  • Client ID field - Enter the [Client ID].
  1. From the CLLI screen, enter a [Y] in S field next to the client and press <F13>.

What information is displayed on the CTCN screen?

The CTCN screen displays the following information:

  • CN MEDICAID AU field - The Assistance Unit (AU) number under which the client is receiving, or has received Categorically Needy (CN) Medicaid Coverage.
  • Potential Continuous Range field - The range start date plus 11 months calculates the range end date. Continuous range is 12 months regardless of the original AU certification period.
  • Prem Tier Level field - The premium Tier level a recipient is “locked” into.
  • End Dt field - The date the Tier level is anticipated to end.
  • Removed field - The date the CN Medicaid range is no longer tracked and is not considered for continuous coverage.

The CTCN screen is an Inquiry only screen and is not part of the data collection screen flow. No fast path or remarks are allowed on the screen. Paging is allowed when more data exists with the most current tracked period appearing at the top of the list. 

NOTE: If no CTCN data exists for that client, the following message is generated: 0215 NO DATA AVAILABLE FOR DISPLAY

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Healthcare for Workers with Disabilities (HWD) (S08)

Created on: 
Nov 22 2019

Online Processing

Mainframe Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is the Healthcare for Workers with Disabilities (HWD) (S08) medical program?

The HWD medical program recognizes the employment potential of people with disabilities. The enactment of the federal Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999 enables many people with disabilities to work and keep their health care.

As a Categorically Needy (CN) Medicaid program, HWD provides access to Medicaid Personal Care services (MPC) and Home and Community Based (HCB) waiver programs administered by the Developmental Disabilities Administration (DDA) and Home and Communities Services (HCS).

Who can process Healthcare for Workers with Disabilities (HWD) (S08) Assistance Units (AUs)?

Users with Secured Task HWD Update in their ACES.online profile can complete the following functions for S08 AUs:

  • Screen a new S08 AU,
  • Re-open an S08 AU,
  • Add-a-person to an S08 AU,
  • Reinstate an S08 AU,
  • Initiate an ER for an S08 AU,
  • Enter a date in the Client Chosen HWD Begin Date field, and
  • Update the HWD Employment Good Cause indicator.

What happens if the Healthcare for Workers with Disabilities (HWD) (S08) premium is not paid for an active S08 Assistance Unit (AU)?

If an HWD premium isn’t paid for 90 days on an active S08 AU, Barcode tickler HW02-90 DAYS NON-PAYMENT OF PREMIUM FEES generates.  This tickler advises the user of record that the client is nearing HWD termination and sanction for non-payment of premiums.

When the premium is paid, Barcode Tickler HW03- S08 DELINQUENT PMT REC'D generates to the user of record when the Office of Financial Recovery (OFR) notifies ACES that an S08 client has made a delinquent premium payment on or before the last day of the 4th month of delinquent payment months.

See the Apple Health eligibility manual - WAC 182-511-1250 Healthcare for workers with disabilities (HWD) -- Premium Payments - Clarifying Information - Initial Premium Amount for information on entering the initial premium amount.

What happens if a client is eligible for Healthcare for Workers with Disabilities (HWD) (S08) and other Categorically Needy (CN) or Medically Needy (MN) medical coverage?

If a client is approved for an MN SSI Related w/Spenddown (S99) Assistance Unit (AU) and they meet S08 employment requirements, Barcode Tickler HW01-S99 SPENDDOWN GREATER THAN HWD PREMIUM generates to the user of record.

See the Apple Health eligibility manual - WAC 182-511-1100 Health care for workers with disabilities (HWD) -- Retroactive coverage - Worker Responsibilities for more information on S08 and S99 eligibility.

How are S08 (Healthcare for Workers with Disabilities) premiums calculated?

For information on how S08 premiums are calculated, see Apple Health eligibility manual - WAC 182-511-1250 Healthcare for workers with disabilities (HWD) - Premium payments.

How do clients pay their S08 (Healthcare for Workers with Disabilities) premiums?

S08 premiums are paid directly to the Office of Financial Recovery (OFR). For more information, see Apple Health eligibility manual - WAC 182-511-1250 Healthcare for workers with disabilities (HWD) - Premium payments - Worker Responsibilities.

What happens if the S08 (Healthcare for Workers with Disabilities) premium is not paid?

If the premium is not paid for four consecutive months an interface from the Office of Financial Recovery communicates this information to ACES.

ACES generates Alert 235 - PREMIUM PAYMENT 120 DAYS OVERDUE. When this alert is received, the worker closes the S08 Assistance Unit and determines eligibility for other medical programs.

If a client does not pay four consecutive monthly premiums, that person is not eligible for S08 coverage for the next four months, and must pay all premium amounts owed before S08 coverage can be approved again.

Online Processing

How do I screen a Healthcare for Workers with Disabilities (HWD) (S08) medical Assistance Unit (AU)?

To screen an S08 medical AU, take the following steps:

  1. From the Welcome Back page in ACES.online, click the Screen New Application link at the top left of the page. The Applicant page displays in a new window.
  2. On the Applicant page:
  • In the Applicant Name field enter the [applicant's name]
  • In the Residential Address field enter the [applicant's residential address].
    • If the applicant's mailing address is different than the residential address, click the box next to Mailing Address same as above to remove the checkmark and enter the applicant's mailing address.
  • To add an Authorized Representative, follow the steps in Screening - Add/Edit/Delete Authorized Representation (AREP).
  • Click the Next button and the Address Validation page displays.
  1. On the Address Validation page:
  • Take the necessary steps to complete the address validation process. See Screening - Address Validation for additional information.
  • Click the Next button and the Programs page displays.
  1. On the Programs page:
  • Click the checkbox next to Healthcare/Workers with Disabilities(HWD) in the Programs section.
    • If appropriate, click the checkbox next to Disabled or Blind in the Programs Determination Criteria section. If no box is checked the default Program Type is Disabled (D).
  1. Continue screening following the steps in the Screening an Application chapter.
  2. On the Finalize page, click the checkbox next to Medical Assistance (MA).
  3. Enter the Application Date in [mmddyyyy] format.
  4. Click the Commit button.

How do I process a Healthcare for Workers with Disabilities (HWD) (S08) medical Assistance Unit (AU)?

To process an S08 medical AU, take the following steps:
  1. From the Case Actions page, select Start Interview.
  2. On the Assistance Unit page: 
  • In the AU ID section, enter [a date] in the Client Chosen HWD Begin Date field:
    • If the client has not chosen a begin date leave this field blank.
NOTE: The S08 AU remains in pending status until a date is entered in the Client Chosen HWD Begin Date field, even when the AU is finalized. 
  • In the Clients section, update the Financial Responsibility with the appropriate program codes from the drop down menu:
    • Applicant (PN) (for only one member of the AU)
    • ABD Parent (AP)
    • Alien Sponsor (AL)
    • Child - SSI/Of SSI-related Parent/Used for HH Size (SC)
    • Ineligible Person (IP)
    • Ineligible Spouse (SP)
    • Non-Member (NM)
  1. On the Client Details page, update the HWD Employment Good Cause indicator:

  • Yes (Y) - Client meets HWD employment requirements
  • No (N) – Client does not meet HWD employment requirement.
NOTE: If the HWD Employment Good Cause indicator is No (N) or blank and there is no earned income coded, the S08 AU will deny for Reason: Employment Requirement Not Met (196).
  1. To complete the interview, follow the steps in Interview - Online Processing.

  2. After committing the interview data, follow the steps in How do I complete Process Application Months?.

NOTE: Barcode Tickler HW06-HWD PENDING, NEED CLIENT CHOSEN START DATE generates to the user of record when an S08 AU is finalized without a date in the Client Chosen HWD Begin Date field.

What is the Healthcare for Workers with Disabilities (HWD) Employment Good Cause indicator?

The HWD Employment Good Cause indicator is used if a client meets HWD employment requirements at Application or during an Eligibility Review and they have no earned income.

The HWD Employment Good Cause indicator changes to [blank] when a new Healthcare for Workers with Disabilities (HWD) (S08) Assistance Unit (AU) is screened, re-opened, or an Eligibility Review is initiated.

How do I finalize a Healthcare for Workers with Disabilities (HWD) (S08) medical Assistance Unit (AU)?

If the client has not chosen an HWD begin date, follow the steps in How do I complete Finalize Application?

NOTE: ACES will generate Letter 0023-02 (Request for Information) asking the client to choose a month for Ongoing Coverage.

If the client has chosen an HWD begin date, take the following steps:

  1. From the Case Actions page, select Start Interview.
  2. On the Assistance Unit page:
  • In the AU ID section, enter [a date] in the Client Chosen HWD Begin Date field.
  1. To complete the interview following the steps in Interview - Online Processing.
  2. To process pending application months, follow the steps in How do I complete Process Application Months?
  3. To finalize the AU, follow the steps in How do I complete Finalize Application?

How do I process Retro Medical for a Healthcare for Workers with Disabilities (HWD) (S08) medical Assistance Unit (AU)?

This function is not available in ACES 3G.  See Mainframe Processing - How do I process Retro Medical for a Healthcare for Workers with Disabilities - HWD (S08) Assistance Unit (AU)? for steps on processing a retro medical request.

Mainframe Processing

How do I process retro medical for a Healthcare for Workers with Disabilities - HWD (S08) medical Assistance Unit (AU)?

To process retro medical for an S08 AU, see:

After finalizing the retro period for an S08 AU, the AU remains in pending status. ACES sends the Office of Financial Recovery (OFR) the AU information for the retro base period and sends the premium notices to the client.  If the client pays the premiums for all or some of the retro months, OFR sends notification to the system and the pending retro months for months paid are AUTO opened.

NOTE: If retro month premiums are not paid within 120 days from the billing date, the pending retro months are AUTO denied.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Hospice

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is Hospice?

Hospice provides a terminally ill client a variety of treatment alternatives while in their home, medical institution, nursing facility including a hospice care center or an alternate living facility. For more information on Hospice as a Home and Community Based Services (HCBS) or Program, see Apple Health eligibility manual - Hospice - Index

Who is eligible for Hospice services?

A person who is eligible for a Categorically Needy (CN) or Medically Needy (MN) medical program is eligible to receive hospice care. Apple Health eligibility manual - Hospice - Overview

Online Processing

How do I add Hospice service to a client active on Categorically Needy (CN) or Medically Needy (MN) medical?

To add Hospice services to a client that is already active on CN or MN medical, take the following actions: 

  1. From the Case Actions page:
  • Select the [month and year] the client elected hospice from the Benefit Month drop down menu and click the Start Changes link. 
  1. On the Contact Information page, add an Authorized Representative/Payees and complete the following:
  • Type drop down menu - Select the appropriate [authorized representative]
  • Name fields - Enter the [hospice agency name] or the [authorized representative name] in the First MI Last fields
  • Attn/Firm field - Enter the [representative's name]
  • Address fields - Enter the [representative's address]
  1. On the Institutional Care page, add a Home and Community Based Service page and complete the following:
  • Type drop down menu - Select Hospice (H).
  • Provider ID field - Enter the [provider number]. To find the provider’s ID number, click the Search link to access the Provider Search pop up window. Enter the provider's name and city in the correct fields and click Search.
  • Start Date field - Enter the [date the client elected hospice].
  • Approval Source drop down menu - Select the appropriate approval source code.
  • Payment Auth Date field - Enter the [date payment is to begin]
  • Private Rate field - Enter the [provider’s private daily rate]. To find the provider's private rate, call the facility.
  • State Rate field - Enter the [provider’s state daily rate]. To find the provider’s state rate, click the Details link next to the Provide ID field. See Vendor Payment – How do I inquire on a vendor?
  1. Click on Eligibility and then click the Commit Changes button to commit the data.

How do I add Hospice as a program?

Clients electing Hospice as a program in an institutional setting and are not receiving any other higher priority services should be screened for Categorically Needy - PACE or Institutional Hospice - SSI Recipients (L31) or Categorically Needy - PACE or Hospice - SSI Related (L32). For more information, see Categorically Needy - PACE or Institutional Hospice - SSI Recipients (L31) or Categorically Needy - PACE or Hospice - SSI Related (L32).

Clients electing Hospice as a program in a NON-Institutional setting and are not receiving any other higher priority services should be screened on Categorically Needy LTC in a Medical Facility - SSI Related (L02) medical. For more information see Categorically Needy LTC in a Medical Facility - SSI Related (L02)

NOTE: Workers may need to add a program to clients not receiving Categorically Needy (CN) or Medically Needy (MN) medical programs.

How do I enter Hospice as a short stay?

To enter Hospice as a short stay, see Short Stay.

How is Hospice participation determined?

Participation in the cost of care for hospice services received in a medical facility is determined according to the Apple Health eligibility manual - WAC 182-513-1380 Determining a person’s financial participation in the cost of care for long-term care (LTC) services. The participation is assigned to the hospice provider, not the medical facility, unless the medical facility is a Hospice Care Center (HC).

Participation for hospice services received in a client’s home is determined according to the Apple Health eligibility manual - WAC 182-515-1505 Home and community services (HCS) authorized home and community based (HCB) waiver services. If the client has both HCS Waiver and hospice services coded concurrently, ACES assigns the participation to the HCS Waiver provider. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

 

Medicaid Alternative Care (MAC)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is Medicaid Alternative Care (MAC)?

MAC provides support services and respite to family caregivers when the care is provided to current recipient of a Categorically Needy or Alternative Benefit Plan (CN/ABP) Medicaid program who resides in an at home setting. For more information,  see the Apple Health Eligibility Manual-the WAC will be posted once policy updates their manual.

Who is eligible for Medicaid Alternative Care (MAC)?

To be eligible for MAC, a client must:

  • Reside in an at home sub-setting;
  • Be Age 55 or older;
  • Be a citizen or federally qualified alien;
  • Have a valid Social Security Number (SSN);
  • Meet Nursing Facility Level of Care;
  • Have income at or below the Special Income Level (SIL); and
  • Be on one of the following Categorically Needy or Alternative Benefit Plan (CN/ABP) medical programs to receive services:
  • L31 (SSI PACE or Institutional Hospice)
  • L32 (SSI Related PACE or Hospice)
  • N01 (MAGI-Parent/Caregiver)
  • N02 (MAGI-Transitional Medical)
  • N03 (MAGI- Pregnancy – Federal)
  • N05 (MAGI- New Adult)
  • N23 (MAGI – Pregnancy State)
  • R03 (Refugee Medical)
  • S01 (SSI Categorically Needy)
  • S02 (SSI Related Categorically Needy)
  • S08 (HWD)
  • S30 (Breast and/or Cervical Cancer Treatment Program)

There is no asset or resource test, no estate recovery and no participation connected with this program.

Services can only be provided in an at home setting and all calculations for the MAC program are calculated offline.

The MAC program does not generate any ACES letters.

Online Processing

How do I add Medicaid Alternative Care (MAC) services for an active client on a Categorically Needy or Alternative Benefit Plan (CN/ABP) Medical Program?

If a client meets the eligibility requirements for MAC services take the following steps:

  1. Update the following on the Case Actions page:
  • Benefit month field -  Select the month and year the client is found eligible for MAC services and click the Start Changes link.
  1. Add a Home and Community Based Service and complete the following field:
  • Type field - Select Medicaid Alternative Care (B).
  1. Click on Eligibility and then click the Commit Changes button to commit the data. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

 

 

 

 

 

 

Medical Care Services (MCS) Medical - A01, A05

Created on: 
Jun 24 2020

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Medical Care Services (MCS) medical (A01)?

Adults with the citizenship  status of  Non-Federally Qualified Alien (NF) or  Federally Qualified Alien (NQ) who are active on an Aged Blind or Disabled (ABD) cash Assistance Unit (AU) and meet the following criteria may be eligible for A01 medical:

For additional information see ACES Manual Chapter Aged, Blind, or Disabled Cash Assistance (ABD).

Who is eligible to receive Medical Care Services (MCS) medical (A05)?

Adults with citizenship status of  Non-Federally Qualified Alien (NF) or Federally Qualified Alien (NQ) who are active on a Housing and Essential Needs (HEN) Assistance Unit (AU) and  meet the following criteria may be eligible for A05 medical:

For additional information see EAZ Manual - WAC - 388-400-0070 Who is eligible for referral to the  Housing and Essential Needs (HEN) Program? 

Online Processing

How do I screen Medical Care Services (MCS) medical?

Only one person can be on an MCS Assistance Unit (AU). A separate MCS AU needs to be screened in for each applicant/recipient .

To screen an MCS medical application, take the following steps:

  1. Follow the instructions in the Screening an Application Chapter.
  2. On the Programs page, check the box next to Medical.
  3. On the Finalize page, click the Specify Program button.
  4. On the Finalize - Program Details page update the following fields using he drop down menus:
  • Program Field - Select Medical Assistance (MA).
  • Medical Coverage Group field - Select Med Care Svc (A01).
  • Program Type field -  Select the appropriate program type.
Note: The Med Care SVC (A01) trickles to a Med Care Svc (A05) AU if the client does not meet the MCS (A01) requirements.

How do I process Medical Care Services (MCS) medical?

Follow the steps in the InterviewProcess Application Months, and Finalize  chapters to process the medical request.

Note: If a client is not active on a Housing and Essential Needs (HEN) (GA-U) or Aged, Blind, or Disabled (ABD (GA-A/B/D) Assistance Unit (AU), the MCS medical AU will deny with Reason Code 163 - Client Must Be GA Eligible.
Note: The Attested Disability (HCA 19-0054) (PA) approval source code  does not meet the eligibility criteria for Medical Care Services (MCS) A01 & Medical Care Services (MCS) A05.  

How long is the Medical Care Services (MCS) certification period?

When an MCS (A01 or A05) Assistance Unit (AU) is approved ACES sets the review end date to match the clients active Housing and Essential Needs HEN (GA-U) or Aged, Blind, or Disabled (ABD) (GA- A/B/D) AU.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Medical Information

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is the Medical Information page?

Medical information received from the ProviderOne Web Service Interface can be viewed on the Medical Information page in ACES.online. For more information about the ProviderOne interface, see Interface - ProviderOne in the ACES User Manual.

What information displays on the Medical Information page?

This page displays real-time, detailed medical information for a given client. Data items displayed are:

  • Client Medical Information:
    • ProviderOne ID
    • Medicare
    • TPL Insurance
    • Placement Code
    • Hospice Indicator
    • Restriction Indicator
    • DDD Client Indicator
  • Managed Care Information:
    • Health Plan
    • Program
    • Start Date
    • End Date

If there is no current ProviderOne data available, the following message displays: The current ProviderOne Data is not available at this time.

If the client currently has no medical information, the following message displays: No Medical Information found.

Online Processing

How do I view medical information in ACES.online?

To access the Medical Information page, take the following steps:

1. From the Welcome Back page, use the Quick Navigation section and update the following fields:

  • Select a Type of ID field - Use the drop down menu and select Client.
  • Enter an ID field - Enter the [Client ID].
  • Select a Page field - Use the drop down menu and select Medical Information.

2. Click the Go button and the Medical Information page displays.

Or,

1. From any client level page, hover over Details and click the Medical Information link. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Medically Needy Non-Institutional Medical in an Alternate Living Facility - No Spenddown (G95)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive G95 (Medically Needy (MN) Non-Institutional medical in an Alternate Living Facility No spenddown)?

SSI-related people paying privately in a state-contracted Alternate Living Facility (ALF) can be considered for this program under medically needy (MN) G95, G99.    For more information see, Apple Health eligibility manual - WAC 182-513-1205 Determining eligibility for non-institutional coverage in an alternate living facility.

Non institutional Medicaid in an ALF has the same program rules as SSI related Medicaid but with a higher income standard. The private daily rate drives the eligibility for G95.

The difference between the SSI related MN series (S95, S99) and the non-institutional in an ALF related MN series (G95, G99) is the income standard. Income must be either over the SIL or over the daily rate x 31 days plus the ABD cash standard of $38.84; or both:

  • If income is over the SIL, but less than the private daily rate: G95; and

  • If income is over the private daily rate; G99

The ACES medical coverage group (MCG) G95/G99 is for private pay clients. 

For more information, see Apple Health eligibility manual - WAC 182-513-1205 Determining eligibility for non-institutional coverage in an alternate living facility.

How long is Medically Needy Non-Institutional Medical in an Alternate Living Facility (G95) certified?

G95 is certified for 12 months.

For more information, see Apple Health eligibility manual - WAC 182-504-0020 Certification periods for the noninstitutional medically needy (MN) program.

Online Processing

How do I screen a G95 (Medically Needy (MN) Non-Institutional Medical in an Alternate Living Facility - No Spenddown) Assistance Unit (AU)?

To screen a G95 AU, take the following steps:

  1. Follow the instructions in Categorically Needy Non-Institutional Medical in an Alternate Living Facility (G03) - How do I screen G03 (Categorically Needy Non-Institutional Medical in an Alternate Living Facility)?

  • The G03 AU trickles to G95 during Finalize, if appropriate, based on the income and the Details page financial responsibility coding.

How do I process a pending G95 (Medically Needy (MN) Non-Institutional Medical in an Alternate Living Facility - No Spenddown) Assistance Unit (AU)?

  1. Follow the steps in Finalize Application - How do I Complete Finalize Application? 
NOTE:  If the AU exceeds the income standard for G03, it may trickle to Medically Needy Non-Institutional Medical in an Alternate Living Facility – No Spenddown (G95)  or Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown (G99) during finalize.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Medically Needy Non-Institutional Medical in an Alternate Living Facility Spenddown (G99)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive G99 (Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown) medical?

SSI-related individuals paying privately in a state-contracted ALF can be considered for this program under medically needy (MN) G95, G99.   For more information, see

Apple Health eligibility manual - WAC 182-513-1205 Determining eligibility for non-institutional coverage in an alternate living facility.

Non-institutional Medicaid in an Alternate Living Facility (ALF) has the same program rules as SSI-related Medicaid but with a higher income standard. The private daily rate drives the eligibility.

The difference between the SSI related series (S95, S99) and the non-institutional in an ALF related series (G95, G99) is the income standard.  If income exceeds the private daily rate, the client will have a Spenddown liability.

The ACES medical coverage group (MCG) G95/G99 is for private pay clients. 

How long is Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown (G99) certified?

G99 defaults to 6 month base period. 

Under certain conditions, the certification (base period) can be set to a period other than the default six months. For more information, see the Overview section of Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program

Online Processing

How do I screen G99 (Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown) medical Assistance Unit (AU)?

To screen a G99 AU, take the following steps:

  1. Follow the instructions in Categorically Needy Non-Institutional Medical in an Alternate Living Facility (G03) - How do I screen G03 (Categorically Needy Non-Institutional Medical in an Alternate Living Facility)?

How do I finalize a pending G99 (Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown) Assistance Unit (AU)?

To finalizes a G99 AU, take the following steps:

  1. Follow the steps in How do I Complete Finalize Application? 
NOTE: Based on the income and the AU's financial responsibility coding, the G03 AU trickles to G95 (Medically Needy Non-Institutional Medical in an Alternate Living Facility - No Spenddown) or G99 during Finalize .

For more information on the Spenddown process, see Apple Health eligibility manual - Apple Health for the Medically Needy and Spenddown overview | Washington State Health Care Authority.

How do I enter Spenddown medical expenses for a G99 (Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown) Assistance Unit (AU) in M status?

To enter medical expenses to meet the client’s Spenddown liability on a G99 AU in M status, take the following steps:

  1. Follow the instructions in Spenddown - How do I enter medical expenses?
  2. After expenses have been added, follow the steps in Spenddown - How do I assign medical expenses and authorize Spenddown?

How do I initiate an Eligibility Review on a G99 (Medically Needy Non-Institutional Medical in an Alternate Living Facility – Spenddown) Assistance Unit (AU)?

To initiate an Eligibility Review on a G99 AU, take the following steps:

  1. Complete the eligibility review on a G99 AU following the instructions in the Eligibility Review chapter.
NOTE: Eligibility reviews can be initiated on Spenddown AUs in Active (A) or MA Spenddown (M) status.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Pregnancy Medical

Created on: 
Aug 11 2017

Family Planning Service Only (P05)

Online Processing

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

What is the Family Planning Service Only (P05) medical program?

P05 medical provides coverage for family planning services for women who were:

  • Eligible for medical coverage on the last day of their pregnancy, or
  • Who were approved retroactive pregnancy medical.

For more information regarding P05 medical, see:

How long is the Family Planning Service Only (P05) certification period?

The P05 certification period is ten months following the client's sixty-day post pregnancy coverage.

When does Family Planning Service Only (P05) medical begin?

The following pregnancy medical assistance units trickle to P05 medical at the end of their regular certification periods:

  • MAGI - Pregnancy - Federal (N03)
  • MAGI - Pregnancy State (N23)
  • Medically Needy Pregnancy (P99)
NOTE: All individuals who receive Washington Apple Health (WAH) pregnancy coverage are auto-opened on P05 through the end of the twelve-month post-partum period.  This occurs for eligible individual(s) whose Modified Adjusted Gross Income (MAGI) coverage is closed and they are not active on any other Categorically Needy (CN) coverage.

What if the client reports a new pregnancy during the family planning extension?

If a client reports a pregnancy during the family planning extension, refer the client the www.wahealthplanfinder.org to apply for pregnancy medical coverage.

Online Processing

What happens if Family Planning Service Only (P05) is not auto-opened at the end of the pregnancy medical certification period?

If P05 medical is not automatically opened at the end of the pregnancy medical certification period, then users should screen in a new P05 Assistance Unit (AU). For more information on how to screen an AU, see Screening an Application. 

 

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

Medically Needy Pregnancy Medical with Spenddown (P99)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who processes P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Units (AUs)

All P99 AUs are processed by Health Care Authority (HCA) users and assigned to Region 9 in one of the following MAGI CSO’s:

  • 181- Houses MAGI AUs that belong to Region 1 geographical/zip catchment
  • 182- Houses MAGI AUs that belong to Region 2 geographical/zip catchment
  • 183- Houses MAGI AUs that belong to Region 3 geographical/zip catchment

Who is eligible to receive P99 (Medically Needy Pregnancy Medical with Spenddown)?

Pregnant woman who meet the criteria in Apple Health Eligibility Manual - WAC 182-505-0115 Washington apple health - Eligibility for pregnant women are eligible for P99 medical. 

How long is the Medically Needy Pregnancy Medical with Spenddown (P99) certification period?

P99 medical is certified to the end of the final month of the base period as described in the Apple Health eligibility manual – WAC 182-505-0115 Washington Apple Health - Eligibility for pregnant women

The base period should be through the end of the final month of pregnancy, not to exceed six months. For additional information, see: 

Can a client receive P99 (Medically Needy Pregnancy with Spenddown) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

When is a pregnant woman not eligible for the post-partum medical extension?

If an application is not submitted and eligibility determined prior to the end of the pregnancy, the pregnant woman is not eligible for the two-month post-partum medical extension, even if medical care is authorized retroactively to cover the pregnancy.

A client can apply for medical assistance to cover the expense of the birth of the baby even after the baby is born.

When a woman is not eligible for the post-partum extension, Family Planning (P05) coverage begins the first of the month following the month the pregnancy ended.

Online Processing

How do I screen a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

To screen P99 medical, take the following steps:

  1. Follow the instructions in How do I screen an application for a client?
  • On the Programs page, select the checkbox next to Medical.
  • On the Finalize page, click Specify Program.
  • On the Finalize - Program Details page select the following:
    • Program drop down - Select Medical Assistance (MA).
    • Medical Coverage Group drop down - Select Medically Needy Pregnancy (P99).
    • ​​Program Type drop down - Select the appropriate option from the list.

How do I process a pending P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

To process a pending P99 AU, follow the steps in the Process Application Months and Finalize Application chapters.

For additional information, for information on the Spenddown process, see Apple Health eligibility manual – Apple Health for the Medically Needy and Spenddown overview.

How do I enter Spenddown medical expenses for a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit in MA - Spenddown (M) status?

To enter medical expenses to meet the client’s Spenddown liability on a P99 AU in MA Spenddown (M) status, see Spenddown - Processing - How do I enter medical expenses? 

After the expenses have been added, follow the steps in Spenddown - Processing - How do I assign medical expenses and authorize Spenddown? 

What if the pregnancy ends before the original due date?

When the pregnancy ends in a month prior to the original due date entered on the Client Details page, take the following steps:

  1. In the Change of Circumstances section on the Case Actions page, use the drop down menu to select the appropriate Benefit Month and click Start Changes.
  2. On the Client Details page, change the pregnancy information to reflect the actual date the pregnancy ended.
  3. Select Review on the Navigation tree. ACES rechecks all AU/client data for errors and required verifications. If no other updates are required, select Eligibility on the Navigation tree.
  4. On the Eligibility page, click the Details link, review the data on the Eligibility Details page and click Confirm Benefits.
  5. On the Eligibility page, click Commit Changes.

What if the pregnancy ends prior to the original due date or prior to the certification end date?

If the Spenddown is met prior to the birth of the baby and the baby is born early, the Medically Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU) certification period cannot be shortened.

Check the certification period, and if the certification period ends after the two months post-partum period, screen a new P99 Assistance Unit (AU) with the correct due date using the steps in Online processing - How do I screen a Medical Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU)? 

What if the pregnancy ends after the original due date or during the post-partum extension?

When the pregnancy ends in a month after the original due date entered on the Client Details page, take the following steps:

  1. Close the current AssistanceAU with a 500 level reason code. For additional information, see Online processing - How do I deny or terminate a case with a 500 level Reason Code?.
  2. Screen and process a new P99 AU with the correct due date.
NOTE: A P99 AU in MA Spenddown (M) status does not allow you to initiate a review. If the P99 is in Active (A) status, displays Spenddown Period Expires in a Future Month.

When do P05 (Family Planning Services) begin?

Medically Needy Pregnancy Medical with Spenddown (P99) does not trickle to a Family Planning (P05) Assistance Unit (AU). If the woman does not meet Spenddown until the baby is born, she is considered eligible for family planning services. Family planning begins after the post-partum period.

Set a tickle to screen a P05 AU for the month after the post-partum period ends. For additional information, see Add a Program if the P99 is still active or see Screening an Application if the AU has closed. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Refugee Categorically Needy (R03)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Refugee Categorically Needy (R03) medical?

A person who meets the following eligibility criteria is eligible for R03 medical:

How long is the certification period for Refugee Categorically Needy (R03) medial?

Refugee medical is certified for up to eight months following the refugee’s entry into the United States. For more information, see:

Online Processing

How do I screen Refugee Categorically Needy (R03) medical?

To screen R03 medical, take the following steps:

  1. Follow the instructions in the Screening an Application chapter.
  2. On the Programs page, complete the following fields:
  • In the Program sections, click the checkbox next to Medical.
  • In the Program Determination Criteria section, click the checkbox next to Refugee.

How do I process a pending Refugee Categorically Needy (R03) medical Assistance Unit (AU)?

To process a pending R03 AU, take the following steps:

  1. On the AU Details page, complete the Financial Responsibility fields as follows:
  • Applicant (PN) for all applicants.
  • Non-Member (NM) for all other persons in household.
  1. On the Client Details page, complete the following fields in the Alien section for each applicant:
  • INS Status field - Select Refugee (RF) from the drop down menu.
  • Date INS Stat Granted field - Enter the [date].
  • Sponsored Alien field - Select Yes (Y) or No (N) from the drop down menu.
  • Country of Origin field - Select the client's country of origin from the drop down menu.
  • US Entry Date field - Enter the [client's date of entry].
  • Initial INS Status field - Select Refugee (RF).
  • Initial INS Date field - Enter the [date].
  • Refugee Resettlement Agency field - Enter the [resettlement agency] if applicable.
  1. After committing the interview data, follow the instructions in the Process Application Months and Finalize Application chapters.

How do I add a new household member to Refugee Categorically Needy (R03) medical when the household has already received Temporary Assistance for Needy Families (TANF) or Refugee Assistance?

There are situations where a refugee household received TANF or Refugee Assistance but is no longer eligible due to income. When a new family member joins the household, the new member is eligible to receive R03 medical.

So that the R03 AU isn't denied for being over income, take the following steps:

  1. Screen in an R03 AU as described in How do I screen Refugee Categorically Needy (R03) medical? with the new person as the Head of Household.
  2. From the Case Actions page, select Start Interview.
  3. On the AU Details page, complete the Financial Responsibility fields as follows:
  • Applicant (PN) for the applicant only.
  • Non-Member (NM) for the spouse who has received TANF or Refugee Assistance.
  • Child - SSI/Of SSI-related Parent/Used for HH Size (SC) for all children in the household to determine the household size.
  1. Complete the application interview. After committing the interview data, follow the instructions in the Process Application Months chapter for all pending months.
  2. After all pending months have been processed, follow the instructions in the Finalize Application chapter to complete the R03 eligibility determination.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Retroactive Medical

Created on: 
Nov 22 2019

Online Processing

Mainframe Processing

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

Who is eligible for retroactive medical?

Clients who are eligible for certain medical programs may be eligible for retroactive medical. For more information, see:

How long is the retroactive medical certification period?

Retroactive medical can be approved for up to three months prior to the application month. For more information, see:

When can retroactive medical be requested for Modified Adjusted Gross Income (MAGI) Assistance Units (AUs)?

Retroactive medical can be approved for MAGI AUs (N-Track) up to three months prior to an Application Date of October 2013, except for MAGI - New Adult (N05) and MAGI - New Adult Alien Emergency (N25) medical AUs. Retroactive medical on N05 and N25 AUs can only be approved back to January 2014.

Online Processing

How do I initiate retroactive medical?

This function does not currently exist for online processing. For more information, see Mainframe Processing - How do I initiate retroactive medical?

How do I process retroactive medical benefit months?

To process a retroactive Medicaid application, take the following steps:

  1. On the Case Actions page, select one of the retroactive months from the Benefit Month drop down menu and click Start Changes.
  2. Review and update case information as needed and commit the changes.
Note: For any month the client won't receive retroactive medical, deny the month by entering [a 500 level reason code] in the Reasons field on the AU Details page. For more information, see How do I deny a pending Assistance Unit (AU) or client in some months?
  1. Repeat steps one and two for the remaining months.

How do I finalize retroactive medical benefits?

This function does not currently exist for online processing. For more information, see Mainframe Processing - How do I finalize retroactive medical benefits?

How do I authorize retroactive medical benefits when the Retro Medicaid Copy function isn’t available for the Assistance Unit (AU) I am working on?

The user must screen in a new AU with a three month Spenddown base period to cover the retroactive medical months. For more information, see How do I setup a retroactive Spenddown base period?

How is retroactive medical determined in ACES for Modified Adjusted Gross Income (MAGI) Assistance Units (AUs)?

This function does not currently exist for online processing. For more information, see Mainframe Processing - How is retroactive medical determined in ACES for Modified Adjusted Gross Income (MAGI) Assistance Units (AUs)?

What reason codes are used to deny retroactive Modified Adjusted Gross Income (MAGI) benefit months?

The following reason codes are allowed to deny retroactive MAGI benefit months:

  • 201 - Living Arrangement - Cash/Medical Assistance
  • 202 - Citizenship/Alien Status
  • 210 - Failed Residency Requirement
  • 220 - Failed Age Requirement - Medical
  • 301 - Exceeds Income Standard
  • 503 - Acceptable Medical Source (and no medical)
  • 504 - Insufficient Information
  • 520 - Change in Federal Law
  • 528 - Eligibility Review Form Incomplete
  • 550 - Voluntary Withdrawal
  • 551 - Whereabouts Unknown
  • 552 - Failed to Provide Verification
  • 559 - Client Already Received Assistance in Another AU For This Benefit Month
  • 561 - Screened in Error - For Administrative Use Only
  • 566 - Refused to Cooperate with the Application Process
  • 577 - Missed Application Deadline - For Administrative Use Only
  • 587 - Already Eligible for Program in Different AU - For Administrative Use Only
  • 588 - Ineligible QI-1 Already Receiving MA
  • 599 - Other - For user Generation Only

How do I initiate and process Modified Adjusted Gross Income (MAGI) retroactive medical?

This function does not currently exist for online processing. For more information, see Mainframe Processing - How do I initiate and process Modified Adjusted Gross Income (MAGI) retroactive medical?

Mainframe Processing

How do I initiate retroactive medical?

To initiate retroactive medical, take the following steps:

  1. On the AMEN screen, complete the following fields:
  • Selection field - Enter [W] - Retro Medicaid Copy.
  • AU ID field - Enter the [Assistance Unit ID] and <TRANSMIT>.
  • Benefit Month (MM YY) field – Enter a [MM YY] benefit month if retro is requested for a previous application period, or leave blank.
  1. On the RMCO screen, enter [Y] - Yes in the Continue field and <TRANSMIT>.

How do I process retroactive medical benefit months?

This function no longer exists for Mainframe processing. For more information, see Online Processing - How do I process retroactive medical benefit months?

How do I finalize retroactive medical benefits?

To finalize retroactive medical benefits, take the following steps:

  1. On the AMEN screen, select Option [X] - Finalize RETRO Medicaid.
  2. <TRANSMIT> and the FRME screen displays.
  3. <TRANSMIT> again and the ELIG screen displays.
  4. Confirm eligibility for all benefit months and finalize.

How do I authorize retroactive medical benefits when the Retro Medicaid Copy function isn’t available for the Assistance Unit (AU) I am working on?

The user must screen in a new AU with a three month Spenddown base period to cover the retroactive medical months. For more information, see How do I set up a retroactive spenddown base period?

How is retroactive medical determined in ACES for Modified Adjusted Gross Income (MAGI) Assistance Units (AUs)?

Retroactive medical eligibility for MAGI medical must be determined offline by the user before finalizing the retroactive medical as ACES does not determine eligibility for these months.

Users have specific reason codes available to deny retro medical on the RMCO screen for months the client is not eligible. MAGI AUs are approved for benefit months with no reason code entered.

No letters generate for MAGI AUs and ACES does not modify a MAGI AU in any way, other than to set the AU status, client status and financial responsibility code. Health Care Authority (HCA) eligibility staff must manually generate the necessary approval and denial letters from the Healthplanfinder system as needed.

What reason codes are used to deny retroactive Modified Adjusted Gross Income (MAGI) benefit months?

When any particular month in the retroactive period needs to be denied, enter one of the following 500-level reason codes on the RMCO screen to deny that particular month:

  • 201 - Living Arrangement - Cash/Medical Assistance
  • 202 - Citizenship/Alien Status
  • 210 - Failed Residency Requirement
  • 220 - Failed Age Requirement - Medical
  • 301 - Exceeds Income Standard
  • 503 - Acceptable Medical Source (and no medical)
  • 504 - Insufficient Information
  • 520 - Change in Federal Law
  • 528 - Eligibility Review Form Incomplete
  • 550 - Voluntary Withdrawal
  • 551 - Whereabouts Unknown
  • 552 - Failed to Provide Verification
  • 559 - Client Already Received Assistance in Another AU For This Benefit Month
  • 561 - Screened in Error - For Administrative Use Only
  • 566 - Refused to Cooperate with the Application Process
  • 577 - Missed Application Deadline - For Administrative Use Only
  • 587 - Already Eligible for Program in Different AU - For Administrative Use Only
  • 588 - Ineligible QI-1 Already Receiving MA
  • 599 - Other - For user Generation Only

How do I initiate and process Modified Adjusted Gross Income (MAGI) retroactive medical?

To initiate and process MAGI retroactive medical, take the following steps:

  1. On the AMEN screen, complete the following fields:
  • Selection field - Enter [W] - Retro Medicaid Copy.
  • AU ID field - Enter the [Assistance Unit ID] and <TRANSMIT>.
  • Benefit Month (MM YY) field - Enter a [MM YY] benefit month if retro is requested for a previous application period, or leave blank.
  1. On the RMCO screen, complete the following:
  1. <TRANSMIT> and the AMEN screen displays.

 

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

SSI Categorically Needy Medical (S01)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

Who is eligible to receive SSI Categorically Needy (S01) medical?

A person who receives federal cash benefits under the Supplemental Security Income (SSI) program is automatically eligible to receive S01 medical. There is no income or resource limit for S01 medical eligibility as long as the client is SSI eligible. For more information, see EA-Z Manual - WAC 182-510-0001 What is supplemental security income (SSI) and who can get it?

Can a client receive SSI Categorically Needy (S01) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

If the client is AUTO closed though the State Data Exchange (SDX) interface, see Online Processing - Does a SSI Categorically Needy (S01) Assistance Unit (AU) AUTO close when a client is incarcerated?.

Online Processing

How is SSI Categorically Needy (S01) medical opened?

S01 medical is usually opened automatically based on information received from the State Data Exchange (SDX) interface, see Interface Data - State Data Exchange.

For clients unknown to ACES, all mandatory client data fields such as address, name, date of birth, and Social Security Number (SSN) are auto-populated using the information on the SDX record.

For clients already known to ACES, S01 is auto-opened when there is an exact match between ACES and the SDX interface on the client’s name, date of birth and SSN. At the time of the auto open the following occurs:

  • The address in the SDX interface is used for clients not currently active on any Assistance Unit (AU).
  • The current address in ACES is used for clients who are currently active.
  • Any existing medical or cash AU is closed if the Supplemental Security Income (SSI) client is the only active member.
  • If applicable to the client’s current situation, Categorically Needy Foster Care / Adoption Support / Juvenile Rehabilitation Medical (D01/D02/D26) medical may be auto-opened in lieu of S01.
  • If the SSI client is active on a medical or cash AU with other active members, the SSI client’s Financial Responsibility code on the AU Details page is changed to SSI Parent (SI) and benefits are recalculated for the remaining AU members.
  • Basic Food benefits are recalculated to include SSI income.

What happens when ACES does not auto-open SSI Categorically Needy (S01) medical?

S01 is not auto-opened in any of the following conditions:

  • There is a discrepancy in the client’s name, date of birth or Social Security number between ACES and State Data Exchange (SDX) interface.
  • The SDX record contains too many lines of address preventing ACES from determining what should be used.
  • The client has an existing Third Party Liability (TPL) non-cooperation sanction.
  • Alert 245 - AUTO-OPEN NOT POSSIBLE REVIEW FOR MEDICAID/MEDICARE ELIGIBILITY is generated. The second line of this alert identifies the discrepancy for the worker to review and take the appropriate case action.

When auto-open is not possible, S01 should be manually opened if appropriate. For more information, see How do I screen SSI Categorically Needy (S01) medical?

What is the begin date for SSI Categorically Needy (S01) medical?

ACES uses the earlier of the Supplemental Security Income (SSI) Eligibility Date or the SSI Medicaid Effective Date from the client’s State Data Exchange (SDX) record when determining the appropriate S01 begin date.

  • The SSI/Eligibility Date field on the SDX page is the date the client was issued the first SSI payment.

S01 is auto-opened for all months that the client was not receiving Categorically Needy medical on any other Assistance Unit.

ACES can auto-open S01 retroactively up to a maximum of 36 months from the ongoing month.

When manually opening S01 medical, use the first of the month listed in the SSI/Eligibility Date field on the SDX record.

How long is the SSI Categorically Needy (S01) medical certification period?

S01 medical has no review end date and is certified for as long as the client is Medicaid eligible. The Medicaid eligibility indicator displays under the Medicaid Eligibility Code field on the SDX page. 

How do I screen SSI Categorically Needy (S01) medical?

To screen S01 medical, take the following steps:

  1. From the Welcome Back page in ACES.online, click the Screen New Application link at the top of the page.
  2. On the Applicant page, take the following steps:
  • Applicant Name field - Enter the [applicant’s name].
  • Primary Language field - Select the client's primary language from the drop down menu.
  • Interpreter Needed field - Select the check box if the client is requesting an interpreter.
  • Residential Address section - Enter the [client’s residential address].
    • If the applicant has a mailing address, click the box next to Mailing Address same as above field to remove the checkmark and enter the applicant’s mailing address.
  • To add an Authorized Representative, follow the steps in How do I add an authorized representative (AREP) during screening?
  1. On the Address Validation page take the necessary steps to complete the address validation process. For additional information, see Screening - Address Validation.
  2. On the Programs page, take the following steps:
  • In the Programs sections, click on the checkbox next to Medical.
  • In the Program Determination Criteria section, click the checkbox next to SSI Eligible.
  • Click Next.
  1. Complete the screening process. For more information, see Screening an Application.

How do I process a pending SSI Categorically Needy (S01) Assistance Unit (AU)?

To process a pending S01 AU, take the following steps:

  1. On the AU Details page, select Applicant (PN) from the Financial Responsibility field drop down menu.
  • An S01 AU can only have one Applicant (PN) coded on the Financial Responsibility field.
  1. On the Unearned Income page, select SSI Benefits (SI) from the Source field drop down menu and enter the unearned income information.
  2. Complete the interview following instructions in the Interview chapter.
  3. After committing the interview data, follow the instructions in the Process Application Months chapter for all pending months.
  4. After all pending months have been processed; follow the instructions in the Finalize Application chapter to complete the S01 eligibility determination.

When is a SSI Categorically Needy (S01) Assistance Unit (AU) AUTO closed?

If the SDX record indicates that a client has died or moved out of state, any active AUs that the client is the only household member are AUTO closed.

When the SDX record indicates a client’s Supplemental Security Income (SSI) benefits have terminated, ACES takes the following actions:

  • Updates the client’s SSI income amount on the Unearned Income page to $0. The SSI Benefits (SI) income code remains in order to keep the S01 AU open while the client’s eligibility for any other medical programs is determined.
  • The Ever Received SSI radio button is marked Yes on the Unearned Income page.
  • The following fields are updated on the Other Agency Application/Benefit page:
    • Type field is updated to SSI (SI).
    • Status field is changed to the appropriate code.
  • Alert 248 - SSI TERMINATED, REDETERMINE MEDICAL ELIGIBILITY is generated.
  • Letter 022-05 (Redetermination for Medical) with an eligibility review (ER) is sent to the client. 
  • When the SDX record indicates a client’s SSI is suspended, LTR 022-05 and the review form are not sent for up to 60 days. 
    • If a client’s status changes from suspended to terminated, the ER form is sent when we receive a SDX record with the termination data. 
    • If the client’s status changed from suspended back to a pay status, all tracking is stopped and no ER form is sent.
    • If the client’s status remains suspended, the ER form is sent 60 days after we received the first SDX record with the suspension data.
  •  Both suspended and terminated clients have 60 days from the date it is sent to return their ER form.
  •  At the end of 60 days, ACES checks the ER Received field on Case Actions page for all active S01 AUs.
    • If there is a Yes (Y)Alert 251 - SSI TERM 60 DAYS AGO / COMPLETE MEDICAL REDETERMINATION is generated and the AU remains active.
    • If there is not Yes (Y), the AU is terminated with Reason Code 235 - Review Not Complete. If the termination occurs during the 10-day notice period, adverse action rules are applied to the termination.
    • Users can manually enter Yes (Y) in the ER Received field at any time during the tracking periods to prevent the AUTO termination.

Does a SSI Categorically Needy (S01) Assistance Unit (AU) AUTO close when a client is incarcerated?

If the State Data Exchange (SDX) record indicates a client is incarcerated the S01 AU remains active and ACES takes the following steps:

  • Updates the client’s Living Arrangement field on the Client Details page to Jail (JL).
  • Updates the Inmate or Resident of a Public Institution? field to Yes (Y) on the Client Details page in ACES 3G and the Shelter page in ACES.online.
  • An indicator is sent to ProviderOne (P1) and medical coverage could be limited based on the client’s incarceration status. 

When the client's State Supplemental Income (SSI) benefits terminate, the system continues the current redetermination process. For more information, see When is a SSI Categorically Needy (S01) Assistance Unit (AU) AUTO closed?  

 

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

SSI Related Medical

Created on: 
Aug 11 2017

Categorically Needy SSI Related Medical (S02)

Created on: 
Nov 06 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Categorically Needy SSI Related (S02) medical?

A person who meets the criteria in the following sections may be eligible for S02 medical:

For more information on how countable income and resources are determined for SSI-related medical assistance, see Apple Health eligibility manual - WACs 182-512-0200 through 182-512-0960 for information on how countable income and resources are determined for SSI-related medical assistance.

How long is the Categorically Needy SSI Related (S02) medical certification period?

S02 Medical is certified for 12 months. For more information, see Apple Health eligibility manual - WAC 182-504-0015 Washington Apple Health - Certification periods for categorically needy (CN) programs.

When is Categorically Needy SSI Related (S02) medical AUTO opened?

S02 is AUTO opened in some instances when a Supplemental Security Income (SSI) recipient's payments are stopped by the Social Security Administration (SSA). For more information, see Apple Health eligibility manual - WAC 182-510-0010 What happens to my categorically needy (CN) medical coverage when my supplemental security income (SSI) cash payment is terminated? 

When a client active on Medically Need (S95) becomes eligible for CN medical, the medical coverage group on the AU is changed to S02 or Non Citizen CN SSI Related (S07).

Can a client receive Categorically Needy SSI Related (S02) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

Online Processing

How do I screen Categorically Needy SSI Related (S02) medical?

To screen S02 medical, take the following steps:

  1. Follow the instructions in How do I screen an application for a client?
  • On the Finalize page, select the program SSI Related Categorically Need (S02).

How do I process a pending Categorically Needy SSI Related (S02) Assistance Unit (AU)?

To process a pending S02, take the following steps:

  1. Go to the Case Actions page. For more information, see How do I access the Case Actions page in ACES 3G?
  2. Complete the interview following the steps in How do I initiate and complete an intake interview?
  3. On the AU Details page, in the Financial Responsibility field select the following from the drop down menu:
  • Applicant (PN) for the applicant and spouse (if the spouse is applying too).
  • Ineligible Spouse (SP) for an ineligible or non-applying spouse.
  • Child - SSI/Of SSI-related Parent/Used for HH Size (SC) for non applying children of the applicant/s.
  • ABD Parent (AP) for the parents of the applicant if the applicant is under 18 years old.
  1. On the Client Details page for each applicant(s) enter the disability information in the Disability/Incapacitated/Psychiatric section.
  • If the S02 program eligibility is based on age, coding the Disability/Incapacitated/Psychiatric section is optional.
  1. If the applicant has ever received Supplemental Security Income (SSI):
  • On the Unearned Income page, in the Ever Received SSI field check Yes.
  • Click the Add icon, under Income select Other Agency Application/Benefit and choose the applicant from the Client dropdown menu.
  • On the Other Agency Application/Benefit page, in the:
NOTE:  Once SSI termination information has been entered in the Ever Received SSI and Application/Benefits fields, these fields are no longer editable. These fields are only editable when ACES receives updated information from SDX and/or BENDEX, AUTO can update the fields as appropriate, or when a user or AUTO enters SSI income back to a case, the information in the fields can be deleted.  Only users with SSI SPECIAL AUTH in their ACES profile are permitted update ability for these fields in ACES 3G only.
  1. On the Expense page, click the Add icon to get to the Shelter Expense page for the applicant. Enter [the applicant's shelter expense information] in the appropriate fields.
  1. On the Resources Vehicles/Vessels page, to exempt the entire value of one vehicle, select Transportation for Disabled Person(TD) in the MA/CA Use field. 
  2. Complete all other screens as needed following the instructions in the Interview chapter.
  3. After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months.
  4. After all pending months have been processed, follow the instructions in the Finalize Application chapter to complete the S02 eligibility determination.

If the AU exceeds the income standard for S02 medical, it may trickle to SSI-Related Medically Needy - No Spenddown (S95) or SSI-Related Medically Needy with Spenddown (S99) during finalize.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Medically Needy SSI Related Medical With No Spenddown (S95)

Created on: 
Nov 06 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Medically Needy SSI Related No Spenddown (S95) medical?

A person who meets the criteria established in the following may be eligible for S95 medical:

For information on how countable income and resources are determined for SSI-related medical assistance, see Apple Health eligibility manual  - WACs 182-512-0200 through 182-512-0960.

How long is the Medically Needy SSI Related No Spenddown (S95) certification period?

S95 medical is certified for 12 months. For more information, see Apple Health eligibility manual - WAC 182-504-0020 Certification periods for the noninstitutional medically needy (MN) program.

Can a client receive Medically Needy SSI Related No Spenddown (S95) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

What happens when a Medically Needy SSI Related No Spenddown (S95) recipient becomes eligible for Categorically Needy (CN) medical?

When a client active on S95 becomes eligible for CN medical, the medical coverage group on the AU is changed to SSI Related Categorically Needy (S02) or Non Citizen CN SSI Related (S07).

Online Processing

How do I screen Medically Needy SSI Related No Spenddown (S95) medical?

An S95 AU is initially screened into ACES as a S02 (SSI Related Categorically Needy) Assistance Unit (AU), following the instructions in How do I screen S02 (Categorically Needy SSI Related) medical?  The S02 AU trickles to S95 during Finalize, if appropriate, based on the income and the AU Details page financial responsibility coding.

How do I process a pending Medically Needy SSI Related No Spenddown (S95) Assistance Unit (AU)?

While pending, the AU is still S02 (SSI Related Categorically Needy) and is processed following the same steps as in How do I process a pending S02 (SSI Related Categorically Needy) Assistance Unit (AU)?

The S02 AU trickles to S95 during Finalize, if appropriate, based on income or AU Details page financial responsibility coding.

If the AU exceeds the income standard for S95, it may trickle to SSI-Related Medically Needy with Spenddown (S99).

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Medically Needy SSI Related Medical With Spenddown (S99)

Created on: 
Nov 06 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who is eligible to receive Medically Needy SSI Related Medical with Spenddown (S99) medical?

A person who meets the criteria established in the following manual sections may be eligible for S99 medical:

For more information on how countable income and resources are determined for SSI-related medical assistance, see Apple Health eligibility manual  - WACs 182-512-0200 through 182-512-0960.

How long is the Medically Needy SSI Related Medical with Spenddown (S99) certification/base period?

The default certification/base period for S99 defaults is six months, which can be shortened to three months following the instructions in Spenddown - How do I set up a spenddown AU and base period?

Under certain conditions, the base period can be set to a period other than three or six months. For more information, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

Can a client receive Medically Needy SSI Related Medical with Spenddown (S99) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

Online Processing

How do I screen Medically Needy SSI Related Medical with Spenddown (S99) medical?

An S99 Assistance Unit (AU) is initially screened into ACES as an SSI Related Categorically Needy (S02) AU by following the instructions in How do I screen SSI Related Categorically Needy (S02) medical?

An S02 AU trickles to S99 during Finalize, if appropriate, when the AU’s countable income exceeds the medically needy income level (MNIL) standard.

How do I process a pending Medically Needy SSI Related Medical with Spenddown (S99) Assistance Unit (AU)?

While pending, the AU is SSI Related Categorically Needy (S02) and is processed following the same steps in How do I process a pending SSI Related Categorically Needy (S02) Assistance Unit (AU)?

The S02 AU trickles to S99 in M - MA Spenddown during Finalize, when the AU’s countable income exceeds the MNIL standard.

For more information on the spenddown process, see Apple Health for the Medically Needy and Spenddown.

How do I add a person to a Medically Needy SSI Related Medical with Spenddown (S99) Assistance Unit (AU)?

When a SSI Related Categorically Needy (S02) AU trickles to  S99, additional AU members cannot be added.

To add a person to an S99 AU, take the following steps:

  1. Manually close the current S99 AU following the instruction in the Online Processing - How do I manually close an Assistance Unit (AU) or client?.
NOTE: Before manually closing the current S99 AU, review the base period and shorten if necessary. For more information, see Online Processing - How do I shorten a spenddown Assistance Unit (AU) base period?.
  1. Screen in a new S02 AU including the new AU member(s) and following the instructions in Online Processing - How do I screen SSI Related Categorically Needy (S02) medical?.
  2. Process the pending S02 AU following the instructions in Online Processing - How do I process a pending SSI Related Categorically Needy (S02) Assistance Unit (AU)? 

How do I enter spenddown medical expenses for an Medically Needy SSI Related Medical with Spenddown (S99) Assistance Unit (AU) in M status?

To enter medical expenses to meet the client’s spenddown liability on an S99 AU in M status, follow the instructions in Spenddown - How do I enter medical expenses?

After expenses have been added, follow the steps in Spenddown - How do I assign medical expenses and authorize spenddown?

How do I initiate an Eligibility Review on an Medically Needy SSI Related Medical with Spenddown (S99) Assistance Unit (AU)?

Eligibility reviews can be initiated on spenddown AUs in A - Active or M - MA Spenddown status.

Complete the eligibility review on an S99 AU following the instructions in the Eligibility Review chapter.

What happens when a Medically Needy Spenddown (S99) – M Status recipient becomes eligible for Categorically Needy (CN) medical or MN SSI Related No Spenddown (S95) medical?

For S99 Assistance Units (AUs) at MA Spenddown (M) status, when the system determines the client is eligible for CN or Medically Needy (MN) no spenddown in any month, users receive edit message: Screen New AU.

What happens when a Medically Needy Spenddown (S99) – A Status recipient becomes eligible for Categorically Needy (CN) medical or MN SSI Related No Spenddown (S95) medical?

When the client’s eligibility changes from an active S99 Assistance Unit (AU) to an SSI Categorically Needy (S01), SSI Related Categorically Needy (S02) / Non Citizen CN SSI Related (S07) / MN SSI Related No Spenddown (S95) AU in the ongoing month, the system:

  • Closes the S99 AU with a paid through date that is the last day of the month prior to month when the new coverage begins.
  • Changes the AU to the new coverage group.
  • Sets certification period according to the new program type (no end date for S01, 12 month for S02 or non-AEM S95).
  • Sends Letter 002-01 (Approval Letter).

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Short Stay

Created on: 
Nov 13 2019

Online Processing

Mainframe Processing

How do I view participation assigned to a short stay provider?

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is a short stay?

A short stay is when a client enters a medical facility or elects Hospice services for a short time frame. For additional information, see Apple Health eligibility manual - Long-Term Care Short Stay.

Financial workers usually learn about short stays after they have ended and the clients have returned to their regular living situation.

How long can a short stay be?

Up to 29 days for:

Up to 90 days for:

  • Clients who meet non-institutional rules active in a TANF or RF AU.
NOTE: Policy allows 180 days, however, at this time ACES only allows 90 days. See the EA-Z Manual – WAC 388-454-0015 Temporary absence from the home for more information.

When is it appropriate to enter a short stay?

Short stay data can only be entered for:

  • Active medical recipients.
  • After the short stay has ended.
  • Historical months.
  • Stays in a medical institution or for hospice services.
  • Clients who return to their original setting when the short stay ends.
EXAMPLE: Client resides in an Adult Family Home (AFH) and is admitted to a Nursing Facility (NF) for two weeks. The client returns back to the same AFH. This situation should be entered as a short stay.
EXAMPLE: Client resides at home and is active on an SSI Related Categorically Needy (S02) Medical Assistance Unit (AU). Client admits to a NF for three weeks. The client returns home. This situation should be entered as a short stay.
EXAMPLE: Client resides in a NF, and has a medical condition requiring hospitalization. The client discharges from the NF and enters the hospital. After two weeks, the client enters a new NF. This situation would not be considered a short stay because the client entered a different NF. 
EXAMPLE: Client resides in an ALF, and has a medical condition that requires a stay in a NF or hospital for over 29 consecutive days. Client then returns to the same ALF. Since the client was in a NF or hospital for over 29 consecutive days this situation would not be considered a short stay.

Online Processing

How do I enter a short stay?

  1. On the Case Actions page in the Change of Circumstances section take the following steps:
  • Benefit Month field - use the drop down menu to select the appropriate benefit month.
  • Click the Start Changes link. 
  1. On the Institutional Care page:
  • Add a Short Stay page for the client and update the following fields:
  1. Stay Living Arrangement field- Select the appropriate living arrangement using the drop down menu.
  2. Facility Type field - Select the medical facility subset using the drop down menu.
  3. HCBS Type field - Select Hospice (H) if appropriate.
  4. Provider ID field - Enter the [provider ID].
  5. Entry Date and Leave Date fields - Enter the [entry and leave dates].
  • The Entry Date must be for the benefit month being processed.
  • The Leave Date cannot be prior to the Begin Date and can’t exceed the current date.
  • If the short stay spans multiple months, see What if the short stay spans multiple months?
  • When multiple stays exist, the dates cannot overlap, except in the following situations:
    • The Leave Date of one short stay is equal to the Entry Date of the next stay.
    • Hospice services as a short stay in a medical facility can be coded concurrently with an institutional stay when the client has elected Hospice services while in an institution.
    • Hospice service data must be entered in the Home Community Based Service (HCBS Type – H) section as a separate entry from the institutional data in order to capture rates for each provider.
  1. Payment Authorization Date field - Enter the [payment authorization date].
NOTE: If the Payment Authorization Date is not entered it is possible that the Assistance Unit (AU) will approve; however, the cost of care will not be calculated.
  1. State Rate Amount field - Enter the [daily state rate].
  1. Click on Eligibility and then click the Commit Changes button to commit the data.

ACES generates the following letters for authorized short stays:

  • For K or L-track clients - Letter 002-17 (Approval for LTC Services) or Letter 002-18 (Approval for Hospice Services) based on the type of stay.
  • For non-institutional and I-track clients – Letter 002-32 (Approval for Short Stays).
    • This letter is addressed to the client for whom the short stay was entered, regardless of the client’s age or whether or not the client is the Head of Household (HOH).
    • This letter does not generate for hospital short stays.
    • If this letter is generated for a D01 or D02 AU it will only be viewable in ACES.online for Foster Care Unit workers.
  • A separate letter generates for each individual stay, unless the stays are for the same provider.

What if a short stay spans multiple months?

When a short stay spans multiple months, the stay must be entered in the month in which the stay begins.

If the user receives message Short Stay spans multiple months - must process each month, other months must be processed and eligibility manually recalculated for each month impacted by the stay.

To recalculate eligibility take the following steps:

  1. On the Case Actions page in the Change of Circumstances section take the following steps:
  • Benefit Month field - use the drop down menu to select the appropriate benefit month.
  • Click the Start Changes link. 
  1. On the Eligibility page click the Calculate Eligibility link.
  2. Click the Details link and the Eligibility Details page displays.
  3. Review the changes and if they are correct, click the Confirm Benefits button.
  4. The Eligibility page redisplays and to commit the data click the Commit Changes button.
NOTE: Each month of a short stay needs to be recalculated individually.

How is participation assigned to a short stay provider?

ACES calculates client cost-of-care responsibility based on data entered on the Short Stays page and the clients circumstances.

Participation is only assigned to short stays with a Payment Authorization Date entry.

Participation is assigned first to providers coded on the Facilities page and if there is any remaining participation, it is assigned to the short stay providers.

NOTE: If the Payment Authorization Date is not entered it is possible that the Assistance Unit will approve; however, the cost of care will not be calculated.

How do I view participation assigned to a short stay provider?

  1. On the Case Actions page in the Change of Circumstances section take the following steps:
  • Benefit Month field - use the drop down menu to select the appropriate benefit month.
  • Click the Start Changes link. 
  1. On the Institutional Care/Expenses page in the Short Stays section click on the short stay provider you want to view participation for and the Short Stay page will display.

In the Cost of Care section the following information displays for 1, 2, or 3 months:

  • Room and Board Amount
  • Participation Amount
  • Third Party Resource Amount
  • Total Payment

Mainframe Processing 

How do I view participation assigned to a short stay provider?

To view participation assigned to a short stay provider, take the following steps:

  1. On the AMEN screen: 
  • Select Option B – AU/Client Inquiry.
  • Enter the [CLID number] in the Client ID field and the [benefit month the short stay began] in the Benefit Month (MM YY) field.
  1. On the STAY screen:
  • Enter a [Y] - Yes in the Sel field next to the short stay to be viewed.
  • Press <F13> and the SSCC screen displays.
  • The SSCC screen displays the following fields for 1, 2 or 3 months, depending on the length of the short stay:
    • Room & Board
    • Third Party Resources
    • Participation
    • Total Payment

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Spenddown - Processing

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is Spenddown?

Spenddown is the process by which a client can receive Medically Needy (MN) coverage when their income exceeds the Medically Needy Income Level (MNIL). For more information, see:

Who is eligible for spenddown medical?

Any client whose excess income makes them ineligible for Categorically Needy medical. For more information, see:

Note: For more information on spenddown medical for a client who is eligible for Long Term Care, see Medically Needy LTC in a Medical Facility - with Spenddown (L99)

How long is the spenddown base period?

ACES automatically defaults to a six-month base period, which may be shortened as needed. A base period cannot be changed once the spenddown has been met and benefits have been authorized.

For more information on spenddown base periods, see Certification Period - What are the certification period defaults?

When do spenddown medical benefits begin?

For information on when spenddown medical benefits begin, see:

EXAMPLE: A client has $300.00 per month is excess income. Spenddown in this example would be $900.00 for a 3 month base period or $1800.00 for a 6 month base period. Client’s base period is from 01/01/16 to 06/30/16. Client has a $2000.00 qualifying Hospital bill for 01/21/16. He has no other medical insurance and is responsible for the entire bill. Medical coverage starts 01/21/16 and client is responsible for the first $1800.00 of the bill.
EXAMPLE: Same scenario as above except the client’s only qualifying medical expense is $1200.00 for hearing aids purchased on 01/22/16 and a $600.00 dental bill dated 01/25/16. Medical coverage starts 01/25/16 and the client is responsible for both medical expenses.

Online Processing

How do I find the client's Spenddown Medical Expenses page in ACES.online?

There are three ways to find the Spenddown Medical Expenses page:

  1. From the Welcome Back page of ACES.online, complete the following fields in the Quick Navigation section:
  • Select a Type of ID field - Select Client from the drop down menu.
  • Enter an ID field - Enter the [client ID].
  • Select a Page field - Select Spenddown Medical Expenses from the drop down menu.
  • Click the Go button and the Spenddown Medical Expenses page displays.
  1. On the client's Summary page, select Spenddown Medical Expenses from the Details dropdown list.
  2. On the Spenddown page in the Clients on this Assistance Unit section, click Expenses next to the client’s name.

How do I shorten a spenddown Assistance Unit (AU) base period?

If the base period needs to be shortened, take the following steps in ACES.online:

  1. On the Spenddown page, click the Start the Assign/Authorize Process button.
  2. On the Spenddown Assign/Authorize Review page, in the Spenddown Details and Liability section, complete the following fields:
  • Spenddown Base Period field - Enter the [new spenddown base period ending month/year].
  • Click the Next button.
  1. The Spenddown Assign/Authorize page displays with the new shortened base period in the Spenddown Base Period field. Click the Next button.
  2. On the Spenddown Assign/Authorize Confirm page, click the Confirm button to confirm the shortened spenddown base period.

How do I enter medical expenses?

Note: For a list of medical expenses that can be applied towards the spenddown, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

To enter medical expenses, take the following steps:

  1. From the Spenddown Medical Expenses page, click Add link.
  2. On the Add Spenddown Medical Expense pop up window, complete the following fields:
  • Expense Type field - Select the appropriate medical expense type from the drop down menu.
  • Rx Description field - Enter [the name of the prescription].
    • This field displays when MA Covered Prescriptions (RX) is selected from the Expense Type drop down menu. 
  • Current Indicator field - Click the radio button to indicate Yes or No.
    • This field displays when Psychiatric Hospitalization (PH) is selected from the Expense Type drop down menu.
  • Verification field - Select the appropriate verification code from the drop down menu.
  • Date Incurred field - Enter the date [MM/DD/YYYY].
  • Expense Amount field - Enter the [expense amount].
  • TPL Amount field - Enter the [amount of the expense covered by another source].
  • Applied Amount field - This is a display only field and displays the amount applied towards a spenddown.
  • Available Amount field - This is a display only field and displays the available amount after deducting the TPL AmountApplied Amount and Other Reductions fields from the Expense Amount.
    • If an amount is entered in the Other Reductions field, the Notes field becomes a mandatory entry field for the user to document why the change was made.
  • Expense Paid field - Click the radio button to indicate Yes or No.
  • Provider Name field - Enter the [name of the provider].
  • Notes field - This is a text field where workers can enter a short note (under 100 characters) about the medical expense.
  1. To add more than one medical expense, click the Add More box, otherwise click the Submit button.
  2. After expenses have been added, follow the steps in How do I assign medical expenses and authorize spenddown?

How do I enter medical expenses for an ineligible spouse or child?

The Spenddown Medical Expenses page is a client level page, so each person listed on a spenddown assistance unit has their own Spenddown Medical Expenses page. To enter medical expenses for the applicant’s ineligible spouse or child, follow the steps in How do I enter medical expenses?

How do I update a medical expense?

To update an existing medical expense, take the following steps:

  1. Click Update next to the expense on the Spenddown Medical Expenses page.
  2. Update the information as needed.
  • Expense Type and Date Incurred fields - These fields are not available to update due to system tracking purposes once the expense has been assigned to a spenddown base period. If an expense entered has the wrong type or date, the expense should be deleted and then re-entered correctly.
  • Applied amount field - This is a display only field and displays the amount applied towards a spenddown.
  • Other Reductions field - Enter an amount that is less than or equal to the Available Amount field.
    • This field is only available once an expense has been assigned to a spenddown base period.
    • If an amount is entered in the Other Reductions field, the Notes field becomes a mandatory entry field for the user to document why the change was made.
  • Available Amount field - This is a display only field and displays the available amount after deducting the amount in the TPL AmountApplied Amount and Other Reductions fields.
  • If the medical expense has already been assigned to a spenddown Assistance Unit (AU) and base period, the only field available to update is the Expense Paid field. If you need to update more information, you can un-assign the bill from the AU, which then opens more fields, see How do I un-assign medical expenses from an Assistance Unit (AU)?
  1. Click the Submit button.

How do I delete a medical expense?

If a medical expense needs to be deleted, take the following steps:

  1. Click Delete next to the expense to be deleted on the Spenddown Medical Expenses page.
  2. Click Submit in the Delete Spenddown Medical Expense pop up window if you want to delete the medical expense. If you do not want to delete the medical expense, click Cancel.

Why are the spenddown medical expenses displayed in different sections or categories?

The spenddown medical expenses are displayed in different section or categories on the Spenddown page based on the policy prioritization rules. The highest priority medical expenses are listed first and then the next highest priority medical expenses are listed below that.

The Priority/Categories are as follows:

  • Category 0: Psychiatric Hospitalization Emergency
  • Category 1: Current Period - Medicare Premiums and Medicare/Private health insurance cost sharing
  • Category 2: Retroactive Period - Paid Bills incurred during 3 months prior to Application date
  • Category 3: Prior - Unpaid Bills
  • Category 4: Current Period - Bills not covered by Medicaid
  • Category 5: Current Period - Bills potentially covered by Medicaid

How do I assign medical expenses and authorize spenddown?

NOTE: When assigning medical expenses to a historical (or retroactive) base period and a current base period, complete the historical (or retroactive) base period first. This ensures the medical expenses are selected and applied in the correct order. Finalize the current base period on the following business day.

To assign medical expenses and authorize a spenddown Assistance Unit (AU), take the following steps:

  1. On the Spenddown page, if the ongoing month is not part of the spenddown base period, select a benefit month within the spenddown base period.
  2. From the Spenddown page, click the Start the Assign/Authorize Process button.
  3. On the Spenddown Assign/Authorize Review page:
  1. On the Spenddown Assign/Authorize page all the spenddown medical expenses entered for all household members are listed in priority order.
  • To select all the available medical expenses, click Auto Assign Medical Expenses. When this is clicked, the system selects all the medical expenses that can be used to meet the spenddown automatically without having to individually select bills.
  • To select each medical bill individually, click the check box next to the medical expense.
    • If you have multiple expenses in one category, you must select the medical expenses in priority order. For Current Period - Bills potentially covered by Medicaid, if the expenses are selected out of order, the system outlines in red the check box next to the expense that should be chosen first.
    • As the expenses are selected, the Available Amount and Applied Amount fields change as the system applies the expenses.
    • When the check box next to the last expense needed to meet spenddown is selected, a green checkmark appears next to the Applied Amount. The Remaining Liability amount in the Spenddown Details and Liability section also displays a green checkmark to indicate the spenddown liability has been met.
  • Click the Next button.
  1. On the Spenddown Assign/Authorize Confirm page:
  • If the spenddown liability has been met, the Eligibility Begin Date field in the AU Status section displays the medical approval date. The date is based on the assigned medical expenses.
  • Click the Confirm button.

How do I view medical expenses assigned to a specific Assistance Unit (AU) and base period?

There are two ways to view which medical expenses are assigned to a specific AU and base period:

  • On the Spenddown Medical Expenses page, the AU ID and Base Period fields display which AU and base period the expense is assigned to.
  • On the Spenddown page, the Medical Expenses section displays the list of expenses assigned to the chosen AU and details about each expense.

How do I view spenddown medical expenses by client ID?

Each client has their own Spenddown Medical Expenses page that lists all their medical expenses, see How do I find the Spenddown Medical Expenses page in ACES.online?

To view medical expenses listed for each client, take the following steps:

  1. From the Summary page for the specific client, select Spenddown Medical Expenses from the Details drop down menu. Or you can click the Expenses link next to the client’s name on the Spenddown page.

How do I view medical expenses history?

When you hover over a medical expense row on the Spenddown Medical Expenses page, the message “Click for expense details” displays.

When the row is clicked, the history of that medical expense displays in the History Details window with the following:

  • When the medical expense was created.
  • When it was assigned to an Assistance Unit (AU).
  • When the user last updated the notes for the expense.
  • When it was unassigned from the AU (if it had been unassigned).

How do I un-assign medical expenses from an Assistance Unit (AU)?

Note: Spenddown medical expenses can be un-assigned until the AU becomes active. Once the AU is active and the medical expense has been used to meet the spenddown, the medical expense is permanently assigned to the AU.

To un-assign medical expenses from an AU, take the following steps:

  1. Click the Start the Assign/Authorize Process button at the bottom of the Spenddown page.
  2. On the Spenddown Assign/Authorize Review page:
  1. On the Spenddown Assign/Authorize page:
  • Un-check the box next to the medical expense to be un-assigned to the specific AU and base period.
    • If you have multiple expenses in one category, you must un-check the medical expenses in priority order. If an expense is un-checked out of priority order, the system outlines in red the checkbox next to the expense that should remain assigned.
  • Click the Next button.
  1. On the Spenddown Assign/Authorize Confirm page, click the Confirm button.

How do I release medical expenses from a closed or denied Assistance Unit (AU) that was opened in error?

In situations where a spenddown AU was opened in error and the AU is currently in closed or denied status, the medical expenses can be released so they are available to be used for a new base period.

NOTE: Medical expenses can only be released if all months in the base period are closed or denied or a combination of both.

To release medical expenses, take the following steps:

  1. On the Spenddown page, click Release Medical Expenses.
  2. The Confirmation pop up window displays. Click OK and all the medical expenses are unassigned from the AU and base period.

How do I make a medical expense no longer available for future spenddowns?

To make a medical expense no longer available for future spenddowns, take the following steps:

  1. From the Spenddown Medical Expenses page, click the Update link next to the expense. The Update Spenddown Medical Expense window opens with all the values of the existing medical expense.
  2. In the Other Reductions field, adjust the amount to zero.
  • The Available Amount is then recalculated. When the Available Amount is zero, the medical expense is unavailable for any future spenddown.
  1. Update the Notes field with a brief explanation and click Submit.

What do I do with a split bill from a prior base period?

For more information about split medical expense bills and which medical expenses are covered, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

When a medical expense is split between meeting the spenddown liability and having a remaining balance, the system indicates the expense is split by displaying the following:

  • The Use field on the Spenddown page displays an S - Split Bill, remaining amount may be available for future spenddown periods.
  • The Available Amount and Applied Amount fields display the following amounts:
    • On the top line, the amount in the Available Amount field is the total expense, the Use code is S and Applied Amount is the amount used to meet the currently selected base period.
    • On the bottom line, the amount in the Available Amount field displays. If the expense is crossed out and the Use code is N - Bill not used to meet spenddown, not available for future spenddown periods the expense cannot be used for future base periods. If the expense is not crossed out and there is no Use code next to the expense, then the amount can be used for a future base period.
  • Users need to determine if the medical expense type is one that can be applied to a new base period. If it can, then users have to find out from the provider what amount the client still owes at the start of the new base period.
  • If the total remaining amount of the bill can be used towards the next spenddown, then the remaining amount displays as an available expense that can be assigned to an Assistance Unit (AU) base period.

How do I create a retroactive spenddown base period?

This feature is not currently available for online processing. For more information on retroactive medical, see the Retroactive Medical chapter.

What happens if a client does not meet their spenddown?

The Assistance Unit (AU) is AUTO denied 30 days after the base period has expired with Reason Code 284 - Failed to meet Spenddown Requirement.

 Medical expenses that were assigned to the spenddown base period are un-assigned from the AU and no longer have a Use indicator. Those expenses are available to assign to another base period. For information on what medical expenses can be applied towards meeting a spenddown base period, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

Can I initiate a review on a Spenddown Assistance Unit (AU)?

If the Spenddown AU for which the review is due is in Active (A) status, a review may be initiated on the following types of AUs:

  • G99 (MN Alternate Living Facility W/Spenddown),
  • K99 (MN Family LTC W/Spenddown),
  • L99 (LTC MN W/Spenddown) or;
  • S99 (MN SSI Related W/Spenddown) the previous AU can be reopened.

If the AU is in MA Spenddown (M) status, an eligibility review can be initiated when the ongoing month is the month after the current base period end month. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Suspended Medical - State Bill (SB) 6430

Created on: 
Jul 14 2017

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is Suspended Medical - State Bill (SB) 6430? 

In the 2016 Legislative Session SB 6430 was passed, allowing clients to receive medical benefits in a suspended status while being an inmate or resident of a public institution.

The Inmate or Resident of a Public Institution? field located on the Shelter page in ACES.online and the Client Details page in ACES 3G is updated to Yes (Y), when a client is coded with one of the following living arrangement codes:

  • Jail (JL)
  • Prison (PR)
  • Institution for Mentally Diseased (IM)
  • Juvenile Rehabilitation (JR)

The client remains active in ACES but medical coverage could be limited based on the client's incarceration status.

What Classic Medical coverage groups allow clients to receive medical benefits in a suspended status when coded as an inmate or resident of a public institution?

These Classic Medical coverage groups no longer deny or terminate a client for being incarcerated:

What Modified Adjusted Gross Income (MAGI) Medical coverage groups allow clients to receive medical benefits in a suspended status when coded as an inmate or resident of a public institution?

These MAGI Medical coverage groups no longer deny or terminate a client for being incarcerated:

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Take Charge Family Planning Service (P06)

Created on: 
Nov 06 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is Take Charge Family Planning Service (P06) medical?

P06 medical is a federally funded waiver program providing family planning services to men and women in Washington State. For more information about P06 medical, see Apple Health eligibility manual - WAC 182-532-700 TAKE CHARGE program -- Purpose.

Who is eligible to receive Take Charge Family Planning Service (P06) medical?

To be eligible for P06 medical a client must meet the criteria described in Apple Health eligibility manual - WAC 182-532-720 TAKE CHARGE program -- Eligibility.

How long is the Take Charge Family Planning Service (P06) certification period?

The P06 certification period is 12 months.

Who can open Take Charge Family Planning Service (P06) medical?

The Take Charge Unit is responsible for the administration of the P06 program.

What happens if a client who is active on Take Charge Family Planning Service (P06) medical applies for another program?

If a client is approved for another coverage type that provides Family Planning services during the P06 certification period, ACES automatically close the P06 Assistance Unit (AU). No termination or change letter is generated for the P06 AU when the new medical program is approved.

If a client is no longer receiving medical assistance that provides Family Planning services, and the client has months remaining under a prior P06 certification period, ACES automatically reopens the P06 AU. Letter 008-07 (Change in Medical) generates when a non-P06 medical coverage AU terminates and the P06 is reopened for the remainder of its certification period. If the AU is marked confidential, the letter is sent to the authorized representative.

Online Processing

How do I screen Take Charge Family Planning Service (P06) medical?

To screen a P06 Assistance Unit (AU), take the following steps:

  1. From the Welcome Back page in ACES.online, click the Screen New Application link at the top of the page.
  2. On the Applicant page, complete the following fields:
  • Applicant Name field - Enter [Applicant’s First and Last Name].
  • Residential Address section - Enter [Client’s Residential Address]
    • If the applicant has a mailing address, uncheck the box next to Mailing Address same as above field to enter the applicant’s mailing address.
  • To add an Authorized Representative (AREP) or Protective Payee, follow the steps in How do I add an Authorized Representative (AREP) during screening?
    • If the Take Charge case is confidential, when adding the AREP on the Add AREP page, select Take Charge Representative (TC) from the Type drop down menu.
    • If the Take Charge case in not confidential, any AREP type other than Take Charge Representative (TC) that is valid for a medical AU can be entered.
  1. On the Address Validation page take the necessary steps to complete the address validation process. For additional information, see Screening - Address Validation.
  2. On the Programs page, take the following steps:
  • In the Programs section, click on the checkbox next to Take Charge.
  • Click Next.
  1. On the Finalize page, take the following steps:
  • Select the checkbox next to the P06 program.
  • Identify if the P06 AU is confidential by selecting the appropriate button.
    • If the AU is marked as confidential, authorized representative type Take Charge Representative (TC) must be entered on the Add AREP page.
  • Application Date field - Enter the [date of application]. The date of application must not be greater than 36 months in the past.
  • Click the Commit button to commit the screening data.

How do I process a pending Take Charge Family Planning Service (P06) medical?

To process a pending P06 Assistance Unit (AU), take the following steps:

  1. On the AU Details page, complete the following fields:
  • Confidentiality field - Update if needed.
    • If the Confidentiality radio button is updated to Yes, the Type field on the Authorized Representatives/Payees page must be updated with type Take Charge Clinic (TC). When a P06 AU is confidential, all letters generated for the AU are sent to the authorized representative only.
  • Household Income Amount field - Enter the [income amount].
  • Household Size field - Enter the [number of people in the household].
NOTE: The P06 income standard is based upon the total number of household members indicated on the AU Details page.
  • Financial Responsibility field - The system defaults the financial responsibility to Applicant (PN).
NOTE: A P06 AU can only have one Applicant (PN) coded under the Financial Responsibility field. If other household members are listed, code their Financial Responsibility field as Non-Member (NM).
  1. On the Client Details page, complete the following fields:
  • Citizen Status field - Select the client's citizenship code from the drop down menu.
  • Identity field - Select how the client's identity was verified from the drop down menu.
  1. After committing the interview data, follow the instructions in the Process Application Months chapter for all the pending months.
  2. Once the pending months have been processed, follow the instructions in the Finalize Application chapter.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.