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.