***This version of the Health Care Programs Manual has been replaced and is no longer in effect. Please see the current Health Care Programs Manual for policy in effect as of December 1, 2006.***

The terminology used to describe people with disabilities has changed over time. The Minnesota Department of Human Services ("Department") supports the use of "People First" language. Although outmoded and offensive terms might be found within documents on the Department's website, the Department does not endorse these terms.

MDHS Health Care Programs Manual (Eligibility Policy through 11/30/06)

Chapter 0907 - Eligibility Groups and Bases of Eligibility

All chapters are numbered beginning with 09. The first chapter is 0901 (Table of Contents).

Chapter 0907

0907

ELIGIBILITY GROUPS AND BASES OF ELIGIBILITY

PDF(s) Oct 03 | Jan 03 | Oct 02 | Jun 02

0907.03

MINNESOTACARE ELIGIBILITY GROUP 1

PDF(s) Jan 05 | Jan 03 | Dec 02 | Jun 02 | Jan 99

0907.05

MINNESOTACARE ELIGIBILITY GROUP 2

PDF(s) Jan 05 |Oct 03 | Jul 03 | Jan 03 | Oct 02 | Jun 02 | Jan 99

0907.07

MINNESOTACARE ELIGIBILITY GROUP 3

PDF(s) Oct 03 | Jan 03 | Oct 02 | Jan 99

0907.08

MINNESOTACARE ELIGIBILITY GROUP 4

PDF(s) Jan 03

0907.09

MINNESOTACARE PREGNANT WOMEN

PDF(s) Apr 02

0907.09.03

MINNESOTACARE AUTO NEWBORNS

PDF(s) Oct 03 | Jan 01

0907.11

MINNESOTACARE CHILDREN UNDER 21

PDF(s) Feb 99

0907.13

MINNESOTACARE PARENTS/ GUARDIANS/ CARETAKERS

PDF(s) Jan 05 | Jul 03 | Jan 03 | Oct 02 | Feb 01

0907.15

MINNESOTACARE ADULTS WITHOUT CHILDREN

PDF(s) Oct 03 | Dec 01

0907.17

MA/GAMC BASES OF ELIGIBILITY

PDF(s) Oct 03 | Mar 03 | Oct 02 | Apr 01

0907.17.03

MA BASIS: MULTIPLE BASES OF ELIGIBILITY

PDF(s) Oct 02 | Aug 01

0907.19

MA FAMILIES AND CHILDREN BASES

PDF(s) Jul 02 | Jul 98

0907.19.03

FAMILIES AND CHILDREN BASIS: CHILD UNDER 21

PDF(s) Jul 04 | Oct 03 | Jul 02 | Jul 00

0907.19.03.03

MA BASIS: CHILDREN IN FOSTER CARE

PDF(s) Apr 01

0907.19.03.05

MA BASIS: ADOPTION ASSISTANCE

PDF(s) Jun 02 | Jul 98

0907.19.05

MA BASIS: PREGNANT

PDF(s) Oct 03 | Jul 03 | Dec 02 | Apr 02

0907.19.05.03

MA BASIS: AUTO NEWBORN

PDF(s) Oct 03 | Oct 02 | Dec 99

0907.19.05.05

ADDING/REMOVING AUTO NEWBORNS

PDF(s) Jan 05 | Oct 03 | Apr 01

0907.19.07

FAMILIES & CHILDREN: PARENTS/CARETAKERS

PDF(s) Jul 04 | Jul 02 | Dec 01

0907.19.07.01

MA: AFDC-RELATED ADULTS -- UP/IP BASES

PDF(s) Jul 99

0907.19.09

MA FAMILIES AND CHILDREN BASIS: MFIP

PDF(s) Jul 02

0907.19.11

TRANSITIONAL/TRANSITION YEAR MA

PDF(s) Jan 05 | Apr 04 | Oct 03 | Jul 03 | Jul 02

0907.19.11.03

TMA/TYMA CHANGES AND REPORTING REQUIREMENTS

PDF(s) Jul 02

0907.19.13

MA FOR BREAST/CERVICAL CANCER (MA-BC)

PDF(s) Apr 04 | Dec 02

0907.21

MA BASIS: AGE 65 AND OVER/ BLIND/ DISABLED

PDF(s) Mar 03

0907.21.03

MA/MEDICARE SAVINGS BASIS: AGE 65 & OVER

PDF(s) May 05 | Mar 03 | Oct 02

0907.21.05

MA/MEDICARE SAVINGS BASIS: BLINDNESS

PDF(s) May 05 | Mar 03 | Oct 02

0907.21.07

MA/MEDICARE SAVINGS BASIS: DISABILITY

PDF(s) Jan 05 | Mar 03 | Oct 02

0907.21.07.03

MA BASIS: 1619 A AND B

PDF(s) Jul 98

0907.21.07.05

MA FOR EMPLOYED PERSONS WITH DISABILITIES

PDF(s) Jan 06| Jan 05 | Jan 04 | Dec 02 | Oct 02 |

0907.21.07.06

MA-EPD: EMPLOYMENT DEFINITION

PDF(s) Jan 06| Jan 05 | Jan 04 |

0907.21.07.07

SPECIAL CATEGORY: DISABLED CHILDREN

PDF(s) Oct 02 | Apr 02

0907.21.09

MA BASIS: MEDICARE SAVINGS PROGRAMS

PDF(s) Apr 04 | Mar 03 | Oct 02 | Jul 02

0907.21.09.03

MEDICARE SAVINGS PROGRAMS: QMB

PDF(s) Jan 05 | Mar 03 | Oct 02

0907.21.09.05

MEDICARE SAVINGS PROGRAMS: SLMB

PDF(s) Mar 03 | Oct 02

0907.21.09.07

MEDICARE SAVINGS PROGRAMS: QWD

PDF(s) Mar 03 | Oct 02

0907.21.09.09

MEDICARE SAVINGS PROGRAMS: QI

PDF(s) Mar 03 | Oct 02 | Apr 02

0907.21.09.11

PRESCRIPTION DRUG PROGRAM: PDP

PDF(s) Apr 04 | Mar 03 | Jul 02

0907.21.11

MA BASIS: MSA RECIPIENTS

PDF(s) Mar 03

0907.21.13

MA BASIS: REFUGEE MEDICAL ASSISTANCE - RMA

PDF(s) Jul 04 | Oct 02 | Jun 02

0907.23

MA WAIVER PROGRAMS

PDF(s) Jul 98

0907.23.03

MA WAIVER PROGRAMS: CADI

PDF(s) Oct 02

0907.23.05

MA WAIVER PROGRAMS: MR/RC

PDF(s) Oct 02

0907.23.07

MA WAIVER PROGRAMS: CAC

PDF(s) Oct 02

0907.23.09

MA WAIVER PROGRAMS: TEFRA

PDF(s) Oct 02 | Apr 02

0907.23.09.03

TEFRA -- SMRT PROCEDURES

PDF(s) May 05| Jan 05 | May 00

0907.23.11

MA WAIVER PROGRAMS: EW

PDF(s) Jul 06 | Jan 06| Jul 05 | Jan 05 | Jul 04 | Jan 04 | Oct 03 | Jul 03 | Jan 03 | Oct 02 | Jul 02 | Jun 02 |

0907.23.13

MA WAIVER PROGRAMS: TBI

PDF(s) Oct 02

0907.25

GAMC PROGRAM TYPES

PDF(s) Apr 04 | Oct 03

0907.25.03

GAMC BASIS: FAMILIES WITH CHILDREN

PDF(s) Oct 03 | Oct 02

0907.25.05

GAMC HOSPITAL ONLY (GHO)

PDF(s) Jan 05 | Oct 03 | Oct 02

0907.25.07

STATE-FUNDED MA BASIS: VICTIMS OF TORTURE

PDF(s) Oct 03

0907.25.09

GAMC: MANDATORY MINNESOTACARE REFERRALS

PDF(s) Apr 04 | Oct 03

0907.27

MA/GAMC BASIS: IMD RESIDENTS

PDF(s) Jan 05 | Oct 03 | Jan 03 | Oct 02 | Jun 02

0907.29

EMERGENCY MEDICAL ASSISTANCE-EMA

PDF(s) Oct 03

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual

ELIGIBILITY GROUPS AND BASES OF ELIGIBILITY 0907

People’s eligibility for the health care programs may vary depending on certain characteristics. The relevant characteristics vary by program but may include age, disability, pregnancy, and presence of children in the home.

MinnesotaCare:

All MinnesotaCare enrollees are assigned to 1 of 4 eligibility groups. Eligibility group status mainly affects insurance barrier requirements and MMIS coding for benefits. Certain characteristics within groups such as pregnancy, age, and income may also affect benefits. See the following sections for more specific information:

§0907.09

MinnesotaCare Pregnant Women.

§0907.11

MinnesotaCare Children Under 21.

§0907.13

MinnesotaCare Parents/Guardians/Caretakers.

§0907.15

MinnesotaCare Adults Without Children.

Adults and children in the same household may be assigned to different eligibility groups. Re-evaluate group status at each renewal. Once people are assigned an eligibility group, their group status remains unchanged between renewals unless:

• They do not maintain continuous enrollment. For purposes of group status, continuous enrollment means that a person has been enrolled in MinnesotaCare without a break in coverage of one month or more.

OR

• They have a change in circumstances that results in a more favorable group status. This includes Group 2 parents or caretakers who report income decreases resulting in Group 4 status. See §0915.15 (Change in MinnesotaCare Eligibility Group).

OR

• A parent loses parental status.

OR

• A child turns age 21.

EXCEPTION:

Children who were enrolled in the Children’s Health Plan on or before 6-30-93 who have maintained continuous enrollment retain Group 1 status until they reach age 21. See §0907.03 (MinnesotaCare Eligibility Group 1).

See §0907.03 (MinnesotaCare Eligibility Group 1), §0907.05 (MinnesotaCare Eligibility Group 2), and §0907.07 (MinnesotaCare Eligibility Group 3) and §0907.08 (MinnesotaCare Eligibility Group 4).

M. S. 256L.02 subd. 4

M. S. 256L.03 subd. 1, 3, and 5

MA:

Each person must meet a basis of eligibility for MA. A basis of eligibility is a set of characteristics such as age, disability, or family status. The bases of eligibility are based on federal eligibility categories. See §0907.17 (MA/GAMC Bases of Eligibility).

GAMC:

People who do not meet a basis of eligibility for MA may be eligible for GAMC. See §0907.17 (MA/GAMC Bases of Eligibility).

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MINNESOTACARE ELIGIBILITY GROUP 1 0907.03

MinnesotaCare:

Also see §0907 (Eligibility Groups and Bases of Eligibility), §0907.05 (MinnesotaCare Eligibility Group 2), and §0907.07 (MinnesotaCare Eligibility Group 3) and §0907.08 (MinnesotaCare Eligibility Group 4).

Group 1 includes:

• Children under 21 whose family income is below 150% FPG. • Children who have been continuously enrolled in Group 1. This includes children who were originally enrolled in the Children’s Health Plan who have maintained continuous enrollment. Continuous enrollment means enrollment in MinnesotaCare or MA/GAMC without a break in coverage of 1 month or more. See CONTINUOUS ENROLLMENT in §0902.07 (Glossary: Client...)

Reevaluate the group status of 21-year-olds currently assigned to Group 1 for the first available month following the 21st birthday. Assign them to the appropriate group depending on their current circumstances. See §0907.05 (MinnesotaCare Eligibility Group 2), §0907.07 (MinnesotaCare Eligibility Group 3) and §0907.08 (MinnesotaCare Eligibility Group 4).

EXAMPLE:

Bobby was enrolled in Group 1 as a child in a family with total income at or below 150% FPG. Re-evaluate group status at the time of each renewal. If family income remains at or below 150% FPG, Bobby will retain Group 1 status. If family income has increased beyond 150% FPG, assign Bobby to Group 2.

EXAMPLE:

Charles was enrolled in the Children’s Health Plan in 1990 at the age of 8. He was terminated from MinnesotaCare effective June 1, 1994, and applied for MA on June 10, 1994. He was enrolled in MA from June 1994 until December 31, 1995. He reapplied for MinnesotaCare on December 10, 1995, and was re-enrolled effective January 1, 1996. Charles has maintained continuous enrollment since he had no break in coverage. Charles’s family’s current income is now over 150% FPG. He retains Group 1 status. If he continues to be continuously enrolled until age 21, reevaluate his group status for the first available month after his 21st birthday.

EXAMPLE:

In 1995, Betty enrolled in MinnesotaCare with her parents. Based on the household income at the time of enrollment, Betty was assigned to Group 1. In 1996, Betty and her parents ended their MinnesotaCare coverage. They reapply in 1998. Determine Betty's group status based on the household income at the time of re-application.

Generally, children with Group 1 status are exempt from the insurance barrier requirements. See §0910 (Other Health Coverage) for a detailed description of the insurance barriers and to whom they apply.

The income limit for children to have Group 1 status is 150% FPG. Children in households with income between 150% and 275% FPG have Group 2 status except for children who were enrolled in the Children’s Health Plan on or before 6-30-93 who have maintained continuous enrollment. See §0912 (Income Eligibility).

• Adults without children whose income is at or below 75% FPG.

M. S. 256L.04 subd. 1 and 7

M. S. 256L.07 subd. 1

MA/GAMC:

No provisions.

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MINNESOTACARE ELIGIBILITY GROUP 2 0907.05

MinnesotaCare:

Also see §0907 (Eligibility Groups and Bases of Eligibility), §0907.03 (MinnesotaCare Eligibility Group 1), and §0907.07 (MinnesotaCare Eligibility Group 3) and §0907.08 (MinnesotaCare Eligibility Group 4).

Group 2 includes:

• Children under 21 with family income over 150% FPG.

EXCEPTION:

Children under 21 who were enrolled in the Children’s Health Plan on or before 6-30-93 who have maintained continuous enrollment may have family income over 150% FPG and retain Group 1 status. See CONTINUOUS ENROLLMENT in §0902.07 (Glossary: Client...) and §0907.03 (MinnesotaCare Eligibility Group 1).

• Parents or relative caretakers of dependent children with incomes at or below 100% FPG or over 200% FPG. Assign parents with incomes over 100% FPG but no more than 200% FPG to Group 4 if they are citizens or have an immigration status that qualifies them for FFP. See §0907.08 (MinnesotaCare Eligibility Group 4).

NOTE:

Always assign pregnant women to Group 2. Husbands of pregnant women may be either Group 2 or Group 4.

• Non-citizen parents or relative caretakers with incomes at or below 275% FPG who do not have an immigration status that qualifies them for FFP. See §0906.03.05 (Non-Citizens Ineligible for Federal Funding). • Legal guardians and foster parents.

Redetermine eligibility for the next available month or at the time they apply for MinnesotaCare coverage on their own case when people enrolled in Group 2:

• Reach age 21.

OR

• Are no longer part of a family with children.

If people who originally enrolled in Group 2 reapply after losing coverage for 1 month or more, redetermine eligibility based on current circumstances.

EXAMPLE:

Joe and Susan Brown and their children, Emily, age 19 and Bruce, age 18, have a family income of 225% FPG. Their family income has been above 150% FPG throughout their enrollment in MinnesotaCare. All household members have Group 2 status.

EXAMPLE:

Emily Brown has reached age 21 and moved out of her parents’ household. She requests to end coverage on her parents case and begin her own MinnesotaCare case. Re-evaluate her eligibility and group status when her application is processed. Since she is now an adult in a household with no dependent children, her income must be equal to or less than 175% FPG. Bruce is now age 20 and remains in his parents’ household. Joe, Susan and Bruce retain Group 2 status.

EXAMPLE:

Bruce moves out of his parents’ household. Assign his parents to a non-parent major program (BB and the appropriate group status) for the next available month with 10-day notice. If their income exceeds 175% FPG, terminate coverage for the end of the month following the month in which excess income is determined. When Bruce submits an application for coverage on his own MinnesotaCare case, reevaluate his group status.

When Group 2 parents report an income decrease that results in meeting Group 4 criteria, change group status for the first available month. Act on income increases at the time of the next renewal.

Generally, Group 2 members cannot have current health insurance and cannot have had health insurance in the 4 months prior to enrollment in MinnesotaCare. They may be subject to restrictions on current and past availability of employer subsidized insurance (ESI). See §0910 (Other Health Coverage) for detailed instructions on which insurance barriers apply to Group 2 individuals.

The income limit at application for Group 2 children, pregnant women and minor parents is 275% FPG. The income limit for other parents, relative caretakers, legal guardians and foster parents is 275% FPG or $50,000, whichever is less.

Children under 21 in Group 2 who meet the MCHA exemptioin and maintain continuous enrollment can have income over the limit and remain enrolled. Pregnant women in Group 2 who maintain continuous enrollment can have income over the limit and remain enrolled until the end of the 60-day postpartum period. See §0912.03.03 (MinnesotaCare Excess Income).

M. S. 256L.04 subd. 1 and 7

M. S. 256L.07 subd. 1

MA/GAMC:

No provisions.

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MINNESOTACARE ELIGIBILITY GROUP 3 0907.07

MinnesotaCare:

Also see §0907 (Eligibility Groups and Bases of Eligibility), §0907.03 (MinnesotaCare Eligibility Group 1), and §0907.05 (MinnesotaCare Eligibility Group 2) and §0907.08 (MinnesotaCare Eligibility Group 4).

Group 3 includes adults who:

• Are not pregnant

AND

• Do not have children under 21 (including foster children or children under guardianship in the household) or adult dependent siblings living with them.

AND

• Have incomes greater than 75% FPG but no more than 175% FPG.

This includes adults previously enrolled in Group 2 or Group 4 who have lost their parental status.

NOTE: Group 3 status is used to identify people who are eligible for MinnesotaCare Limited Benefit (MLB) on MMIS. Adults without children with incomes equal to or less than 75% FPG have a different benefit set and MMIS coding.

EXAMPLE:

John, age 26, is applying for MinnesotaCare for the first time. He has no children under 21 in his household. His income is 100% of FPG. Assign John to Group 3.

EXAMPLE:

Mary and Joe are Group 2 parents. Their children have left the household. Since Mary and Joe no longer have minor children in their household, re-determine their eligibility as adults without children.

Group 3 members are subject to all the insurance barriers. See §0910 (Other Health Coverage).

The income limit for Group 3 is 175% FPG.

M. S. 256.9354 subd. 1 and 5

M. S. 256.9357 subd. 1, 2, and 3

M. S. 256.9366 subd. 1, 2, 3, and 4

MA/GAMC:

No provisions.

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MINNESOTACARE ELIGIBILITY GROUP 4 0907.08

MinnesotaCare:

Also see §0907 (Eligibility Groups and Bases of Eligibility), §0907.03 (MinnesotaCare Eligibility Group1), §0907.05 (MinnesotaCare Eligibility Group 2), and §0907.07 (MinnesotaCare Eligibility Group 3).

Group 4 includes parents and relative caretakers who:

• Have household incomes over 100% FPG but at or below 200% FPG.

AND

• Are U. S. citizens or have an immigration status that qualifies for federal financial participation (FFP). See §0906.03.03 (Qualified Non-Citizens).

Group 4 is used to identify parents and relative caretakers for whom DHS receives enhanced federal funding. Use MMIS major program FF for all group 4 enrollees.

Except for citizenship/immigration status and income, Group 4 parents and caretakers have the same eligibility requirements as Group 2 parents and caretakers. See §0907.05 (MinnesotaCare Eligibility Group 2) and §0907.13 (MinnesotaCare Parents and Caretakers).

See §0907.05 (MinnesotaCare Group 2) for information on when to re-evaluate group status when people lose parent or caretaker status.

MA/GAMC

No provisions.

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MINNESOTACARE PREGNANT WOMEN 0907.09

MinnesotaCare:

Pregnant women may be:

• Group 2 adults who become pregnant.

OR

• Pregnant adults applying for the first time or after a break in coverage of one month or more. These adults will have Group 2 status. Group 3 adults who become pregnant will also have Group 2 status.

OR

• Pregnant children under 21 with either Group 1 or Group 2 status.

If an applicant or enrollee states she is pregnant, contact her to obtain the date of diagnosis and estimated date of delivery. If you are unable to reach her, use an estimated date of delivery pending receipt of verification. Verification of pregnancy must be submitted within 60 days. If verification is not received, determine whether the woman is eligible under another basis.

Require medical verification of pregnancy. Use the Request for Pregnancy Verification Form (DHS 3236) or accept any other verification of the conception, due date, and date of diagnosis signed by a physician, registered nurse, or licensed nurse midwife, or physician’s assistant. If a pregnant woman is on MA, also accept a current MAXIS STAT/PREG screen with one of the verification fields coded Y as verification.

Pregnancy affects MinnesotaCare eligibility and benefits in the following ways:

• Effective the first day of the month in which the pregnancy is diagnosed, pregnant women are eligible for the same benefits as MA enrollees with minor exceptions. If the date of diagnosis is unknown, begin the pregnancy span on the first day of the month following the report of pregnancy. They are not subject to deductibles, co-payments, or service limitations that apply to other adults. If a pregnant woman has paid any co-payments since her pregnancy was diagnosed, she may request a refund from the provider to whom she paid the co-payment. • Pregnant women who are eligible for MinnesotaCare and meet the citizenship and immigration requirements of the MA program are eligible for federal financial participation. See §0906.03 (Citizenship and Immigration Status). Pregnant women who meet all MinnesotaCare requirements but do not meet the MA citizenship and immigration requirements are eligible for the same benefits as other pregnant women but are not eligible for federal funding. • Pregnant women are considered a family household regardless of whether the woman has other children. They are subject to the families with children income limit of 275% FPG at initial enrollment. See §0912 (Income Eligibility). • Pregnant women cannot be canceled for non-payment of premiums or for being over the income limit during the pregnancy and the 60-day postpartum period. See §0915.11 (Fail to Pay Premium/Voluntary Cancellation). • Pregnant women are not required to cooperate with establishing paternity and obtaining medical support for any child during the pregnancy and the 60-day postpartum period. See §0906.13.03.03 (Medical Support Referral--Newborns).

See §0915.13 (Enrollee Becomes Pregnant) for instructions on changing status to pregnant woman.

M. S. 256.9366 subd.2

M. S. 256.9367

MA:

See §0907.19.05 (MA Basis: Pregnant Woman).

GAMC:

No provisions.

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MINNESOTACARE AUTO NEWBORNS 0907.09.03

MinnesotaCare:

Children born on or after 1-1-99 to mothers who were enrolled in MinnesotaCare during the month of delivery are automatically eligible for MinnesotaCare as long as the child continues to live with the mother. Automatic eligibility begins on the 1st day of the month of the child's birth and continues through the last day of the month of the child's 1st birthday without regard to premium payments, income, household composition, or insurance availability. If other insurance exists, notify Benefit Recovery so benefits can be coordinated. See §0910 (Other Health Coverage).

NOTE:

The age limit for auto newborn eligibility changed from age 2 to age 1 effective July 1, 2003. Children who were enrolled as auto newborns and who turned age 1 before July 1, 2003, remain eligible as auto newborns through the month of the 2nd birthday.

EXAMPLE:

Nora is born on February 2. Her mother, father, and brother are enrolled in MinnesotaCare at the time of her birth. The family loses eligibility at the time of the next scheduled renewal in May because they have insurance. Nora remains eligible as an auto newborn through the month of her 1st birthday as long as she continues to live with her mother. Notify Benefit Recovery if Nora has other health insurance.

If the mother applied after the end of her pregnancy or too late in the course of her pregnancy to be determined eligible for any month she was pregnant, transfer the application to the applicant's county of residence for retroactive MA coverage if the mother requests it. See §0904.09.07 (MinnesotaCare With Retroactive MA/GAMC).

EXAMPLE:

Tina applies for MinnesotaCare on May 28. She is determined eligible on June 7. Her initial premium payment is received on June 20 and enrollment begins July 1. Tina has a baby on June 15. Tina requests MA to cover the costs of the birth. Transfer the application to her county of residence for determination of retroactive MA eligibility. If Tina is eligible, she may choose to enroll her child in either MinnesotaCare or MA as an auto newborn.

Children who are eligible as auto newborns on MA are also eligible as auto newborns on MinnesotaCare if the mother chooses to receive coverage for the child through MinnesotaCare instead of MA at any time between the child’s birth and the month of the child’s 1st birthday. See §0907.19.05.03 (MA Basis: Auto Newborn).

Consider the child to live with the mother through the 60-day postpartum period even if the child remains in the hospital after the woman is discharged. If the child leaves the hospital but lives apart from both parents for more than 1 full calendar month, cancel MinnesotaCare. If a foster parent or relative caretaker applies for MinnesotaCare for the child, the child must meet all eligibility criteria.

EXAMPLE:

Brian is born on March 4, 1999, to a woman enrolled in MinnesotaCare. Brian remains in the hospital because of medical problems until April 15, when he is placed in foster care. Terminate MinnesotaCare for Brian effective May 1.

If the mother legally relinquishes control of the child before the child leaves the hospital, consider the child to be out of the mother's household starting with the first full calendar month for which you can give 10-day notice after papers are signed giving custody and control of the child to an agency or person other than the mother. This could be a pre-adoptive placement or foster home placement of any duration. Terminate MinnesotaCare for the first available month. Advise the child's foster or pre-adoptive family that they may apply for MinnesotaCare for the child unless the child is on MA. The child is no longer eligible as an auto newborn and must meet all eligibility criteria. See §0908.03 (Determining MinnesotaCare Household Size).

If the child is legally adopted, terminate MinnesotaCare for the first available month. The adoptive parents must apply for the child as part of their household.

If legal custody and control of the child is returned to the mother, the child again becomes automatically eligible for MinnesotaCare through the month of the child’s 1st birthday.

EXAMPLE:

Brian was born on March 4, 1999, to a woman enrolled in MinnesotaCare. He was placed in foster care on April 15. MinnesotaCare was terminated and MA was approved effective May 1. Brian returns to live with his mother on August 10. MA is terminated effective September 1. His mother requests continued MinnesotaCare coverage for him, although she is no longer eligible and is not requesting coverage for herself. Approve MinnesotaCare for Brian effective September 1. Do not require a new application even if the last application is more than 11 months old.

Auto newborns will continue on the existing renewal schedule even if no other household members remain eligible. Do not cancel an auto newborn for non-renewal before the month following the child’s 1st birthday. If auto newborns are canceled by the system for non-renewal, the MMIS Help Desk will send E-Mail to MinnesotaCare representatives to reinstate eligibility for the newborn only. If the renewal is received, continue coverage for the newborn regardless of information reported on the renewal. Redetermine the newborn’s eligibility for the month after the 1st birthday.

M.S. 256L.05 Subd. 3

M.S. 256B.057

MA:

See §0907.19.05.03 (MA Basis: Auto Newborn).

GAMC:

No provisions.

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MINNESOTACARE CHILDREN UNDER 21 0907.11

MinnesotaCare:

Children under 21 may have Group 1 or Group 2 status. Children's eligibility is affected in the following ways:

• Children under 21 are eligible for the same benefits as MA enrollees with minor exceptions. They are not subject to deductibles, co-payments, or service limitations that apply to some adults. • Children under 21 who are eligible for MinnesotaCare and meet the citizenship and immigration status requirements of the MA program are eligible for federal financial participation. See §0906.03 (Citizenship and Immigration Status). Children who meet all MinnesotaCare requirements but do not meet the citizenship and immigration status requirements of the MA program are eligible for the same benefits as other children but are not eligible for federal funding. • Children under 21 are considered a family household regardless of whether they live with parents or a legal guardian. They are subject to the families with children income limit of 275% FPG. See §0912 (Income Eligibility). • Caretakers of children under 21 other than foster parents must cooperate in establishing paternity and obtaining medical support for the children unless they show good cause. Children's eligibility is not affected by a caretaker's failure to cooperate. See §0906.13 (Assigning Rights to Medical Support) and §0906.13.03 (Medical Support Referrals). • Children under 21 may have had access to employer subsidized insurance within the past 18 months. Other insurance barrier requirements vary with group status. See §0910 (Other Health Coverage).

If a child under 21 is pregnant, treat her as a pregnant woman for purposes of medical support and premium requirements. See §0907.09 (MinnesotaCare Pregnant Women). See §0907.09.03 (MinnesotaCare Auto Newborns) for special provisions applying to children born to a woman enrolled in MinnesotaCare.

M. S. 256.9366 subd. 2

M. S. 256.3967

MA:

See §0907.19.03 (Families and Children Bases: Child Under 21).

GAMC:

See §0907.25.03 (GAMC Basis: Families With Children).

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MINNESOTACARE PARENTS/GUARDIANS/CARETAKERS 0907.13

MinnesotaCare:

MinnesotaCare parents, guardians, foster parents, or relative caretakers have either Group 2 or Group 4 status. Group 4 includes parents and caretakers with incomes over 100% FPG but no more than 200% FPG who are citizens or have an immigration status that qualifies for FFP. Children previously enrolled in Group 1 who become adults and are caretakers of children also have Group 2 or Group 4 status. See §0907.05 (MinnesotaCare Eligibility Group 2) and §0907.08 (MinnesotaCare Eligibility Group 4).

See §0908.03 (Determining MinnesotaCare Household Size) to determine who may qualify as a legal guardian or relative caretaker.

Parental, guardianship and relative caretaker status affect MinnesotaCare eligibility in the following ways:

• Funding. Parents and relative caretakers qualify for federally funded MinnesotaCare if they:

-Have children under age 21 in the household.

AND

-Are U.S. citizens or have a qualified immigration status.

AND

-Have incomes equal to or less than 275% FPG. Those with incomes over 100% FPG but no

more than 200% FPG qualify for enhanced federal funding.

Parents and relative caretakers qualify only for state-funded MinnesotaCare if they:

-Have a non-qualified immigration status.

OR

-Are legal guardians or foster parents.

Legal guardians and foster parents are eligible for state-funded MinnesotaCare only.

For a person who is both a parent/relative caretaker AND a legal guardian or foster parent, use

the federally funded basis of parent or relative caretaker.

EXAMPLE:

An aunt is her nieces’ legal guardian. Use the relative caretaker status based on her relationship

to her niece.

See §0906.03.13 (MinnesotaCare Major Programs) for more information.

• MinnesotaCare parents, legal guardians, and relative caretakers have come benefit limitations, deductibles, and co-payments which vary depending on household income. • Parents, legal guardians, and relative caretakers whose total household income is over 175% but less thank or equal to 275% FPG have a $10,000 limit on inpatient hospital benefits. They do not have hospital co-payments. • Parents, legal guardians and relative caretakers whose household income is equal to or less than 175% FPg are not subject to a $10,000 limit on inpatient hospital benefits and do not have hospital co-payments. • Parents, legal guardians, and relative caretakers and foster paarents who apply with the children in their care have limited dental coverage and have co-payments for some services, including prescriptions and eyeglasses, regardless of income. • All MinnesotaCare parents, legal guardians, and relative caretakers and foster parents who apply with the children in their care are considered family households and are subject to the family income limit of 275% FPG. See §0912 (Income Eligibility). • Adults who care for children under 21 who live with them but who are not the biological or adoptive parent, stepparent, legal guardian, relative caretaker, or foster parent of any of the children are not considered to be a member of a family with children. See §0907.15 (MinnesotaCare Adults Without Children).

When adults lose parent or caretaker status, change eligibility to the appropriate non-parent major program (BB or XX) and Group 3 status effective the first available month after the change.

M. S. 256L.04 subd. 13

MA:

See §0907.19.07 (MA Families & Children: AFDC-Related Adults).

GAMC:

See §0907.25.03 (GAMC Basis: Families With Children).

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MINNESOTACARE ADULTS WITHOUT CHILDREN 0907.15

MinnesotaCare:

MinnesotaCare adults without children include people age 21 and over who are not pregnant and are not parents, relative caretakers, or foster parents of children under 21 in their care. This includes relative caretakers and foster parents who have no biological or adoptive children living with them and who choose not to apply for relative or foster children in their care.

It also includes adults previously enrolled in Group 1, Group 2 or Group 4 who are now age 21 and over and do not have children in their home.

Being an adult without children affects MinnesotaCare eligibility in the following ways:

• Adults without children are not eligible for federal financial participation regardless of group status. They must meet the residency requirements for MinnesotaCare adults without children and must have or apply for a social security number. See §0906.05.05 (State Residence--MinnesotaCare Adults) and §0906.11 (Social Security Number--MinnesotaCare). • The income limit for adults without children is 175%. Adults without children with incomes equal to or less than 75% FPG are eligible for the Basic Benefit Set Plus One. Adults without children with incomes greater than 75% FPG but equal to or less than 175% FPG are eligible for MinnesotaCare Limited Benefit (MLB) set.

Certain disabled adults without children must apply for MA. Refer the following MinnesotaCare applicants to MA:

• People who receive SSI based on disability or blindness. Refer SSI recipients under age 65 regardless of whether they indicate they are disabled on the application. • People who receive other benefits, including RSDI, based on disability or blindness if they are potentially eligible for MA without a spenddown. Income must be equal to or less than 100 percent of FPG for the household size. See §0912.07.100 (100 Percent of FPG Standard). Refer these people if information on the application indicates assets are equal to or less than $3,000 for a household of 1 or $6,000 for a household of 2. Also refer them if the asset information on the application is missing or incomplete. See §0909.05 (Asset Limits).

Refer people ages 21 to 62 who receive RSDI and are potentially eligible without a spenddown regardless of whether they indicate they are disabled on the application.

Refer people who meet these criteria to their county of residence to apply for MA. They may request to have the HCAPP transferred or they may choose to contact the county directly. Advise people who choose to contact the county directly that they will have to complete another HCAPP. See §0904.09.03 (Transfers From MinnesotaCare to MA/GAMC).

Approve MinnesotaCare for people who meet MinnesotaCare eligibility criteria while the MA application is pending. People may receive MinnesotaCare for up to 60 days beginning with the first day of the month coverage begins. People who have not cooperated with the MA determination by the end of the 60-day period must be canceled for the next available month.

At the end of the first month of eligibility, check MAXIS to determine if the client appears to be cooperating with MA or if the client is eligible for MA.

• For clients who have not yet been determined MA eligible, send a letter reminding them that MinnesotaCare eligibility will end if they fail to cooperate with the MA determination and that, if eligible for MA without a spenddown, they must accept MA and MinnesotaCare will be closed. • If the client has already been determined MA eligible, cancel MinnesotaCare for the first available month.

For clients who have not yet been determined MA eligible at the end of the first month of MinnesotaCare eligibility, check MAXIS again at the end of the 2nd month.

• If the client has been denied MA for non-cooperation, cancel MinnesotaCare effective the last day of the month following the end of the 60-day time period. • If the client has been approved for MA, cancel MinnesotaCare for the 1st available month. • If MA eligibility has not yet been determined and the client is cooperating, allow MinnesotaCare to continue until a determination is made.

Contact the county financial worker if you are unsure of the client's status after checking MAXIS.

EXAMPLE:

Marcia, an adult without children, applies for MinnesotaCare on October 13. She indicates she is disabled and receives SSI. MinnesotaCare notifies her that she must apply for MA. She does not wish to have her application transferred and indicates that she will contact her county of residence. She is found eligible for MinnesotaCare and is enrolled effective November 1 after making her initial premium payment.

The MinnesotaCare representative checks MAXIS at the end of November and finds that Marcia has not yet applied for MA. The representative sends a letter reminding Marcia that she must cooperate with the MA determination and that MinnesotaCare will end if she fails to cooperate. MinnesotaCare eligibility continues for December. At the end of December, the enrollment representative checks MAXIS and finds that Marcia has not yet submitted an application. Send a notice terminating MinnesotaCare effective February 1.

M. S. 256.9354 subd. 5

MA:

No provisions.

GAMC:

See §0907.25 (GAMC Program Types).

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MA/GAMC BASES OF ELIGIBILITY 0907.17

MinnesotaCare:

No provisions.

MA:

Each person must meet a basis of eligibility for MA. A basis of eligibility is a set of characteristics such as age, disability, or family status. The bases of eligibility are based on federal eligibility categories.

Generally, all children under age 21 meet a basis of eligibility. See §0907.19.03 (Families and Children Basis: Child Under 21). Some children may meet more than 1 basis. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

Adults meet a basis of eligibility if they are:

• Pregnant. See §0907.19.05 (MA Basis: Pregnant Women). • Caretakers who meet a parent/caretaker basis. See §0907.19.07 (MA Families & Children: Parents/Caretakers). • Age 65 or older. See §0907.21.03 (MA/Medicare Savings Basis: Age 65 & Over). • Blind. See §0907.21.05 (MA/Medicare Savings Basis: Blindness). • Disabled. See §0907.21.07 (MA/Medicare Savings Basis: Disability).

Adults who receive MSA or RCA or who are eligible for TMA/TYMA also meet a basis. People who receive MSA or RCA do not have to accept automatic MA.

See the following sections:

§0907.19.09

(MA Determination for MFIP)

§0907.19.11

(Transitional/Transition Year MA)

§0907.21.11

(MA Basis: MSA Recipients)

§0907.21.13

(MA Basis: Refugee Medical Assistance - RMA)

Certain qualified immigrants who do not meet immigration status requirements for federally funded MA program MA may qualify for MA services through state-funded MA program NM if they meet an MA basis of eligibility. The instructions in this chapter governing MA bases of eligibility apply to both program MA and program NM.

People who are age 65 or over, blind, or disabled may be eligible for QMB, SLMB, QWD, or QI benefits instead of or in addition to MA. See §0907.21.09 (MA Basis: Medicare Savings Programs) for an explanation of these programs.

Some people are eligible for a waiver of certain eligibility requirements or additional covered services through the waiver programs. The waiver programs have disability and/or age requirements. See §0907.23 (MA Waiver Programs).

Except for certain waivers, people who meet a basis must meet all other program requirements to be eligible.

EXAMPLE:

Maria is 16. She has an MA basis of eligibility as a child under 21 and has income within the MA limits. She is an undocumented non-citizen. Because she doesn’t meet the citizenship and immigration requirements for MA program MA or MA program NM, she is not eligible for MA. She could be eligible for EMA if she has a medical emergency. See §0907.29 (Medical Emergency Programs).

EXAMPLE:

Paul meets a disabled basis of eligibility for MA. His assets exceed the limit. He is not eligible for MA even though he meets a basis because he does not meet the asset requirements of the program.

Assist people who meet more than 1 basis of eligibility in determining which basis is most advantageous. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

The basis of eligibility determines which eligibility method to use. There are 2 methods. Method A is based on the rules of the former AFDC program in effect as of 7-16-96. People using a families with children basis of eligibility use Method A. See §0907.19 (MA Families and Children Bases).

Method B is based on the rules of the SSI program. People with an aged, blind, or disabled basis of eligibility used Method B. See §0907.21 (MA Basis: Age 65 and Over/Blind/Disabled).

The eligibility method governs the determination of countable income and assets, including exclusions and allowable income deductions. Chapter 9 (Assets) and Chapter 11 (Income) contain instructions on treatment of various types of income and assets. In some cases, Method A and Method B do not differ. When Method A and Method B have different rules, follow the instructions for the appropriate method.

EXAMPLE:

Susan and Bill are both self-employed and claim depreciation on their tax forms. Susan uses Method A and Bill uses Method B. Method A does not allow a deduction for depreciation, while Method B does. Compute Susan's net income using Method A rules. Compute Bill's net income using Method B rules.

If people become ineligible under 1 basis, determine if they meet another basis. Leave MA open under the original basis while the determination is in process. See §0915.15.01 (Change in MA/GAMC Basis of Eligibility).

GAMC:

Consider eligibility for GAMC for people between age 21 and age 65 who do not meet an MA basis. See §0907.25 (GAMC Program Types).

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MA BASIS: MULTIPLE BASES OF ELIGIBILITY 0907.17.03

MinnesotaCare:

No provisions.

MA:

Some people meet more than 1 basis of eligibility. The choice of basis will determine whether the person's eligibility is determined under Method A or Method B. Countable income and assets may be different depending on the method. Many of the waiver programs which provide additional covered services require enrollees to have a disabled basis of eligibility and use Method B.

The choice of basis may determine the manner through which services are delivered. In managed care counties, some clients must receive services through managed care health plans. People under age 65 who are certified disabled are not required to enroll in managed care regardless of the basis of eligibility they choose. If they choose a basis other than disabled, they may enroll voluntarily. If they choose the disabled basis, they may not enroll. People age 65 and over who use a disabled basis must enroll in managed care unless they are excluded for another reason.

See §0906.15 (Disability Determinations), §0906.15.03 (Disability Determination/SMRT Referral), and §0914.03.03 (Managed Care Exclusions).

Examples of situations in which an applicant or enrollee meets more than 1 basis of eligibility include:

• A disabled person with dependent children is eligible for MA as a parent/caretaker and also meets the criteria for an MA disabled basis of eligibility. • A child who is eligible for MA as an auto newborn or as a child under 21 also meets the criteria for an MA disabled basis of eligibility. • A person age 65 or over is the caretaker of a child under 21 and meets a parent/caretaker basis as well as an age 65 or over basis.

EXAMPLE:

Gerald, age 66, is the caretaker for his 10-year-old grandson. He meets a parent/caretaker basis as an eligible relative caretaker of a child under 21. He also meets an MA basis as a person age 65 and over. Gerald is employed. The choice of basis will determine whether Gerald’s countable income is determined using Method A or Method B disregards and deductions.

People with blindness or disabilities or who are age 65 and over must use Method B for the Medicare Supplement Programs regardless of which method they choose for MA. See §0907.21.09 (Medicare Supplement Programs).

Applicants and enrollees have the right to choose their basis of eligibility. Assist clients in making an informed choice. Do not change an enrollee’s basis of eligibility based on a request from a health plan or other 3rd party unless that person is the enrollee’s authorized representative. If a client under age 65 requests to be excluded from managed care due to a disability, help the client gather information for a disability determination if needed. Refer people who are undecided about their choice of service delivery to a managed care presentation or to managed care staff.

EXAMPLE:

Tara is certified disabled by SSA and receives RSDI. She receives MA under a disabled basis using Method B. She has a monthly spenddown and is excluded from managed care enrollment. She notifies her financial worker she is pregnant. The financial worker explains the MA/PW basis of eligibility. Tara chooses the PW basis because she will not have a spenddown with the higher PW income limit. She may remain excluded from managed care because of her disability certification.

EXAMPLE:

Amy receives MA as a parent/caretaker. She wants to continue receiving services through her family physician who is not a health plan provider. The SMRT has determined that Amy is disabled pending an SSA determination. Inform Amy that she may choose her MA basis as either a parent/caretaker or as a disabled adult. Regardless of which basis she chooses, she may choose to be excluded from managed care enrollment. If she wants to enroll in managed care, she must use the parent/caretaker basis.

GAMC:

No provisions.

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MA FAMILIES AND CHILDREN BASES 0907.19

MinnesotaCare:

No provisions.

MA:

The following groups have an MA Families with Children basis of eligibility. These groups use Method A to determine income and resource eligibility. Some groups are automatically eligible without regard to income and/or assets. See the specific sections for detailed information on income and asset requirements:

Families and Children Basis: Child Under 21. See §0907.19.03.

MA Basis: Children in Foster Care. See §0907.19.03.03. Placement in foster care is not a separate basis of eligibility. These children are eligible as children under 21. This section describes certain special considerations applicable to children in foster placement.

MA Basis: Adoption Assistance. See §0907.19.03.05. Children receiving adoption assistance are also eligible as children under 21, but have special eligibility provisions based on federal and state law.

MA Basis: Pregnant Women. See §0907.19.05.

MA Basis: Auto Newborn. See §0907.19.05.03. These children are also eligible as children under 21 but have special eligibility provisions due to being born to an MA-eligible woman.

MA Families & Children: Parents/Caretakers. See §0907.19.07.

Transitional Medical Assistance (TMA) and Transition Year Medical Assistance (TYMA). These sections describe the specific conditions and standards that apply to families who are eligible for up to 12 months of TYMA following loss of eligibility for MA Method A under the 100% of FPG standard. See §0907.19.11 (Transition/Transition Year MA) and §0907.19.11.03 (TMA/TYMA Changes and Reporting Requirements).

GAMC:

See §0907.25.03 (GAMC Basis: Families With Children).

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FAMILIES AND CHILDREN BASIS: CHILD UNDER 21 0907.19.03

MinnesotaCare:

No provisions.

MA:

All children under 21 have a basis of eligibility for MA if they meet the citizenship/immigration requirements for either program MA or program NM. Undocumented children are not eligible for ongoing MA, but may be eligible for EMA. See §0906.03 (Citizenship and Immigration Status) and §0907.29.03 (Emergency MA).

Children under 21 who are also blind or disabled may be able to choose which basis of eligibility to use. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility). Children who are eligible under a deeming waiver, such as TEFRA, or who receive certain waivered services such as MR/RC or CADI must use a disabled basis. See §0907.23 (MA Waiver Programs).

Use Method A for children using the Child Under 21 basis. Do not require verification of age.

Asset limit:

There is no asset limit for children under age 21.

Income limit:

For children ages 0-2 who are not eligible as auto newborn, the income standard is 280% FPG (MAXIS Standard K). See §0912.07.280 (280 Percent of FPG Standards). Children ages 0-2 with incomes over 280% FPG may be eligible by spending down to the 100% of FPG standard (MAXIS Standard E). See §0912.07.100 (100 Percent of FPG).

Children ages 0-1 who are born to a woman on MA or MinnesotaCare are eligible without regard to income if they continue to live with the mother. See §0907.19.05.03 (MA Basis: Auto Newborn).

For children ages 2 through 18, the income standard is 150% FPG (MAXIS Standard G) effective July 1, 2004. See §0912.07.150 (150 Percent of FPG). The standard through June 30, 2004 was 170% FPG. Children with incomes over 150% FPG may be eligible by spending down to the 100% FPG standard (MAXIS Standard E). See §0912.07.100 (100 Percent of FPG).

For children ages 19-20, the income standard is 100% of FPG. See §0912.07.100 (100 Percent of FPG). Children ages 19-20 with incomes over this standard may be eligible by spending down to 100% of FPG.

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MA BASIS: CHILDREN IN FOSTER CARE 0907.19.03.03

MinnesotaCare:

No provisions.

MA:

There are 2 ways in which children in foster care get MA coverage:

• Automatic coverage for IV-E foster care children. IV-E is a cash program with eligibility based on the rules of the old AFDC program. IV-E funds pay for the placement if the child meets IV-E eligibility criteria and the placement is eligible for IV-E funding. See §0906.09.01 (Institutional Residence--MA/GAMC). Children on whose behalf IV-E foster care payments are made qualify for MA automatically without a separate application or eligibility determination.

IV-E foster children placed in another state become that state's financial responsibility. IV-E children placed in Minnesota from other states become Minnesota's financial responsibility. This applies to all IV-E foster children regardless of whether the state, county, or another party has legal custody of the child and regardless of whether the child is placed by another state. See §0906.05.03 (State Residence--MinnesotaCare Families, MA).

• Separate MA eligibility determination. Some foster children do not receive IV-E funds for the cost of care because they do not meet the IV-E eligibility rules or their placement does not qualify for IV-E reimbursement. Usually county social service funds pay for the cost of care for these children. These children must file an application and must meet MA criteria to get MA. The placement must be in a facility or licensed foster home in which residents are MA-eligible. See §0906.09.01 (Institutional Residence--MA/GAMC).

Base the child's eligibility on the child's income only beginning with the first full calendar month that the child is out of the parental home. There is no asset limit for children under 21.

If the child requests coverage for the month of placement, deem the parents' income for the month of placement only. Count only the child's income for the remaining months of the 6-month budget period. If the child is eligible without a spenddown, approve MA effective the 1st day of the month of placement. If the child is unable to meet a 6-month spenddown, deny MA for the placement month and begin a new budget period beginning with the month after placement using only the child's income. See §0908.09 (Who Must Be Excluded from the Household), §0908.13.03 (Temporary Absence --MA/GAMC).

EXAMPLE:

Ashley is placed in a licensed foster home from the home of her parents and her 11-year-old sister on August 12. County funds pay her cost of care because she does not meet IV-E criteria. The social worker files an MA application for Ashley and requests MA effective August 1. Ashley's parents are employed and have net income of $1,200 for August. For the budget period of August-January, count parental income for August and use a household size of 4. Because Ashley has no income, count 0 income and use a household size of 1 for September through January. Ashley is eligible for MA without a spenddown effective August 1.

Foster children who do not get IV-E funds and who have income in excess of the MA limits may be required to meet a spenddown to qualify.

EXAMPLE:

Tyler is a foster child who does not qualify for IV-E funding. His social worker files an MA application. Tyler has $5,000 in an account with the county's social welfare fund. The county receives an RSDI check of $625 per month on his behalf because one of his parents is disabled. Tyler must meet a spenddown to qualify for MA. Do not consider the social welfare fund account since Tyler has no asset limit.

Tyler may also qualify for MinnesotaCare. Work with the social worker and MinnesotaCare staff to determine which program is more beneficial.

Foster children who do not get IV-E funding and are placed in another state may remain the responsibility of the placing state. Non-IV-E foster children who move to another state without formal placement must reapply for MA in the new state. See §0906.05.03 (State Residence--MinnesotaCare Families, MA).

If Minnesota retains financial responsibility for a child living in another state, the child's medical providers must enroll as providers in Minnesota to receive Minnesota MA payment. Providers may call the Provider Help Desk at DHS (651-282-5545) for information on provider enrollment.

If a child in foster care returns to the parental home, begin deeming the parental income for the first full month in which the child lives at home. This includes trial home visits when the county retains custody for both IV-E and non- IV-E children. Federal law allows IV-E children to retain IV-E status with no payments for up to 6 months during trial home visits. Automatic MA is not available unless IV-E payments are made on the child’s behalf. If the child returns to placement and IV-E payments resume, the child is again eligible for automatic MA without a new application.

Do not require a new application to determine the child’s eligibility in the parental home. Leave the child’s MA open while the determination is pending.

GAMC:

No provisions.

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MA BASIS: ADOPTION ASSISTANCE 0907.19.03.05

MinnesotaCare:

No provisions.

MA:

Children receive adoption assistance in 2 ways:

• IV-E Adoption Assistance. Title IV-E makes adoption assistance payments on behalf of children who are eligible for adoption assistance and meet the requirements of the IV-E program. Children with a signed and approved IV-E Adoption Assistance agreement are automatically eligible for MA without a separate application or eligibility determination.

IV-E adoption assistance children who move to another state become the financial responsibility of that state. IV-E adoption assistance children who move to Minnesota from another state become the financial responsibility of Minnesota.

• State Adoption Assistance. Minnesota's adoption assistance program makes adoption assistance payments on behalf of children who are eligible for adoption assistance and do not meet the requirements of the IV-E program. Children with a signed and approved State Adoption Assistance agreement are eligible for MA up to age 21 if: • They have a special need for medical or rehabilitative care.

AND

• They were eligible for MA at the time the Adoption Assistance Agreement was signed. In most cases, the child will be enrolled in MA at the time the agreement is signed. However, if the placing agency did not request MA for the child before the agreement, the child still qualifies for MA if the child would have been MA-eligible when the agreement was signed. Do not consider the income and assets of the adoptive parents when determining if the child would have been MA-eligible.

Under federal law, states have the option of accepting financial responsibility for state adoption assistance children from other states. Minnesota selected this option. State adoption assistance children who move to Minnesota from another state become the financial responsibility of Minnesota. State adoption assistance children who move from Minnesota to another state become the responsibility of the new state if that state has chosen the federal option. If the new state does not accept financial responsibility, the child remains Minnesota's responsibility. See §0906.05.03 (State Residence--MinnesotaCare Families, MA).

If Minnesota retains financial responsibility for a child living in another state, the child's medical providers must enroll as providers in Minnesota to receive Minnesota MA payment. Providers may call the Provider Help Desk at DHS (651-282-5545) for information on provider enrollment.

Do not consider the income or assets of the child, adoptive parents, and/or biological parents for either IV-E or state adoption assistance. Verify that the adoption assistance agreement remains in effect at each annual recertification. See §0905 (Reviews and Renewals). Require children to enroll in the adoptive parents' health insurance plan if cost effective. See §0910.05.03 (Health Insurance Premium Payment).

Children receiving title IV-E or State Adoption Assistance who receive waivered services must have a disabled basis of eligibility. See §0907.21.07 (MA/Medicare Supplement Basis: Disability), §0907.23 (MA Waiver Programs), and TEMP Manual TE02.05.28 (Adoption Assistance Cases). All other adoption assistance provisions remain in effect, including determining financial responsibility.

GAMC:

No provisions.

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MA BASIS: PREGNANT WOMEN 0907.19.05

MinnesotaCare:

See §0907.09 (MinnesotaCare Pregnant Women).

MA:

All pregnant women have a basis of eligibility for MA (program MA or program NM). See §0906.03 (Citizenship and Immigration Status). The pregnancy must be verified by a physician, registered nurse, licensed nurse midwife or physician’s assistant. If the pregnancy has already been verified by MinnesotaCare or a cash program, do not require additional verification. If an applicant or enrollee states she is pregnant, contact her to obtain the estimated date of conception and delivery. If you are unable to reach her, use an estimated date of delivery pending receipt of verification. Verification of pregnancy must be submitted within 60 days. If verification is not received, determine whether the woman is eligible under another basis.

Pregnant non-immigrants and undocumented non-citizens are eligible for program NM through the 60-day postpartum period. They may be eligible for EMA for labor and delivery costs. It is not necessary to change pregnant women’s eligibility from NM to MA for labor and delivery. MMIS will identify any emergency claims and submit them to EMA.

Eligibility may begin on the first day of the verified month of conception, but no sooner than 3 months before the month of application.

Use Method A.

There is no asset limit for pregnant women.

Consider the pregnant woman to be a household of 2, or more if she is expecting a medically verified multiple birth.

The income standard for pregnant women (program MA and program NM) is 275% of FPG (MAXIS Standard C). See §0912.07.275 (275 Percent of FPG Standards). Women with income in excess of this standard must spend down to 100% of FPG (MAXIS Standard E) to qualify. See §0912.07.100 (100 Percent of FPG Standards).

Expedite applications from pregnant women. See §0904.07.03 (Date of Application). Allow pregnant women who want to apply for MA-only to file an application at certain locations other than the county agency. See §0904.07 (Accepting and Processing Applications).

If a woman applied before or after the end of her pregnancy and was eligible without a spenddown for the budget period, her eligibility continues through the last day of the month in which the 60-day postpartum period ends. The pregnancy can end with birth, abortion, miscarriage, or stillbirth. Once you determine verified eligibility as a pregnant woman, do not consider changes in income during the pregnancy or 60-day post partum period.

If the woman was eligible with a spenddown, she must continue to meet the spenddown to remain eligible through the post partum period. Do not increase the spenddown due to increases in income. However, changes in earned income disregards or household composition may affect the spenddown amount.

Assess continued MA eligibility for women during the 60-day post partum period. If the woman was on MA before she became pregnant, OR other household members are on MA with the same basis that would apply to the woman after pregnancy, continue eligibility with no spenddown without further review until the next regularly scheduled review date. For other women, redetermine eligibility using information in the case record. Request other information from the woman if necessary. If eligibility continues under another basis, leave MA open under the new basis. If eligibility does not exist under another basis, close MA on the last day of the month after the 60-day post partum period. See §0905 (Reviews and Renewals).

Children up to age 1 born to a woman eligible for MA at the time of the birth have a basis of eligibility which is not dependent on the mother's continued eligibility, as long as the child continues to live with the mother. This includes children born to women who applied after the birth and were made eligible retroactively to the date of birth or before. See §0907.19.05.03 (MA Basis: Auto Newborn).

EXAMPLE:

Christine applies for MA when she is 3 months pregnant. She is single and has no other children. She is found eligible for MA-PW. She marries the child’s father 3 months later. His income combined with Christine’s exceeds the income limits. Do not terminate Christine’s MA. If she applies for continued MA at the end of the 60-day postpartum period, consider her husband’s income. The child remains eligible through the month of the 1st birthday, if living with Christine, without regard to Christine or the father’s income.

Do not require a pregnant woman to cooperate with any paternity or medical support matter for any child in her household during the pregnancy or 60-day postpartum period. See §0906.13.03.03 (Medical Support Referral--Newborns).

EXAMPLE:

Maureen receives MFIP and MA for herself and her son Patrick. On May 15, she reports she is pregnant and due in November. On June 10, the child support officer reports that she is not cooperating in establishing paternity for Patrick. Do not terminate Maureen's MA for non-cooperation. Follow MFIP rules to determine her continued eligibility for cash. At the end of the 60-day postpartum period, she must cooperate with the child support office if she wants continued MA for herself.

Require pregnant women to cooperate with TPL and tort requirements as a condition of initial and continued eligibility. See §0910 (Other Health Coverage).

EXAMPLE:

Greta is pregnant and applies for MA. She has insurance through her job which will cover some of the pregnancy costs. The insurance is determined to be cost effective. The county must pay the premiums and Greta must keep the insurance as long as it remains cost effective and available to her. Terminate or deny MA if Greta refuses to cooperate with the cost effectiveness determination or with keeping the cost effective coverage in effect.

NOTE:

Do not consider leaving employment or taking a maternity leave as non-cooperation.

Apply state residency requirements to pregnant women. See §0906.05.03 (State Residence MinnesotaCare Families, MA).

EXAMPLE:

Marlene is 6 months pregnant and has been receiving MA for 4 months. She reports she is moving to Utah permanently. Terminate MA effective the first month for which you can give 10-day notice following the move.

GAMC:

No provisions.

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MA BASIS: AUTO NEWBORN 0907.19.05.03

MinnesotaCare:

See §0907.09.03 (MinnesotaCare Auto Newborns).

MA:

All children born to women who applied for MA before or after the birth and were eligible at the time of the birth are automatically eligible and remain eligible for MA through the month of their 1st birthday without regard to income, assets, or household composition as long as the child continues to live with the mother in Minnesota.

NOTE:

The age limit for auto newborn eligibility changed from age 2 to age 1 effective July 1, 2003. Children who were enrolled as auto newborns and who turned age 1 before July 1, 2003, remain eligible as auto newborns through the month of the 2nd birthday.

Auto newborn eligibility includes:

• Children born to women on MA program MA. • Children born to women on MinnesotaCare program LL or KK, if they choose to receive MA rather than MinnesotaCare for the newborn. • Children born to women on program NM or EMA.

EXAMPLE:

Joan receives MFIP and MA. Her daughter Melissa is born on January 12. Joan’s 60-day postpartum period ends March 31. On April 10 she marries Melissa’s father, Pete. MFIP for Joan and Melissa and MA for Joan terminate effective April 30 because Pete’s income exceeds the limits for both programs. Melissa remains eligible for MA as an auto newborn through the month of her 1st birthday.

EXAMPLE:

Marike is an immigrant permanently admitted to the U.S. She does not meet the immigration status requirements for program MA and receives program NM. She has a child on October 12. EMA pays for the delivery costs. The child is eligible for MA program MA throughout the month of the 1st birthday as long as the child continues to live with Marike.

EXAMPLE:

Brad and Sandra are enrolled in MinnesotaCare with their 2 children. Sandra is pregnant and receives program LL. They have a baby on November 2 and choose to enroll the baby in MA instead of MinnesotaCare. The baby is eligible as an auto newborn throughout the month of the 1st birthday.

If a child eligible as an auto newborn is part of a household who loses eligibility for MA under another basis, such as TMA or TYMA, continue the child’s eligibility as an auto newborn through the month of the child’s 1st birthday.

EXAMPLE:

Renee gives birth to a son, Greg, while receiving MA. When Greg is 6 months old, Renee’s earnings increase and she now has a spenddown. She is eligible for TYMA. Greg remains eligible as an auto newborn throughout the TYMA period and through the month of his 1st birthday.

Consider the child to live with the mother through the 60-day postpartum period even if the child remains in the hospital after the woman's discharge. If the child leaves the hospital but lives apart from both parents for more than 1 full calendar month, redetermine the child's eligibility using only the child's income, starting with the first full calendar month apart.

EXAMPLE:

Barbara gives birth to a son on August 12. She is discharged from the hospital on August 14. The child remains hospitalized until October 16 due to medical problems. On October 16, the child leaves the hospital and goes to live with Barbara's mother. Consider the child eligible as an auto newborn on Barbara's case through October. Remove the child from Barbara's case effective November 1. The grandmother may apply for MA for the child.

If the child returns to live with Barbara before the 1st birthday, the child regains auto newborn status through the month of the 1st birthday.

See §0907.19.05.05 (Adding/Removing Auto Newborns) for additional provisions relating to auto newborns.

GAMC:

No provisions.

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ADDING/REMOVING AUTO NEWBORNS 0907.19.05.05

MinnesotaCare:

No provisions.

MA:

Also see §0907.19.05.03 (MA Basis: Auto Newborn).

If the mother legally relinquishes control of the child before the child leaves the hospital, consider the child to be out of the mother's household starting with the 1st full calendar month for which you can give 10-day notice after papers are signed giving custody and control of the child to an agency or person other than the mother. This could be a pre-adoptive placement or foster home placement of any duration. The most common forms of documentation are the Voluntary Foster Care Placement Agreement, the Agreement Conferring Authority to Place Child for Adoption, or a court order. Redetermine eligibility using only the child's income. Continue basing eligibility on only the child's income until either:

• The child is legally adopted. Begin deeming the adoptive parents' income starting with the 1st full calendar month after the adoption is finalized, unless the child receives adoption assistance. See §0907.19.03.05 (MA Basis: Adoption Assistance).

OR

• Legal custody and control of the child is returned to the mother. At that time, the child would again become automatically eligible through the end of the auto newborn period.

EXAMPLE:

Anne has a baby on June 2 and voluntarily places the child in foster care. Add the child to Anne's MA effective June 1 and remove the child effective June 30. The child returns to Anne's care and custody on September 5. The child regains auto newborn status through the month of the 2nd birthday.

All children born to women enrolled in MA are eligible on the mother’s case as an auto newborn for the month of birth, including children who are placed for adoption immediately. Enroll newborns born on or after 10/01/04 retroactively in the same health plan the mother was enrolled in during the birth month. See §0914.03.13 (Adding/Removing People From Managed Care).

Obtain the newborn child's name and birth date. For MA-only cases, do not require an addendum. Document the information in the case record. Also do not require a name as a condition of adding a child for whom the mother has relinquished care or control.

EXAMPLE:

Sheila receives MA and gives birth to a son on March 23. She signs papers relinquishing control of the child to an adoption agency on March 24. She does not name the child. The health plan provides verification of the birth date. Add the child to Sheila’s case as an auto newborn effective March 1. Remove the child effective April 1, the first full month in which he lives apart from Sheila. If the child requires continued MA, a representative of the adoption agency, foster parent, or other responsible person may apply on his behalf. See §0904.11 (Authorized Representatives). The adoption agency is not responsible for the cost of the baby’s medical care.

If you are unable to contact the mother to determine if she wants continued MA for a newborn, add the child for the birth month only. Send a notice to add the child for the birth month and a notice to remove the child the following month. If the mother contacts the county later requesting continued coverage for the child, reinstate MA for the child back to the date of removal if the child has continued to live with the mother.

EXAMPLE:

Rhonda receives GAMC. The worker receives notification that she had a pregnancy-related medical claim. The worker confirms and verifies the pregnancy and opens MA-PW. On August 10, the health plan notifies the county agency that Rhonda had a baby boy on August 2. The worker attempts to contact Rhonda by phone on August 12 and leaves a message asking Rhonda to call by August 22. Rhonda does not respond and the worker makes a 2nd attempt asking Rhonda to call by September 3. Rhonda has not contacted the worker by September 20.

Add the newborn to Rhonda's MA for the month of August only. Send a notice to Rhonda's last known address advising her that the newborn has been added to MA effective August 1 and removed effective September 1. If Rhonda calls asking for continued coverage for the baby, reinstate MA effective September 1 if the baby continues to live with Rhonda.

Terminate MA if the child and mother move out of Minnesota. If the mother and child return to live together in Minnesota before the end of the auto newborn period, the child regains auto newborn status as of the date the mother and child regain Minnesota residency.

EXAMPLE:

Tonya receives MA and gives birth to Amanda on August 4. Tonya and Amanda move to Indiana on October 10. Terminate MA effective November 1.

Tonya and Amanda move back to Minnesota the following June 16 when Amanda is10 months old. Amanda regains auto newborn status from June 16 through the month of her 1st birthday. See §0906.05.03 (State Residence--MinnesotaCare Families, MA) for procedures if Amanda is on MA in Indiana.

Assess continued MA eligibility before terminating the child’s coverage at the end of the auto newborn period. Require a renewal if no one in the household has completed a renewal within the past 12 months. See §0905 (Reviews and Renewals).

GAMC:

No provisions.

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FAMILIES & CHILDREN: PARENTS/CARETAKERS 0907.19.07

MinnesotaCare:

No provisions.

MA:

Caretakers (including parents) of children who meet the MA definition of a dependent child have a basis of eligibility for MA. See the MA definition of DEPENDENT CHILD in §0902.09 (Glossary: Denial...)

See RELATIVE CARETAKER in §0902.33 (Glossary: Quality...) for a list of caretakers who can qualify for a parent/caretaker basis. Non-parent relative caretakers do not have a parent/caretaker basis if a biological or adoptive parent is in the home. This includes stepparents.

EXAMPLE:

Ruth lives with her husband Sam and her child from a previous marriage, Jonah. They have no children in common. Sam does not meet a parent/caretaker basis because Ruth is in the home. If Ruth were not in the home, Sam could meet a parent/caretaker basis as an eligible relative caretaker.

Both biological or adoptive parents can meet a parent/caretaker basis if they live in the home. Only 1 non-parental caretaker can meet a parent/caretaker basis.

EXAMPLE:

Janelle lives with her husband Ron and her niece. Either Janelle or Ron (but not both) can meet a parent/caretaker basis. The second spouse must meet a different MA basis or be considered for GAMC.

If the parents are unmarried, paternity must be legally acknowledged or adjudicated for the father to have a parent/caretaker basis.

EXAMPLE:

Maria and Peter live with their baby, Clifford. Paternity has not been adjudicated, and Peter has not signed an Acknowledgment of Paternity. Maria has a parent/caretaker basis of eligibility for MA. Peter is not considered to be Clifford’s legal parent and must meet another basis or be considered for GAMC.

If paternity is later adjudicated or legally acknowledged, both parents have a parent/caretaker basis.

Income limit: 100% of FPG (MAXIS standard E). See §0912.07.100 (100 Percent of FPG Standard). People with incomes over 100% FPG may be eligible by spending down to 100% of FPG.

Asset limit: $10,000/$20,000. See §0909.05 (Asset Limits).

GAMC:

No provisions.

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MA AFDC-RELATED ADULTS -- UP/IP BASES 0907.19.07.01

MinnesotaCare:

No provisions.

MA:

The information in this section was removed effective 7-1-99 because the Unemployed Parent and Incapacitated Parent bases no longer apply. See §0907.19.07 (MA Families & Children: AFDC-Related Adults) for information on the AFDC-related basis for adults with children under age 18 or age 19 if the child is in high school and expected to graduate by the 19th birthday.

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MA FAMILIES AND CHILDREN BASIS: MFIP 0907.19.09

MinnesotaCare:

No provisions.

MA:

Determine MA eligibility for MFIP applicants and enrollees. Follow MA rules. Although most MFIP participants qualify for MA, eligibility is not automatic. MFIP status does not affect MA eligibility.

Do not require a separate Health Care Application for people who apply for MFIP. Use the information on the CAF to determine MA eligibility. If the household is not eligible for MA, determine MinnesotaCare eligibility if your county is a MinnesotaCare enrollment site. If your county is not a MinnesotaCare enrollment site, refer the application to MinnesotaCare Operations. See §0904.09.05 (Transfers from MA/GAMC to MinnesotaCare).

If a household active on MFIP only later requests MA, do not require a new application. Document the request for health care and determine eligibility using information in the case record.

Leave MA open when MFIP terminates unless the household no longer meets MA eligibility rules. If the household is no longer MA-eligible due to increased child/spousal support, earned income or loss of an earned income disregard, evaluate eligibility for TMA or TYMA. See §0907.19.11 (Transitional/Transition Year MA) and §0907.19.11.03 (TMA/TYMA Changes and Reporting Requirements). MAXIS will not autoclose MA when MFIP terminates due to failure to submit HRFs or recertification forms. MAXIS tracks MA renewals separately.

Determine MinnesotaCare eligibility for enrollees whose MA ends because of excess income (if not eligible for TYMA) if your county is a MinnesotaCare enrollment site. If your county is not a MinnesotaCare enrollment site, forward the request for a MinnesotaCare determination to MinnesotaCare Operations within 5 days of determining that the enrollee no longer qualifies for MA. See §0904.09.05 (Transfers From MA/GAMC to MinnesotaCare). See §0904.09.05 (Transfers From MA/GAMC to MinnesotaCare).

GAMC:

No provisions.

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TRANSITIONAL/TRANSITION YEAR MA 0907.19.11

MinnesotaCare:

No provisions.

MA:

Some members of families with children who lose eligibility for regular MA may be eligible for additional coverage under Transitional MA (TMA) or Transition Year MA (TYMA). TMA provides 4 months of additional coverage to people who meet the criteria described in this section who become ineligible for MA Method A under the 100% FPG standard due to increased child or spousal support. TYMA provides up to 12 months of additional coverage to people who meet the criteria described in this section who become ineligible for MA Method A under the 100% FPG standard due to increased earned income.

Determine potential eligibility for TMA or TYMA separately for each family member who:

• Has a Method A (families with children) basis of eligibility, even if they choose a Method B (elderly/disabled) basis for MA eligibility

AND

• Is one of the following:

-A parent or relative caretaker with a dependent child in the household

OR

-A dependent child with a parent or relative caretaker in the household

OR

-A pregnant woman in her 3rd trimester.

It is not necessary that all household members be on MA, although only those on MA will be potentially eligible for TMA/TYMA

AND

• Has net countable income equal to or less than 100% FPG using Method A deeming and income computation rules. See §0912.100 (100 Percent of FPG Standard).

Flag each person meeting the criteria, including those who use Method B for ongoing eligibility. If the person later loses eligibility for MA Method A under the 100% FPG standard due to increased child/spousal support, increased earned income or loss of the earned income disregard, determine actual eligibility for TMA or TYMA.

EXAMPLE:

Ron and Cathy apply for MA with their daughter, Christina, age 5. Ron is disabled. Cathy is working. Ron, Cathy and Christina all meet an MA Method A basis. Ron meets an MA Method A basis even if he chooses to use his disabled basis for actual eligibility. Each household member is a parent or dependent child. If each person’s countable income using Method A deeming, disregards and deductions is at or below 100% FPG, MAXIS will flag all 3 for potential TMA/TYMA

EXAMPLE:

Anthony and Karen apply for MA with Karen’s daughter Melissa, age 2. Anthony is Melissa’s stepfather. Anthony does not meet a basis for MA Method A. Karen and Melissa both meet an MA Method A basis. Karen is a parent and Melissa is a dependent child. If Karen and Melissa have income at or below 100% FPG using Method A deeming, disregards and deductions, MAXIS will flag both for potential TMA/TYMA. Anthony is not potentially eligible for TMA/TYMA.

Determine actual TMA or TYMA eligibility at the time each person’s countable income for Method A increases beyond 100% FPG. To be eligible, the person must:

• Have received MA and been flagged as potentially eligible for TMA/TYMA in at least 3 of the 6 months preceding the income increase.

AND

• Remain in a household that includes a dependent child.

AND

• Lose eligibility for MA Method A under the 100% FPG standard because of increased child/spousal support (TMA), or a parent/caretaker’s increased earned income or loss of an earned income disregard (TYMA). Increased income also includes the employment of a returning parent. It does not include marriage of the caretaker to a stepparent.

EXAMPLE:

Mary has received MA for herself and her 2 children since January. In June, her husband Perry returns to the home. He is the children’s father and his income is deemed to the rest of the household. He is employed and his earnings cause the rest of the family’s income to exceed 100% FPG. Mary, Perry and the children are eligible for up to 12 months of TYMA if Mary and the children were flagged in at least 3 of the last 6 months.

See §0907.19.11.03 (TMA/TYMA: Changes and Reporting Requirements) for information on when returning household members can be added to TMA or TYMA.

If a person becomes ineligible for MA Method A under the 100% FPG standard for more than 1 reason, determine if increased earnings would have caused ineligibility without regard to the other change. If yes, the person is eligible for TYMA.

EXAMPLE:

Jeanine has received MA for herself and 3 children for 6 months. They have been flagged as potential TMA/TYMA eligibles. One child leaves the home, resulting in a smaller household size. Jeanine gets a job the same month which would have resulted in income exceeding 100% FPG for each member of the original household size of 4, as well as for the current household size of 3. Jeanine and her 2 children are eligible for up to 12 months of TYMA because the increased earnings would have caused ineligibility for regular MA without regard to the household composition change.

If the household becomes ineligible due to a combination of a parent/caretaker’s increased earnings and increased child or spousal support, they are eligible for up to 12 months of TYMA.

Because children under age 19 and pregnant women have a higher MA income standard, they may be eligible for regular MA and TMA/TYMA concurrently. Different household members may begin TMA/TYMA eligibility at different times.

EXAMPLE:

Nancy and her son Ray, age 3, have received MA for 6 months and have been flagged as potential TMA/TYMA eligibles for all 6 months. Nancy begins receiving child support for Ray that causes his income to exceed 100% FPG. His income remains below his standard of 170% FPG. Since the child support is not counted for Nancy, her income remains below 100% FPG.

Because Ray’s income now exceeds 100% FPG, his 4-month TMA eligibility begins even though he remains eligible for regular MA. If his income increases beyond 170% FPG during the 4-month TMA period, he is eligible for TMA for any remaining months.

In the third month of Ray’s TMA eligibility, Nancy reports increased earnings. Her income now exceeds 100% FPG. Ray’s total income, including child support and Nancy’s deemed earnings, exceeds 170% FPG. Nancy and Ray are now eligible for up to 12 months of TYMA. MAXIS will close Ray’s TMA and open TYMA.

People with fluctuating income may move between regular MA and TMA/TYMA. If TMA/TYMA enrollees have an income reduction resulting in renewed eligibility for regular MA under the 100% of FPG standard,stop counting the TMA/TYMA months. Determine how many remaining TMA/TYMA months are available when income again increases beyond 100% FPG. Also determine if the person meets the criteria for a new TMA/TYMA period.

EXAMPLE:

Carlos, Michelle and their son Lorenzo, age 3, have been enrolled in MA since August. They all have net income below 100% FPG and have been flagged for potential TMA/TYMA since August. On November 15, Michelle reports that Carlos got a raise from his employer. Their income is now above 100% FPG, but below 150% FPG. Since all three have been flagged in three of the last six months and there was an increase in earned income, TYMA eligibility begins December 1. Lorenzo remains eligible for regular MA, with TYMA eligibility running concurrently.

On January 9, Michelle calls to report that Carlos has been laid off. Their income is now below 100% FPG. They are now eligible for regular MA. MAXIS does not count the regular MA months toward the TYMA eligibility period. On February 13, Michelle calls to report that Carlos has found another job. Their income is now again over 100% FPG but below 150% FPG. TYMA begins again on March 1 with 10 remaining months available. TYMA and regular MA run concurrently for Lorenzo.

If regular MA eligibility had continued for 3 months with countable income equal to or less than 100% FPG, the household would again be eligible for a full 12 months of TYMA when regular MA ends.

People who were flagged for TMA/TYMA under Method A but use Method B for ongoing eligibility may also become eligible for regular TMA/TYMA and MA Method B concurrently.

EXAMPLE:

Melissa and George apply for MA for themselves and their son Ryan. Melissa works part time and earns less than 100% of FPG. George recently became disabled and has applied for RSDI. He is certified disabled by SMRT and found eligible for the CADI waiver. He must use Method B. Melissa’s income is not deemed to him. All three are flagged for TMA/TYMA.

Melissa’s income increases above 100% FPG when her disregard cycle ends. She and Ryan become eligible for TYMA. George remains on CADI Method B with no income deemed to him. TYMA runs concurrently. Four months later, George is approved for RSDI and will now have a spenddown. If he continues to receive CADI services, he must remain on Method B with the spenddown. If he discontinues CADI, he can receive TYMA for the remaining months of the familiy’s TYMA eligibility.

People must meet ALL the following conditions throughout the period of TMA/TYMA eligibility:

• The household must contain a dependent child. See the MA definition of DEPENDENT CHILD in §0902.09 (Glossary: Denial...).

Send the Transition Year Medical Assistance First Quarterly Report (DHS 2975a) at the end of the 3rd month of TYMA. If the enrollee returns the form indicating there is no longer a dependent child in the home, close TYMA for the 1st month for which you can give 10-day notice. Determine if MA eligibility continues under another basis. If the enrollee does not return the form, assume the household still contains a dependent child. It is not necessary to monitor the return of the 1st quarterly report form.

• They must remain Minnesota residents. People who lose state residency but return to Minnesota within 12 months of beginning TYMA eligibility (4 months for TMA) may qualify for any remaining months in the original period if they meet all other TMA/TYMA requirements.

EXAMPLE:

Gene and Barbara and their children are found eligible for TYMA beginning February 1. In May they move to North Dakota to accept a new job. They move back to Minnesota in October. Reopen TYMA from the date they regain Minnesota residency through January 31 for all family members who meet all other TYMA requirements.

• The caretaker must enroll in the employer's cost effective health care plan if available. Terminate TMA/TYMA for caretakers who refuse to enroll. The children remain eligible. • The caretaker must cooperate with medical support requirements. Terminate TMA/TYMA for caretakers who fail to cooperate without good cause. The children remain eligible.

TMA/TYMA are not available to any household member who is convicted of MA fraud for any of the 6 months before termination of regular MA or for any month of TMA/TYMA. medical. Remove caretakers who are convicted of fraud. The children may remain on TMA/TYMA.

Also see §0907.19.11.03 (TMA/TYMA: Changes and Reporting Requirements).

GAMC:

No provisions.

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TMA/TYMA CHANGES AND REPORTING REQUIREMENTS 0907.19.11.03

MinnesotaCare:

No provisions.

MA:

Also see §0907.19.11 (Transitional/Transition Year MA).

When a new member enters the household when at least 1 member of the existing household is receiving TMA or TYMA, first determine if the new member is eligible for regular MA. If the new member is not eligible for MA without a spenddown, follow the rules below to determine if the new member is eligible to be added to TMA or TYMA. The new member must have an MA basis of eligibility.

• If the new member’s spouse receives TMA or TYMA, give the new member the same eligibility as the spouse. • If the new member’s spouse is not on MA but the new member’s child receives TMA or TYMA, give the new member the same eligibility as the child. • If the new member has no spouse in the household but has a child who receives TMA or TYMA, give the new member the same eligibility as the child. • If the new member is a child whose parent receives TMA or TYMA, give the child the same eligibility as the parent. • If the new member is a stepparent or stepchild of a person who receives TMA or TYMA, the new member is not eligible to be added.

Add new members who are eligible to be added to TMA or TYMA effective on the 1st day of the 1st full month they are in the household. Their TMA/TYMA will continue for the same time period as the spouse or child to whose TMA/TYMA they are added. The new member will be subject to quarterly reporting on the same time schedule. For new members added during the 2nd 6 months of TYMA, gather income information to determine continued eligibility before adding the person. Follow the policies later in this section for quarterly reporting and eligibility during the 2nd 6 months.

EXAMPLE:

Kelli’s daugher Isabelle has received TYMA since August 1. Her son Charles has received TYMA since December 1. Isabelle’s father Michael returns to the home on November 3. He is not eligible for MA without a spenddown. He is eligible to be added to TYMA with Isabelle effective December 1. TYMA will continue for Michael and Isabelle through the following July 31 if they meet all other eligibility requirements in this section.

People who have had 6 months of TYMA may receive an additional 6 months if they meet the following conditions in addition to the conditions in §0907.19.11 (Transitional/Transition Year MA):

1. Gross earned income less actual child care costs must be equal to or less than 185% FPG. Use income from the previous 3 months as reported in the 7th and 10th months of TYMA eligibility. Allow only dependent care costs that the household is responsible for. Do not deduct costs paid by the Child Care Fund or other 3rd parties from gross earnings. Do not allow any other disregards or deductions. Do not require verification of earnings or child care costs.

TYMA households must report earnings and child care costs for the previous 3 months by the 21st day of the 7th and 10th months of TYMA eligibility. MAXIS does not send reporting forms. If you need information not available in the case record and you cannot obtain the information by telephone, send the Transition Year Medical Assistance Quarterly Report (DHS 2975). Enrollees may report the information on the form or by telephone. Do not request information already available in the case record, including information the household previously reported on monthly or 6-month report forms. If the household reports monthly for MFIP, Food Support or MA, use the information reported on the last 3 HRFs to determine continued TYMA eligibility.

If the household contains one or more members who submitted a 6-month income renewal for MA within 2 months of the month in which the TYMA report is due, determine if the 6-month renewal form contains necessary earnings and child care information for TYMA. Contact the enrollee by phone for any missing information. Follow up by mail if you cannot reach the enrollee by phone. Indicate for which month(s) you need information.

EXAMPLE:

Joan and her daughter begin receiving TYMA in January. Her husband Roy remains on MA Method B and submits 6-month income renewals because the household has varying income. Joan must report gross earnings and child care costs for July-September in October (the 7th month of TYMA). Roy submitted a 6-month income renewal form in August which included the household’s July earnings and child care costs. Obtain earnings and child care cost information for August and September to determine if average gross earnings less actual child care costs are equal to or less than 185% FPG for July-September.

2. A caretaker relative in the household must have earned income or good cause for unemployment in each month. The caretaker may be employed at a job other than the job that initially resulted in TYMA eligibility. In a 2-parent household, either parent may be employed.

EXAMPLE:

Stephanie and her children were found eligible for TYMA effective October 1 because Stephanie’s earnings caused each household member’s income to exceed 100% FPG. At the time of the quarterly report due in the 7th month of TYMA eligibility, Stephanie reports that she changed jobs. Her earned income less actual child care costs remains within TYMA limits. The family remains eligible for TYMA since she is still employed.

EXAMPLE:

Jan and Don and their children were found eligible for TYMA effective April 1 because Jan found employment causing income to exceed 100% FPG. At the end of the first 6 months, Don begins employment and Jan quits her job. The family remains eligible for TYMA if all other requirements are met because 1 caretaker is employed.

Do NOT count unearned income for TYMA. Do not consider assets for any household member during the TYMA period.

EXAMPLE:

Carol and her 2 children begin receiving TYMA effective August 1. They remain eligible for the 2nd 6-month period based on Carol’s quarterly income reports. On the quarterly report for February-April, Carol reports winning $10,000 at a casino. Do not consider this money as income or as an asset. The family remains eligible for TYMA if Carol continues to be employed and gross earned income less child care costs is less than 185% FPG.

Suspend TYMA with 10-day notice for people who fail to report earnings and child care costs by the 21st day of the 7th and 10th months. If the person later reports the necessary information and remains eligible, reopen TYMA effective the first day of the following month for the remainder of the orginal 12-month period. Continue to monitor suspended cases and send subsequent quarterly reports if needed. Do not close TYMA for non-reporting before the end of the 12th month. Suspended TYMA cases will remain active on the worker’s MAXIS caseload.

Terminate people whose reported earnings less child care costs exceed 185% FPG at the end of the 7th or 10th month. Terminate TYMA for all enrollees at the end of 12 months. Determine if MA eligibility continues under another basis before terminating the person’s eligibility. Do not require a new application or renewal form unless the person has been active for 12 months or more without a renewal. If the person is due for a renewal, send a Minnesota Health Care Programs Renewal Form (DHS 3418). Allow 10 days for the person to return the renewal form and any other required information. Allow a longer period if the person is attempting to obtain the information. Assist the person in obtaining the information as needed.

If the person is not due for renewal, determine continued eligibility from information in the case file. If you do not have enough information, request the needed information. Allow 10 days for the person to return the information. Allow a longer period if the person is attempting to obtain the information. Assist the person in obtaining the information as needed.

If the person submits a completed renewal form (if needed) and is cooperating in obtaining needed information, leave MA open until all information is received and you determine whether eligibility continues under another basis. Provide 10-day notice of closing if the person is not cooperating with providing needed information. If you determine that some household members remain eligible but others do not, provide 10-day notice of termination for the ineligible members.

If one or more household members is ineligible for continued MA because of excess income (or excess assets if using Method B), determine MinnesotaCare eligibility if your county is a MinnesotaCare enrollment site. If your county is not a MinnesotaCare enrollment site, refer the case to MinnesotaCare Operations for a MinnesotaCare determination within 5 days of determining that MA eligibility no longer exists. See §0904.09.05 (Transfers From MA/GAMC to MinnesotaCare).

GAMC:

No provisions.

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MA FOR BREAST/CERVICAL CANCER (MA-BC) 0907.19.13

MinnesotaCare:

No provisions.

MA:

Women who have been screened and found to need treatment for breast or cervical cancer, including precancerous conditions and early stage cancer, may be eligible for MA-BC if they:

• Have been screened by the Sage Screening Program and used program funds to pay for the screening

AND

• Need treatment, including diagnostic services to determine the extent and course of treatment for breast or cervical cancer, including precancerous conditions and early stage cancer

AND

• Are under age 65

AND

• Are not eligible for MA under any of the following bases:
• Parents/Caretakers. See §0907.19.07 (MA Families and Children Basis: Parents/Caretakers). • Children Under Age 19. See §0907.19.03 (MA Families and Children Basis: Child Under 21). • Pregnant Women. See §0907.19.05 (MA Families and Children Basis: Pregnant Women). • Blind or disabled receiving SSI, OR who have income at or below 100% FPG and are eligible for the Disabled Adult Children Disregard, Widow/ Widowers’ Disregard, or Pickle Disregard. See §0912.05.19 (Disabled Adult Children Disregard), §0912.05.17 (Widow and Widower’s Disregard) and §0912.05.23 Pickle Disregard). • 1619(a) or (b). See §0907.21.07.03 (MA Basis: 1619a and b). • Blind or disabled and receiving MSA . See §0907.21.11 (MA Basis: MSA Recipients). • Women who are eligible for MA under a basis not listed above may choose to enroll in either regular MA or MA-BC.

AND

• Are not covered by any of the following other creditable health insurance plans:
• Group health plans, unless the plan does not cover the needed cancer treatment • Individual health insurance coverage, unless the plan does not cover the needed cancer treatment. • Medicare • MA • Armed forces insurance (CHAMPUS/TRICARE, CHAMPVA). • MCHA. See §0918.11 (Minnesota Comprehensive Health Association).

AND

• Have an immigration status that qualifies them for either federally-funded MA (program MA) or state-funded MA (program NM). See §0906.03 (Citizenship and Immigration Status). MA-BC is federally funded for women who have an MA qualifying status and state-funded for those who have a program NM status.

Women who meet all of these conditions are eligible for all MA-covered services for as long as they need treatment. There is no income or asset limit. Women enrolled in MA-BC receive MA on a fee-for-service basis.

Providers who participate in the Sage Screening Program may choose to register with DHS to become presumptive eligibility providers for MA-BC. See POLI TEMP TE02.07.444 (Presumptive Eligibility Providers for MA-BC) for a list of authorized presumptive eligibility providers.

Authorized providers will determine presumptive MA-BC eligibility for Minnesota women who:

• Complete one of the following Sage Screening Program forms: Enrollment form, Return Visit Form or Colposcopy Program Form. These forms were included with Bulletin #02-21-07 (Medical Assistance Coverage for Women Screened by the Minnesota Breast and Cervical Cancer Control Program) dated June, 20, 2002. They do not have DHS form numbers.

AND

• Have been screened through the Sage Screening Program and need treatment for breast or cervical cancer, including precancerous conditions and early stage cancer.

AND

• Are under age 65

AND

• Have no health coverage

After determining presumptive eligibility, the provider will:

• Obtain the client’s signed consent to share the Sage Screening Program form with the county agency. • Complete a Temporary Medical Assistance Authorization (DHS 3525B) and fax a copy to the county’s designated MA-BC staff: along with the completed Sage Screening Program form. • Give the applicant the Enrollee Copy of the DHS 3525B as temporary proof of eligibility until she receives a Minnesota Health Care Programs ID Card and a Minnesota Medical Assistance Breast and Cervical Cancer Coverage Group Application/ Renewal (MA-BC Application/ Renewal, DHS 3525) to complete and return to the county agency within 30 days. The date of application is the date the provider grants presumptive eligibility.

Sage Screening Program providers who choose not to determine presumptive eligibility may give applicants a copy of their Sage Screening Program form and an MA-BC Application/Renewal to submit to their county agency, or they may forward the completed forms to the county agency. The date of application is the date the county agency receives the MA-BC Application/Renewal.

COUNTY ACTION: PRESUMPTIVE ELIGIBILITY

Approve MA-BC effective the 1st day of the month presumptive eligibility was determined by the provider. Complete the approval on MAXIS and MMIS the day you receive the forms from the provider. Do not approve retroactive coverage until the woman is determined eligible for ongoing MA-BC.

Allow the applicant 30 days from the date of the Temporary Medical Assistance Authorization to submit a completed MA-BC Application/Renewal. Terminate MA-BC for the first month for which you can give 10-day notice if you do not receive the completed MA-BC Application/Renewal or another approved DHS health care application form by the due date. Do not terminate MA-BC before the end of the 30-day period, even if the woman submits a completed application immediately and is found to be ineligible.

COUNTY ACTION: ONGOING MA-BC

Review the MA-BC Application/Renewal to determine if the applicant is potentially eligible for MA under one of the bases listed at the beginning of this section. If the applicant appears to have an MA basis, compare the income on the Sage Screening Program form to the income limit for the applicant’s basis and household size. If the applicant appears to be eligible without a spenddown, contact the applicant by phone to obtain additional information to determine MA eligibility. Send the applicant a HCAPP to complete and return if you are unable to contact the applicant OR if the additional information collected appears to support MA eligibility.

For applicants who were found presumptively eligible, continue MA-BC until you receive the HCAPP or until the end of the presumptive eligibility period. For applicants who were not found presumptively eligible, pend the MA-BC application. See §0904.07.07 (Pending the Application). Deny MA-BC if the applicant fails to return the HCAPP within 45 days.

Enroll women who are eligible for MA without a spenddown in regular MA using the appropriate basis. If they become ineligible for regular MA at a later date, redetermine eligibility for MA-BC. Require verification of the continuing need for treatment if the Sage Screening Program form is more than 12 months old.

For women who are not eligible under another mandatory MA basis, determine eligibility for MA-BC. Request verification of immigration status for women who report they are non-citizens. Do not require sponsor information for MA-BC. If the applicant reports other health care coverage, contact her to determine if it is creditable coverage. Do not require verification if she states he insurance does not cover her cancer treatment. Enter insurance information in MMIS and determine if the premium is cost effective. Follow §0910.05.01 (Current Health Insurance–MA/GAMC).

Review MA-BC eligibility annually. Mail an MA-BC Application/ Renewal and a Certification of Further Treatment Required (DHS 3525A) following the timelines in §0905.03.01 (Annual Renewal Timelines--MA/GAMC). Redetermine MA under another basis for MA-BC enrollees who report they are no longer in need of treatment for breast or cervical cancer, including precancerous conditions and early stage cancer.

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MA BASIS: AGE 65 AND OVER/BLIND/DISABLED 0907.21

MinnesotaCare:

No provisions.

MA:

People who are age 65 and over or certified as blind or disabled have a basis of eligibility for MA. These bases apply to adults and to blind or disabled children under 21 who choose a blind or disabled basis instead of a child under 21 basis. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

People who are age 65 and over or certified as blind or disabled also have a basis of eligibility for the Medicare Savings Programs. See §0907.21.09 (MA Basis: Medicare Savings Programs) for a description of these programs and the eligibility requirements. People who meet one of these bases may also be eligible for additional services and/or waiver of some eligibility requirements. See §0907.23 (MA Waiver Programs).

Use Method B to determine countable income and assets for people who use an age 65 or over, blind, or disabled basis. For a description of the requirements for each basis, see:

§0907.21.03

MA/Medicare Savings Basis: Age 65 & Over.

§0907.21.05

MA/Medicare Savings Basis: Blindness.

§0907.21.07

MA/Medicare Savings Basis: Disability.

GAMC:

No provisions.

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MA/MEDICARE SAVINGS BASIS: AGE 65 & OVER 0907.21.03

MinnesotaCare:

No provisions.

MA:

People who are age 65 and over have a basis of eligibility for MA. They may qualify for the Medicare Savings Programs. See §0907.21.09 (MA Basis: Medicare Savings Programs) for a description of these programs and the eligibility requirements.

Do not require verification of age.

Use Method B to determine countable income and assets.

The asset limit for MA for people age 65 and over is:

• $3,000 for a household of 1. • $6,000 for a household of 2. • $200 for each additional household member.

See §0909.05 (Asset Limits).

Effective 7-1-01, the income limit is 100% of FPG. See §0912.07.100 (100% of FPG).

People with incomes over 100% of FPG may be eligible by spending down to 75% of FPG effective 7-1-02 (70% of FPG from 7-1-01 through 6-30-02). See §0912.07.075 (75% of FPG).

The spenddown type depends on the person's living arrangement. See §0913.05 (Which Spenddown Type to Use).

People age 65 and over who qualify for MA are eligible for all MA covered services.

GAMC:

No provisions.

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MA/MEDICARE SAVINGS BASIS: BLINDNESS 0907.21.05

MinnesotaCare:

No provisions.

MA:

People who are certified as blind have a basis of eligibility for MA. They may qualify for the Medicare Savings Programs. See §0907.21.09 (MA Basis: Medicare Savings Programs) for a description of these programs and the eligibility requirements. People whose basis of eligibility is blindness may be eligible for a waiver of spousal or parental deeming requirements and/or expanded MA services. See §0907.23 (MA Waiver Programs).

Either the SSA or the SMRT must certify blindness. See §0906.15 (Disability Determinations). There is no age limit.

Blind children may qualify under more than one basis. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

Use Method B to determine countable income and assets.

The asset limit for MA for people with a blindness basis of eligibility is:

• $3,000 for a household of 1. • $6,000 for a household of 2. • $200 for each additional household member.

See §0909.05 (Asset Limits).

Effective 7-1-01, the income limit is 100% of FPG. See §0912.07.100 (100% of FPG).

People with incomes over 100% of FPG may be eligible by spending down to 75% of FPG effective 7-1-02 (70% of FPG from 7-1-01 through 6-30-02). See §0912.07.075 (75% of FPG).

The spenddown type depends on the person’s living arrangement. See §0913.05 (Which Spenddown Type to Use).

People with a blindness basis of eligibility who qualify for MA are eligible for all MA covered services.

GAMC:

No provisions.

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MA/MEDICARE SAVINGS BASIS: DISABILITY 0907.21.07

MinnesotaCare:

No provisions.

MA:

People who are certified as disabled have a basis of eligibility for MA and may also qualify for the Medicare Savings programs. See §0907.21.09 (MA Basis: Medicare Savings Programs) for a description of these programs and the eligibility requirements. People whose basis of eligibility is disability may be eligible for a waiver of spousal or parental deeming requirements and/or expanded MA services. See §0907.23 (MA Waiver Programs).

Either the SSA or the SMRT must certify disability. See §0906.15 (Disability Determinations). There is no age limit.

Disabled children may qualify under more than one basis. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

Use Method B to determine countable income and assets.

The asset limit for MA for people with a disabled basis of eligibility is:

• $3,000 for a household of 1. • $6,000 for a household of 2. • $200 for each additional household member.

See §0909.05 (Asset Limits).

Effective 7-1-01, the income limit is 100% of FPG. See §0912.07.100 (100% of FPG).

People with incomes over 100% of FPG may be eligible by spending down to 75% of FPG effective 7-1-02 (70% of FPG through 6-30-02). See §0912.07.075 (75% of FPG).

The spenddown type depends on the person’s living arrangement. See §0913.05 (Which Spenddown Type to Use).

People with a disabled basis of eligibility who qualify for MA are eligible for all MA covered services.

GAMC:

No provisions.

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MA BASIS: 1619 A AND B 0907.21.07.03

MinnesotaCare:

No provisions.

MA:

Employed disabled people who received MA the month before the initial month they were certified for special SSI status under sections 1619 (a) and (b) of the Social Security Act are eligible for MA without regard to income or assets. Verify 1619 (a) or (b) certification with the SSA.

If people lose 1619 (a) or (b) status and then regain it, determine if they were receiving MA the month before the original certification.

EXAMPLE:

Joe is certified disabled by the SSA and received MA and SSI. He became employed in June 1998 and was given 1619 status in July 1998. Joe remains eligible for MA because he was receiving MA in June, the month before he was certified for 1619 status. If Joe later loses 1619 status, he will lose automatic MA eligibility. However, if he is recertified at a later date, he will regain automatic MA.

People remain eligible without an income or asset test as long as they retain 1619 (a) or (b) status. If people lose this status, they must meet all MA eligibility requirements including those for income and assets. See §0912.07 (Income Standards) and §0909.05 (Asset Limits).

GAMC:

No provisions.

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MA FOR EMPLOYED PERSONS WITH DISABILITIES 0907.21.07.05

MinnesotaCare:

No provisions.

MA:

The Medical Assistance for Employed Persons with Disabilities (MA-EPD) program provides MA coverage to certain employed disabled people who would not otherwise be eligible.

The following groups are not eligible for MA-EPD:

• People age 65 and older. • People under age 16.

Consider people to be under age 65 through the month of the 65th birthday. See §0915.15.01 (Change in MA/GAMC Basis of Eligibility). Consider people to be age 16 beginning with the month of the 16th birthday.

• SSI recipients. • People with 1619(a) or (b) status. See §0907.21.07.03 (MA Basis: 1619 A and B). • People ineligible for GRH who reside in a GRH facility and whose MA spenddown is fully met with remedial care costs. • People who reside in a long term care facility and are expected to remain for at least 30 consecutive days.

People who are terminated from SSI, RSDI or 1619(a) or (b) benefits because of excess income, assets or other non-disability factors may be eligible if they meet all other eligibility factors.

People may not be eligible for MA-EPD concurrently with the following programs:

• The EW and AC waivers. These waivers are limited to people age 65 and over. See §0907.23.11 (MA Waiver Programs: EW) and §0918.05 (Alternative Care - AC). • QI. See §0907.21.09.09 (Medicare Supplement Programs: QI). QI and MA-EPD may overlap only when a QI enrollee requests retroactive coverage for MA-EPD. If MA-EPD eligibility will continue, close QI for the first month for which you can give 10-day notice. • GAMC. • MinnesotaCare. MA-EPD may overlap with non-federally funded MinnesotaCare. Close MinnesotaCare for the first available month after approving MA-EPD. Do not charge MA-EPD premiums for the month(s) of overlap. • Refugee Medical Assistance (RMA). See §0907.21.13 (MA Basis: Refugee Medical Assistance - RMA). • QWD. See §0907.21.09.07 (Medicare Supplement Programs: QWD). • Prescription Drug Program. See §0907.21.09.11 (Medicare Supplement Programs: PDP).

NOTE:

People who are otherwise eligible for MA-EPD while residing in an IMD may be eligible for program IM. See §0907.27 (MA/GAMC Basis: IMD Residents)

MA-EPD may not be the right choice for all employed people with disabilities. Determine eligibility for regular MA first. People with net countable incomes equal to or less than 100% FPG for their household size qualify for MA without a spenddown if they meet other MA eligibility requirements, including asset limits. All MA-EPD enrollees must pay premiums. The initial premium must be paid to the county prior to approving MA-EPD eligibility. See §0913.01.03 (MA-EPD Premiums). Allow people who qualify for both regular MA and MA-EPD to choose between them.

Employed people with disabilities may be eligible for MA-EPD if they meet all of the following conditions. This includes people who receive waivered services through CAC, CADI, MRRC and TBI. See §0907.23 (MA Waiver Programs).

• Are certified disabled by SSA or SMRT or who have been certified by the county case manager as eligible to receive services through the MR/RC waiver. See §0907.23.05 (MA Waiver Programs: MR/RC). Refer people whose SSI, RSDI, 1619(A) or 1619 (b) benefits are terminated, and people with no current disability certification from either SSA or SMRT.

For MA-EPD only, SMRT will determine disability without regard to the person’s earnings level.

See §0906.15 (Disability Determinations).

• People who are in non-pay status for RSDI continue to be certified disabled by SSA during the period of non-pay status. Do not refer these people to SMRT. • Some people may remain disabled but lose RSDI because they earn more than the Substantial Gainful Activity (SGA) level. If they are enrolled in Medicare, these people are eligible for a Medicare extension. Because SSA considers them to remain disabled during the Medicare extension, they continue to meet a disabled basis for MA. Do not refer them to SMRT.

People who are eligible for Medicare Part B must enroll as a condition of MA-EPD eligibility, regardless of their income level and the amount of the Part B premium. Approve MA-EPD for Part B eligibles who failed to enroll. Require them to enroll during the next general enrollment period (January-March of each year) as a condition of continued eligibility. Reimburse Part B premiums for MA-EPD enrollees with incomes no greater than 200% FPG who are not eligible for QMB or SLMB. See §0910.05.05 (Medicare Premium Payments). People mayb be eligible for MA-EPD concurrently with QMB and SLMB. To be eligible for QMB or SLMB, MA-EPD enrollees must meet all the eligiblity requierements of those programs, including deeming of spousal income and assets. See §0907.21.09.03 (Medicare Savings Programs: QMB) and §0907.21.09.05 (Medicare Savings Programs: SLMB).

• Receive an average of more than $65 per month in earned income from employment or self-employment. The earnings must have Medicare and Social Security taxes withheld or paid by the self-employed applicant or enrollee. State and federal income taxes need only be paid or withheld if the person earns enough to be required to pay those taxes. See §0907.21.07.06 (MA-EPD: Employment Definition) for a definition of earned income for MA-EPD. • Have countable assets equal to or less than $20,000, excluding retirement accounts and medical expense accounts. Exclude spousal assets, including the spouse’s share of jointly held assets. Follow all other Method B asset exclusions. See §0909.11 (Excluded Assets) and §0909.11.01 (Additional Excluded Assets for Method A/B) for more information. Follow other asset policies in §0909 (Assets), including verification, availability, asset reduction, and treatment of specific types of assets. • When an MA-EPD enrollee stops working for any reason, continue to apply the MA-EPD asset rules and $20,000 limit when determining regular MA eligibility for up to 12 months after the person loses MA-EPD status. • Pay required premiums and unearned income obligations.

All MA-EPD enrollees have monthly premiums based on a sliding scale or a minimum of $35, whichever is greater. Premiums are calculated in MAXIS on the EBUD panel. Count only the MA-EPD applicant or enrollee’s income when determing the premium, unless the applicant or enrollee is age 16 or 17 and lives with one or both biological or adoptive parents. Count parental income in those cases. Follow §0908.05 (Determining MA/GAMC Household Size) to determine the household size, except for married couples who both apply for MA-EPD. In this case, use a household size of 1, plus children, for each spouse. Use the MA-EPD household size when a person is receiving services through one of the waivered services (CAC, CADI, MRRC and TBI). See §0913 (Premiums and Spenddowns) and §0913.01.03 (MA-EPD Premiums).

MA-EPD enrollees with unearned income also have an unearned income obligation of one-half of 1 percent of the unearned income, in addition to the monthly premium.

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MA-EPD: EMPLOYMENT DEFINITION 0907.21.07.06

MinnesotaCare:

No provisions.

MA:

See §0907.21.07.05 (MA for Employed Persons With Disabilities) for a description and general eligibility requirements for the MA-EPD program.

Consider the following types of payments as earned income for MA-EPD:

• Wages, including salaries, commissions, tips, bonuses, vacation pay, sick pay, and severance pay (if based on accrued leave time), if all of the following conditions are met: • Average gross monthly earnings for the 6-month certification period are over $65 (at least

$65.01).

AND

• Social Security and Medicare taxes are withheld. State and federal income taxes need only be paid or withheld if the person earns enough to be required to pay those taxes. • Earnings from self-employment if all of the following conditions are met: • Average countable (gross receipts minus business expenses) monthly earnings is over $65 (at leat $65.01).

AND

• The person pays Medicare and Social Security taxes from self-employment income at least annually. Quarterly estimated tax payments and state and federal income taxes need only be paid if the person earns enough to be required to pay those taxes. • Royalties earned in connection with publication of a person’s work if all of the following conditions are met: • Average gross monthly earnings for the 6-month certification period are over $65 (at least $65.01).

AND

• Social security and Medicare taxes are withheld or paid if the person is filing self-empolyment taxes. State and federal income taxes need only be paid or withheld if the person earns enough to be required to pay those taxes. • Honoraria or stipends received for services rendered if all of the following conditions are met: • Average gross monthly earnings for the 6-month certification period are over $65 (at least $65.01).

AND

• Social security and Medicare taxes are withheld or paid if the person is filing self-employment taxes. State and federal income taxes need only be paid or withheld if the person earns enough to be required to pay those taxes.

The enrollee must receive wages, royalties, honoraria or stipends, or must engage in self-employment activities each month unless:

• The enrollee changes jobs and receives no pay checks for one month because of different pay periods in each job

OR

• The enrollee is on a temporary medical leave. Allow up to 4 calendar months’ leave from work without earned income. Require a physician’s statement to verify the need for medical leave. If the physician’s statement indicates the enrollee is expected to be unable to work for more than 4 calendar months, send 10-day notice to terminate MA-EPD eligibility effective the 1st day of the month following the the first 4 full calendar months the enrollee was unable to work. Determine eligibility for MA under another basis before terminating MA-EPD.

EXAMPLE:

Maria, an MA-EPD enrollee, works 20 hours per week at a discount store. Her employer withholds Medicare and Social Security taxes. On July 17, her physician advises her to take 15 weeks off work due to a worsening medical condition. She anticipates returning to work November 15. Maria remains eligible for MA-EPD through November.

On November 5, Maria submits a new physician’s statement extending her recommended medical leave through December 16. Terminate eligibility for MA-EPD effective December 1 since Maria’s medical leave will exceed 4 calendar months. Determine eligibility for regular MA for December. Advise Maria that she may again qualify for MA-EPD when she returns to work if she continues to meet all other eligiblity criteria.

OR

• The enrollee is without earnings for up to 4 months due to job loss that was not caused by or attributed to the enrollee. Situations which would allow a 4-month extension include, but are not limited to layoffs due to lack of work, business closing or plant shutdown.

EXAMPLE:

Colleen is enrolled in MA-EPD and is employed part time at a local business. Her employer withholds Medicare and Social Security taxes. She is laid off in January due to staffing cuts. She receives her last paycheck on January 9. Consider January to be her last month of employment. She may remain enrolled in MA-EPD without earnings through May.

Employees who become unemployed while on medical leave from their jobs may remain enrolled for 4 additional months following the month in which they are terminated or laid off.

EXAMPLE:

Yanni has been on medical leave from his job since mid-August. His MA-EPD enrollment continues through December under the medical leave provision. In November, he is laid off. He may remain enrolled in MA-EPD for 4 additional months, December through March, without earnings.

Enrollees who remain eligible for MA-EPD due to the 4-month job loss extension may not further extend eligibility with a medical leave.

EXAMPLE:

Joanna is enrolled in MA-EPD. She loses her job and receives her last pay check in January because the company goes out of business. She may remain enrolled in MA-EPD through May under job-loss provision. In March, Joanna is injured and is not recovered sufficiently to find a new job by the end of May. She is not eligible for any further extension. End MA-EPD and determine eligibility for regular MA beginning June 1.

MA-EPD enrollees who become unemployed for reasons attributable to them, such as poor work performance, discharge for misconduct, or resignation for reasons other than medical leave, are not eligible for the 4-month extension.

Enrollees who are employed in seasonal or temporary jobs are not eligible for the extension when laid off at the end of the work season. Allow the extension only if the job ends before the expected date due to reasons not caused by the employee. Extend MA-EPD eligibility only through the month in which the job was expected to end.

EXAMPLE:

Joe works for a landscaping company which withholds Medicare and Social Security taxes from his wages. He is normally employed from May through November and is eligible for MA-EPD during those months. The business closes early, in October due to unseasonable weather. Joe’s MA-EPD eligibility may be extended through November. He is not eligible for a job loss or medical leave in December through March since he is not normally employed during those months.

Do not consider the following payments to be earned income for MA-EPD:

• Gratuitous money allowances • Honoraria or stipends to the extent that these payments only reimburse expenses or do not have Medicare and Social Security taxes withheld. • Payments for participation in a clinical trial • Payments for the sale of blood or blood plasma • Work study

Require verification of earnings (with Medicare and Social Security taxes withheld) and employment status at application and 6-month and annual renewals.

Do not require monthly reports of income. MA-EPD enrollees must report changes in income and employment status within 10 days.

Do not interrupt the 6-month certification period if eligibility changes from MA-EPD to regular MA. See §0913.19.05 (When Not to Interrupt 6-Month Cert. Period).

Individuals with two sources of earned income, one source that has taxes withheld and one source that does not, may remain eligible for MA-EPD. To remain eligible, the gross earnings from which taxes are withheld must exceed $65 per month. Only the income from which taxes are withheld or paid may be considered employment for purposes of MA-EPD.

EXAMPLE:

Roman works two hours per week at Home Depot earning $60 per month. Home Depot

withholds Medicare and Social Security taxes. He also receives earnings of $90 per month from a

DT&H that is not required to withhold taxes. He has no other earned income. Roman is not eligible for MA-EPD because his gross monthly taxed earnings are not more than $65 per month.

All earned income (whether taxed or not) will continu to be counted for the premium determination.

Accept only the following forms of verification, in order of preference, for MA-EPD:

WAGES

• Pay stubs showing the employee’s name or SSN, hours worked, gross pay, Social Security and Medicare taxes withheld, applicable state and federal income taxes withheld, net pay, period covered by earnings, and employer’s name.

Social Security and Medicare taxes must be withheld from wages. If these taxes are not withheld,

do not consider the payment as a wage for MA-EPD. These taxes must also be withheld from

payment for services performed in a Day Training and Habilitation (DT&H) facility, sometimes

referred to as a sheltered workshop or work activities center.

• A completed Consent for Release of Employment Information (DHS 2146). Require this form only if the employee does not provide pay stubs containing the required information.

SELF-EMPLOYMENT

• Federal tax forms if the person was required to file Federal income taxes for the previous year. For 2003, people with net earnings of $400 or more were required to file.

To be acceptable as verification of self-employment status for MA-EPD, tax forms must include:

-Quarterly Schedule ES (Form 1040) Estimated Tax for Individuals, or Schedule SE

(Form 1040) Self-Employment Tax

OR

-Form 1040 U.S. Individual Income Tax Return with line 55, self-employment tax,

completed.

OR

-Scheduled SE, Self-Employment Tax, with Section A, line 5, or Section B, line 12,

completed.

• Business records if the person has not been in business long enough to file a Federal income tax return or quarterly estimated taxes. Advise the person to maintain records and to submit a copy of the federal tax return when it becomes available.

See §0911.09.03 (Self-Employment Income) for acceptable forms of business records. Count seasonal self-employment income only in the months in which it is received. This is an exception to the policy of annualizing seasonal self-employment for regular MA in §0911.09.09 (Seasonal Income).

An individual cannot retain MA-EPD eligibility or become eligible for MA-EPD simply by filing self-employment taxes. The individual must also be engaged in a trade or business, and have average gross self-employment earnins minus business expenses, or countable self-employment income of more than $65.

ROYALTIES, HONORARIA AND STIPENDS

If royalties, honoraria or stipends are the person’s only source of earned income, payments must be received each month to qualify for MA-EPD. Accept the following forms of documentation which show the nature and amount of payments, the date received, the requency of payments, and medicare and Social Security taxes:

• Tax forms for the previous year showing evidence of royalties, honoraria or stipends with Medicare and Social Security taxes paid, such as entries on Form 1040, Schedule C, Schedule SE or Form 1099-Misc. • Pay stubs or written statement from the source of payment showing Social Security and Medicare taxes withheld, the person’s name and SSN, amount of the payment, period covered, and name of the issuer. • Quarterly Schedule ES (Form 1040) Estimated Tax for Individuals or Schedule SE (Form 1040) Self-Employment Tax.

NOTE:

Royalties from oil, gas or mineral properties are not considered earned income for MA-EPD.

GAMC:

No provisions.

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SPECIAL CATEGORY: DISABLED CHILDREN 0907.21.07.07

MinnesotaCare:

No provisions

MA:

Children who lost Supplemental Security Income (SSI) payments due to changes in childhood disability criteria under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) are eligible for MA under a special MA category.

Children are eligible under this category if they meet ALL the following conditions:

• The child is under age 18. • The child was receiving SSI payments on August 22, 1996. • The child was terminated from SSI solely due to an inability to meet the new, more restrictive SSI childhood disability criteria. • The child continues to meet the childhood disability criteria in effect before PRWORA.

SSA initially determined disability for these children. The SSA determination of disability remains in effect until the first MA recertification following the SSI termination. SMRT must redetermine the disability using the childhood disability criteria in effect before PRWORA at the time of recertification. Complete a Determination of Disability form (DHS-1467A) when submitting information to SMRT. Identify the child as eligible under the special category of MA children in the comments section of the Determination of Disability form. SMRT will certify these children as eligible under this category for 1-7 years depending on the disability determination.

See §0906.15 (Disability Determinations) and §0906.15.03 (Disability Determination/SMRT Referral) for more information on the SMRT process.

EXAMPLE:

Dana has been receiving SSI benefits and has been eligible for MA as a disabled child for 10 years. Dana’s SSI benefits ended on September 30 because SSA determined that her disability no longer met the criteria under the changes due to PRWORA. Dana’s next MA recertification is due in December. Dana remains eligible for MA following the end of her SSI benefits under a disabled basis due to her status under the special MA category for disabled children. The worker informs Dana’s parents that they must supply information related to Dana’s disability as part of the recertification. The worker sends the information to SMRT with the DHS 1467A form indicating Dana is eligible for MA under the special category for disabled children. If SMRT determines that Dana continues to meet the pre-PRWORA childhood disability category, she remains eligible under the special category.

Use Method B to determine countable income. Disregard parental income. Count only the income of the child. There is no asset limit for these children.

Effective 7-1-01, the income limit is 100% FPG. See §0912.07.100 (100% of FPG).

Children with incomes over 100% of FPG may be eligible by spending down to 75% of FPG. See §0912.07.075 (75% of FPG). Use a household size of 1. See §0913.05 (Which Spenddown Type to Use.)

Children eligible under the special category of disabled children may qualify for MA under more than one basis. A child with more than one MA basis may choose the most advantageous basis. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

EXAMPLE:

David received SSI benefits and was eligible for MA until September 30. David’s SSI benefits ended because he was no longer considered disabled after the changes in disability criteria under PRWORA. David’s mother applied for MA for herself, David and her two other children. MA eligibility was approved for all and began on October 1. Even though David may qualify for MA under the special category of disabled children, he may choose to remain on a child under age 21 MA basis using Method A. If he becomes ineligible for MA without a spenddown as a child under age 21, redetermine David’s eligibility for MA under another basis. He may remain eligible for MA under the special category for disabled children if he meets all other eligibility factors.

See the TEMP manual TE02.07.384 (MA for Children Terminated from SSI) for MAXIS instructions for this category.

If SMRT determines the child no longer meets the pre-PRWORA disability criteria, redetermine the child’s eligibility under a family and children’s basis. See §0907.19 (MA Families and Children Bases).

GAMC:

No provisions.

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MA BASIS: MEDICARE SAVINGS PROGRAMS 0907.21.09

MinnesotaCare:

No provisions.

MA:

Some people who are eligible for Medicare may qualify for a Medicare Savings Program with or in place of MA. The QWD program is limited to people with a blind or disabled basis of eligibility. The QMB, SLMB and QI programs are available to all Medicare eligibles who meet all other Medicare Savings Program requirements. While the majority of Medicare eligibles are over age 65, blind, or have disabilities, some people may become Medicare eligible while a disability certification is pending or be eligible for a Medicare extension after their eligibility for RSDI ends. These people may be eligible for QMB, SLMB or QI based on their receipt of Medicare. Use Method B and the income deductions that would apply under the applicable blind or disabled status to determine eligibility for the Medicare Savings Programs.

EXAMPLE:

Don, age 35, has End Stage Renal Disease (ESRD). He is found eligible for Medicare on an expedited basis designed for people with ESRD. He has also applied for RSDI and SSI, but his Medicare is approved before the RSDI/SSI disability certification. He applies for health care. Based on his income, assets and receipt of Medicare, he is eligible for QMB. Use Method B and appropriate deductions for people with disabilities. He is not eligible for MA until he is certified disabled by SSA or SMRT.

NOTE:

Some people may remain disabled but lose RSDI because they earn more than the Substantial Gainful Activity (SGA) level. These people are eligible for a Medicare extension. They are eligible for the Medicare Savings Programs during the extension if they meet income and asset limits. Because SSA considers them to remain disabled, they continue to meet a disabled basis for MA. Do not refer them to SMRT.

The savings programs have higher income and asset limits than MA.

See the following sections for a description of each program, the services it covers, and eligibility requirements:

§0907.21.09.03

Qualified Medicare Beneficiary (QMB).

§0907.21.09.05

Service Limited Medicare Beneficiary (SLMB).

§0907.21.09.07

Qualified Working Disabled (QWD).

§0907.21.09.09

Qualified Individuals (QI).

People who receive Medicare Part A or B simultaneously with MA or any of the Medicare savings programs are known as dual eligibles. This means they have coverage through both Medicare and Medicaid.

In addition to the federally funded savings programs, Minnesota funds the Prescription Drug Program (PDP) for certain QMB- or SLMB-eligibles. See §0907.21.09.11 (Prescription Drug Program: PDP). People who are eligible for MA without a spenddown are not eligible for PDP.

Seniors who are eligible for SIS-EW are not eligible for PDP because prescription bills do not apply to the waiver obligation. They are eligible for full MA, including drug costs, regardless of whether they meet a waiver obligation.

People can be eligible for the Medicare Savings Programs and PDP, and the Alternative Care (AC) program at the same time. See §0918.05 (Alternative Care - AC).

People residing in Institutions for Mental Diseases (IMDs) are not eligible for the Medicare savings programs unless they meet one of the conditions in §0907.27 (MA/GAMC Basis: IMD Residents) that allows MA eligibility in an IMD. People who would be eligible for the Medicare savings programs if they did not reside in an IMD may be eligible to have their Medicare premiums reimbursed as cost-effective coverage. See §0910.05.05 (Medicare Premium Payment).

Use Method B to determine eligibility for the Medicare Savings Programs. If people who are eligible for both regular MA and a Medicare savings program meet more than one MA basis, they may choose the most advantageous basis for MA. They must use Method B for the Medicare savings programs.

EXAMPLE:

Duane applies for MA and QMB. He receives RSDI based on disability. He lives with Susan and their 2 children. He pays child support for a child outside the home. He may have MA eligibility determined under Method A if it is to his advantage. He must use Method B for QMB.

GAMC:

No provisions.

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MEDICARE SAVINGS PROGRAMS: QMB 0907.21.09.03

MinnesotaCare:

No provisions.

MA:

People who are enrolled or are eligible to enroll in Medicare Part A may qualify for Qualified Medicare Beneficiary benefits (QMB). People who meet QMB requirements may receive QMB only or in addition to MA. Although most Medicare eligibles are age 65 and over, blind or have disabilities, some people without a current disability certification may be enrolled in Medicare and potentially eligible for QMB. See §0907.21.09 (Medicare Savings Programs) for more information on these situations.

QMB provides the following benefits:

• Payment of Medicare Part A and Part B premiums. • Payment of Medicare cost-sharing (co-payments and deductibles) for Medicare services provided by Medicare-eligible providers.

The asset limit and income standard for QMB are higher than for MA only.

Asset limit effective 10-1-00:

• $10,000 for a household of 1. • $18,000 for a household of 2 or more.

See §0909.05 (Asset Limits).

Income standard:

• 100% of FPG.

See §0912.07.100 (100 Percent of FPG Standards).

Follow MA household size and deeming rules for QMB. See §0908.05 (Determining MA/GAMC Household Size).

Disregard RSDI cost of living adjustments (COLA) at the beginning of each year. See §0912.05.15 (RSDI COLA Disregard).

QMB has no spenddown provisions. People with income in excess of the standard are not eligible for QMB.

EXAMPLE:

Bud's income is 125% FPG. He is ineligible for QMB even if he has covered expenses that would allow him to spend down to 100% FPG.

People may qualify for MA and QMB concurrently.

People with incomes at or under 100% of FPG qualify for MA without a spenddown if their assets are within MA limits. They also qualify for QMB. Because QMB allows a $20 income deduction and MA does not, people with incomes over 100% FPG but no more than 100% FPG + $20 are within the QMB income limit but must meet a spenddown to qualify for MA. People with incomes at or under 100% of FPG, but assets between the MA and the QMB limits, qualify for QMB only.

EXAMPLE:

Blanche has monthly income of $770 per month and countable assets of $2,000. Her MA income standard is $776. She qualifies for MA and QMB.

EXAMPLE:

Clara has monthly income of $790 and countable assets of $2,000. Her income is within QMB limits after deducting $20 but exceeds MA limits since the $20 is not allowed. She qualifies for QMB but must spend down to 75% of FPG to qualify for MA.

Do NOT use an LTC spenddown for people who are open as QMB-only in an LTCF. See §0913.13 (Long Term Care Spenddown Calculation). However, you must enter an LTCF living arrangement on the STAT/FACI screens in MAXIS and on the RLVA screens in MMIS.

Medicare Part A covers very limited skilled nursing care. Payment may not be confirmed until several months after the care is received. This makes it rarely advantageous for people in LTC to be QMB-only. However, if you know Medicare Part A is covering any of the LTCF costs, it is advantageous for people to be QMB-only because there wouldn't be an LTC spenddown. If Medicare retroactively covers any of the LTCF costs of people who are open on both QMB and MA while in an LTCF, the LTCF must reimburse the person for any amounts overpaid to the facility.

Determine eligibility for QMB promptly. Eligibility begins the first day of the month after the month in which the county agency makes an eligibility determination. Eligibility is not possible before or for the month of application. QMB-eligibles may be eligible for SLMB for payment of Part B premiums for up to 3 months before the month of application until the first month of QMB eligibility. See §0907.21.09.05 (Medicare Savings Programs: SLMB). People who are eligible for QMB may not receive SLMB once they are approved for QMB.

EXAMPLE:

Melba’s income and assets are within QMB limits. She requests to receive only SLMB benefits on an ongoing basis because she only wants payment of her Part B premium and does not wish to receive any other QMB benefits. Because she is eligible for QMB, she cannot choose SLMB. Advise her that she does not need to use her QMB for Medicare co-payments and deductibles if she does not wish to.

People residing in Institutions for Mental Diseases (IMDs) are not eligible for QMB unless they meet one of the conditions in §0907.27 (MA/GAMC Basis: IMD Residents) that allows MA eligibility in an IMD. People who would be eligible for QMB if they did not reside in an IMD may be eligible to have their Medicare premiums reimbursed as cost-effective coverage. See §0910.05.05 (Medicare Premium Payment).

GAMC:

No provisions.

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MEDICARE SAVINGS PROGRAMS: SLMB 0907.21.09.05

MinnesotaCare:

No provisions.

MA:

People may qualify for Service Limited Medicare Beneficiary (SLMB) benefits in addition to or instead of MA if they are enrolled or are eligible to enroll in Medicare Part A and enrolled or eligible to enroll in Medicare Part B. Although most Medicare eligibles are age 65 and over, blind or have disabilities, some people without a current disability certification may be enrolled in Medicare and potentially eligible for SLMB. See §0907.21.09 (Medicare Savings Programs) for more information on these situations.

• They are enrolled or are eligible to enroll in Medicare Part A and enrolled or eligible to enroll in Medicare Part B. • They meet an age 65 or over, blind, or disabled basis of eligibility for MA.

MA pays the Medicare Part B premium for SLMB eligibles. This is the only benefit SLMB provides.

Asset limit effective 10-1-00:

• $10,000 for a household of 1. • $18,000 for a household of 2 or more.

See §0909.05 (Asset Limits).

Income standard:

• 120% of FPG.

See §0912.07.120 (120 Percent of FPG Standards). People whose income falls below 100% of FPG are eligible for QMB which offers more covered services.

Follow MA household size and deeming rules for SLMB. See §0908.05 (Determining MA/GAMC Household Size).

Disregard RSDI cost of living adjustments (COLAs) at the beginning of each year. See §0912.05.15 (RSDI COLA Disregard).

People may qualify for SLMB and MA concurrently. They will have a spenddown for the MA program. There are no spenddown provisions for SLMB.

SLMB benefits are available for the 3 months before the month of application, as well as for the application and processing month(s), for people who meet all eligibility requirements. People who apply for QMB may request SLMB for the 3-month retroactive period and the processing month(s), as QMB is only effective after the month in which you determine QMB eligibility. Once QMB is approved, QMB-eligibles may not choose to receive SLMB instead.

EXAMPLE:

Myrtle applies for QMB on March 10. Her income is under 100% FPG and assets are within the $10,000 limit for a household of 1. The earliest QMB can be opened is April. Myrtle is eligible for SLMB effective December 1 (3 months before the application month). Change Myrtle's coverage from SLMB to QMB effective April 1.

People residing in Institutions for Mental Diseases (IMDs) are not eligible for SLMB unless they meet one of the conditions in §0907.27 (MA/GAMC Basis: IMD Residents) that allows MA eligibility in an IMD. People who would be eligible for SLMB if they did not reside in an IMD may be eligible to have their Medicare premiums reimbursed as cost-effective coverage. See §0910.05.05 (Medicare Premium Payment).

GAMC:

No provisions.

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MEDICARE SAVINGS PROGRAMS: QWD 0907.21.09.07

MinnesotaCare:

No provisions.

MA:

People may qualify for Qualified Working Disabled (QWD) benefits if:

• They are eligible to enroll in Medicare Part A under the Qualified Working Disabled Adult provisions of the Social Security Act. QWDs are employed people under age 65 with disabilities who lost their RSDI benefits because their income exceeds Substantial Gainful Activity (SGA) limits. • They meet a blind or disabled basis of eligibility for MA.

People who qualify for QWD are eligible for payment of Medicare Part A premiums. This is the only benefit provided by QWD.

Asset limit:

• $4,000 for a household of 1. • $6,000 for a household of 2.

See §0909.05 (Asset Limits).

Income standard:

• 200% of FPG.

See §0912.07.200 (200 Percent of FPG Standards).

There are no spenddown provisions for QWD eligibility.

People who qualify for MA are not eligible for QWD. People who are eligible for MA may be eligible for payment of Medicare Part A premiums through the buy-in. See §0910.05.05 (Medicare Premium Payments).

Eligibility may begin up to 3 months before the date of application assuming all other factors are met.

GAMC:

No provisions.

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MEDICARE SAVINGS PROGRAMS: QI 0907.21.09.09

MinnesotaCare:

People cannot be eligible for QI and MinnesotaCare at the same time.

M.S. 256L.07 subd 3

Minnesota Rule 9506.0020 subp. 1d

MA:

Certain people who meet all QMB requirements but have excess income for QMB are eligible as Qualified Individuals (QIs). To be eligible as QIs, people must:

• Be enrolled or are eligible to enroll in Medicare Part A and eligible to enroll in Medicare Part B. Although most Medicare eligibles are age 65 and over, blind or have disabilities, some people without a current disability certification may be enrolled in Medicare and potentially eligible for QI. See §0907.21.09 (Medicare Savings Programs) for more information on these situations. • Have income in excess of both the QMB limit of 100% FPG and the SLMB limit of 120% FPG but within the QI limits described below.

Until 12-31-02, there were 2 groups of QIs. Congress eliminated funding for the 2nd group (QI-2) effective 12-31-02. QI-2s were eligible for payment of a portion of their Medicare Part B premiums ($3.91 per month in 2002). They will receive their final payments for July-December 2002 in June 2003.

The asset limit for QI is:

• $10,000 for a household of 1. • $18,000 for a household of 2 or more.

See §0909.05 (Asset Limits).

The first QI group, known as QI-1s, remains eligible after 12-31-02. QI-1s must have income greater than 120% FPG but less than 135% FPG. QI-1s are eligible for payment of the Medicare Part B premium. This is the only benefit available to QI-1s. They are eligible for Part B payment through the Buy-In. See §0910.05.05 (Medicare Premium Payment).

The 2nd QI group, known as QI-2s, must have income of at least 135% FPG but less than 175% FPG. For QI-2s, the only benefit of the QI program is payment of that portion of the Medicare Part B premium attributable to the transfer of home care benefits from Medicare Part A to Part B under the Balanced Budget Act of 1997. DHS will make these payments to enrollees each June for the previous year using information on MAXIS. For 2001, the amount is $3.09 per month or a maximum of $37.08 per year. For 2002, the amount is $3.91 per month or a maximum of $46.92 per year.

Disregard RSDI cost of living increases (COLAs) for January through June of each year when determining QI eligibility. See §0912.05.15 (RSDI COLA Disregard).

There are no spenddown provisions for QI. QI benefits are available for the month of application and the retroactive months.

People cannot be eligible for QI concurrently with MA, QMB, or SLMB. People with incomes between 100 and 120% FPG may qualify for payment of Medicare Part B premiums through SLMB. People with incomes under 100% FPG may qualify for full QMB benefits including payment of Part B premiums.

MA and QI may overlap when a person receiving QI benefits requests retroactive MA. If MA eligibility will continue beyond the month in which eligibility is approved, close QI for the 1st month for which you can give 10-day notice.

EXAMPLE:

John is eligible for QI1 benefits. On September 12, he applies for MA and requests coverage retroactive to July. On October 15, the worker finds him eligible for MA effective July 1 and continuing. Close QI effective November 1.

QI benefits are funded through a capped federal entitlement. Enroll eligible applicants on a 1st-come, 1st-served basis in the order in which they apply. DHS will notify counties by MAXIS E-mail if the QI allocation is exhausted for a particular year.

People residing in Institutions for Mental Diseases (IMDs) are not eligible for QI unless they meet 1 of the conditions in §0907.27 (MA/GAMC Basis: IMD Residents) that allows MA eligibility in an IMD. People who would be eligible for QI-1 if they did not reside in an IMD may be eligible to have their Medicare premiums reimbursed as cost-effective coverage. See §0910.05.05 (Medicare Premium Payment).

GAMC:

People cannot be eligible for QI and GAMC at the same time.

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PRESCRIPTION DRUG PROGRAM: PDP 0907.21.09.11

MinnesotaCare:

No provisions.

MA:

Certain people who are eligible for QMB or SLMB are eligible for the Prescription Drug Program (PDP). See §0907.21.09.03 (Medicare Savings Programs: QMB) and §0907.21.09.05 (Medicare Savings Programs: SLMB) for eligibility requirements for QMB and SLMB.

PDP covers those prescription drugs that are covered by the MA program if the manufacturers have a Prescription Drug rebate agreement with the state.To qualify for PDP, QMB and SLMB eligibles must:

• Be age 65 and over.

OR

• Be under age 65 with a disability.

AND

• Be eligible for QMB or SLMB.

OR

Be dually eligible for MA with a spenddown and QMB or SLMB.

Residents of long term care facilities can receive PDP unless they are eligible for MA without a spenddown or have a long term care spenddown.

EXAMPLE:

Pete enters a long term care facility for convalescent care for 2-3 months following surgery. He is enrolled in SLMB and PDP. His assets exceed $3,000. Medicare and his supplemental policy will pay the majority of his nursing home costs. He does not want to reduce assets to qualify for MA with a spenddown. He may remain on PDP while in the facility.

AND

• Be a permanent Minnesota resident for at least 180 days. See §0906.05.03.03 (State Residence--Prescription Drug).

AND

• Not have prescription drug coverage (including Medigap) for the month of application and the preceding 3 months. See §0910.03.03 (Other Coverage--Prescription Drug) for information on what types of coverage are considered other prescription drug coverage when determining Prescription Drug Eligibility.

Asset limit:

• $10,000 for a household of 1 • $18,000 for a household of 2 or more.

See §0909.05 (Asset Limits).

Income standard:

• 120% of FPG.

See §0912.07.120 (120 Percent of FPG Standards). People are not eligible for PDP if they:

• Are eligible for QMB or SLMB and MA without a spenddown, or are eligible for MA with a long term care spenddown. • Choose the client option or designated provider spenddown. • Are currently enrolled in MinnesotaCare. • Are enrolled in SIS-EW.

People enrolled in MSHO, MnDHO or AC may also be enrolled in PDP.

PDP enrollees with spenddowns may use any spenddown type. However, only the automated monthly spenddown will automatically deduct prescriptions paid by PDP from the spenddown. Help clients determine which spenddown type or combination of programs best meets their needs. See §0913.05 (Which Spenddown Type to Use).

PDP enrollment begins the month following the month in which the PDP application is approved.

PDP enrollees have a $35 monthly deductible. Most enrollees will pay the deductible directly to the pharmacy. If the pharmacy does not have point-of-sale billing, the deductible will be processed like a spenddown.

PDP deductibles and prescription costs paid by PDP may all be used toward the spenddown for the PDP enrollee and other family members. Bills used to meet a spenddown for 1 family member may not be applied to the PDP deductible for other family members. See §0913.21 (Allowable Medical Bills to Meet Spenddown) for more information on using PDP expenses toward spenddowns.

Help clients with spenddowns determine whether they will benefit from the PDP by comparing expected out-of-pocket expenses with and without PDP coverage.

Clients who can meet their spenddowns with prescription drug costs and have few or no other regular medical expenses will have lower out-of-pocket expenses on PDP, since the $35 deductible will be less than the monthly spenddown.

EXAMPLE:

Albert is determined to be eligible for MA with a $220 monthly spenddown. He will meet the spenddown using only prescription drug costs. He would have out-of-pocket expenses of $2,640 per year ($220 x 12) on MA. If he enrolled in PDP, he would have out-of-pocket expenses of $420 per year ($35 monthly deductible x 12). If he also incurs non-prescription costs, his $35 deductible will be applied toward the spenddown, and MA will pay for covered services over the spenddown amount.

EXAMPLE:

Jack is determined to be eligible for MA with a $225 monthly spenddown. He can meet the spenddown with a combination of prescription and non-prescription charges. He would have out-of-pocket expenses of $2700 per year ($225 x 12) on MA. If he enrolled in PDP, he would have a $35 monthly deductible for prescriptions, which could be applied toward his monthly spenddown. He would benefit from PDP and MA with a spenddown.

People who regularly meet their spenddowns on the 1st of the month with non-prescription costs, such as services received through a home and community based waiver (CAC, CADI, MR/RC, TBI) or GRH remedial care, may not need PDP coverage but may choose to enroll.

Applicants may have different effective dates for QMB, SLMB, and PDP. Redetermine PDP eligibility at the time of the annual recertification for QMB or SLMB. Terminate PDP for enrollees who lose QMB or SLMB eligibility.

EXAMPLE:

Theola is enrolled in QMB. She is found eligible for PDP on January 21. PDP begins February 1. She loses QMB eligibility effective June 1 because of a quarterly payment that results in excess income for that month. PDP also ends June 1. She regains QMB eligibility effective July 1. She is again eligible for PDP effective July.

EXAMPLE:

George applied for retroactive SLMB with ongoing QMB and PDP on February 10. On March 8, he was approved for SLMB for November 1-March 31 with QMB and PDP effective April 1. His recertification is due for November. If eligibility continues, George will remain eligible for PDP and QMB until the scheduled November annual review. If he is found ineligible for QMB or fails to submit his review, terminate QMB and PDP effective October 31.

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MA BASIS: MSA RECIPIENTS 0907.21.11

MinnesotaCare:

No provisions.

MA:

People who receive benefits from MSA are automatically eligible for MA without a separate application or eligibility determination. People must be age 65 and over, blind, or disabled to receive MSA.

EXCEPTION:

Complete a long term care budget for people who receive MSA and reside in long term care facilities or receive EW services.

MSA recipients do not have to accept MA. They may decline health care coverage. They may not choose state-funded coverage through MinnesotaCare or GAMC.

Most MSA recipients also receive SSI and/or RSDI. Receipt of SSI and/or RSDI does not automatically qualify a person for MA. See the Combined Manual for more information on MSA eligibility requirements. See §0911.09.15.01 (Income From RSDI and SSI--MA/GAMC).

GAMC:

No provisions.

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MA BASIS: REFUGEE MEDICAL ASSISTANCE - RMA 0907.21.13

MinnesotaCare:

No provisions.

MA:

Refugee Medical Assistance (RMA) is a federally authorized program providing MA to refugees. To be eligible for RMA, refugees must meet ALL the following conditions:

• Have been in the U.S. 8 months or less.

AND

• Be ineligible for MA. Consider MA eligibility first. If refugees are ineligible for MA, send a notice denying MA. See §0916 (Notices).

AND

• Have one of the following immigration statuses: • Refugee. See §0906.03.11.05 (Refugees). • Asylee. See §0906.03.11.07 (Asylees). • Cuban and Haitian Entrant. See §0906.03.11.15 (Cuban/Haitian Entrants). • Amerasian. See §0906.03.11.17 (Amerasian Immigrants). • Dependent children of people with any of the above statuses who live in the same household if the only parent or both parents in the household have refugee status. Children with a non-refugee parent in the household are not eligible for RMA.

NOTE:

Although federal RMA guidelines include dependent children, in practice these children will qualify for regular MA if they have a qualifying status. However, they may become eligible for RMA if income increases beyond the applicable standard for regular MA during the first 8 months of U.S. residence.

• Victims of trafficking. See §0906.03.11.25 (Trafficking Victims).

People who adjust to LPR status also qualify if they previously held 1 of the statuses above and meet all other requirements, including being in the U. S. for less than 8 months.

AND

• Provide the name of their resettlement agency to the county human services agency.

AND

• Not be full-time students in an institution of higher learning, unless their enrollment is part of a state approved plan.

Refugees who meet these requirements are eligible for RMA for 8 months. Count the month they entered the U.S. or the month the INS granted asylum status, whichever is later, as month 1 of this period.

Refugees receiving RCA are automatically eligible for RMA if they are not eligible for regular MA. Consider eligibility for regular MA first. Refugees do not have to apply for RCA as a condition of eligibility for RMA.

The income and asset limits for RMA are the same as MA. Use Method A. See §0909.05 (Asset Limits) and §0912.07.100 (100% of FPG).

Base eligibility determinations on the income and resources on the date of application. Exclude the same income as regular MA Method A. See §0911.05 (Excluded Income) and §0911.05.03 (Excluded Income--Program Provisions). In addition, disregard all new sources or amounts of income received or expected to be received after the date of application, including earnings from starting employment. Follow §0910.05.03 (Health Insurance Premium Payment) if the refugee has cost-effective health insurance available through employment.

EXAMPLE:

Josef, age 35, entered the U.S. as a refugee on April 10. He is single and has no dependent children. He applies for health care coverage on April 27. He does not meet an MA basis of eligibility. He had no income on the date of application. His only resource is $300 in cash. The worker contacts Josef on May 5 to follow up on information needed to process the application and learns that Josef began employment on May 1. His employer does not offer health insurance. If he meets all RMA requirements, base eligibility for the 8-month period on 0 income. Do not consider his earnings or require him to provide verification of his employment.

EXAMPLE:

Rolf, age 22, entered the U.S. as a refugee on July 25. He applies for RMA on August 10. He reports he is employed 20 hours per week at $6.00 per hour. Project this income for the 8-month RMA eligibility period. Do not consider increases or new income sources that begin after the month of application.

Do not consider earnings from employment that begin or increase after approval of RMA. Refugees whose income increases beyond the RMA limits remain eligible for RMA until the end of the original

8-month eligibility period. Do not require RMA enrollees to report or verify employment.

Determine if MA eligibility continues under another basis at the end of the 8-month RMA period. Do not require a new application. Require verification of earnings if applicable. If there is no MA basis, review for MinnesotaCare or GAMC eligibility. See §0904 (Applications).

If refugees who receive regular MA become ineligible due to increased earnings, consider eligibility for Transition Year Medical Assistance (TYMA) first. See §0907.19.11 (Transitional/Transition Year MA). If there is no eligibility for TYMA and the refugee has been in the U. S. for less than 8 months, approve RMA for the remainder of the 8-month period without an eligibility determination.

EXAMPLE:

Sonja and her 2 children entered the U.S. as refugees on September 12. They were approved for MA effective September 1. Sonja reports beginning employment on October 5. Her earnings will exceed the MA standard for herself and the children. She does not meet the eligibility criteria for TYMA. Close MA November 1 and open RMA for the remainder of the 8-month period.

GAMC:

No provisions.

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MA WAIVER PROGRAMS 0907.23

Some people may be eligible to have certain MA rules waived. Approved waivers may allow the person to receive additional services beyond those covered by MA, and/or to have eligibility determined without regard to the income and assets of the person's spouse or parents.

The waiver programs include:

• Community Alternatives for the Disabled (CADI). See §0907.23.03. • Mental Retardation and Related Conditions (MR/RC). See §0907.23.05. • Community Alternative Care (CAC). See §0907.23.07. • TEFRA option. See §0907.23.09. • Elderly Waiver (EW). See §0907.23.11. • Traumatic Brain Injury Waiver (TBI). See §0907.23.13.

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MA WAIVER PROGRAMS: CADI 0907.23.03

MinnesotaCare:

No provisions.

MA:

The Community Alternatives for Disabled Individuals (CADI) program is a federally-approved waiver program. It allows people living in the community to receive services in addition to their regular MA coverage.

Covered services include:

• Adult day care. • Respite care. • Homemaker services. • Adaptations to the person's home or vehicle and other adaptive equipment. • Extended home health services, including LPN, RN, respiratory therapy, speech therapy, physical therapy, occupational therapy, and supplies and equipment. These services are available through CADI only after regular MA coverage is exhausted. • Extended personal care attendant services after regular MA coverage is exhausted. • Case management. • Independent living skills. • Family counseling and training. • Assisted living. • Adult foster care. • Residential care services.

To be eligible for CADI-funded services, a person must meet ALL the following conditions:

• Have a disabled basis of eligibility for MA (disability certification from either the State Medical Review Team (SMRT) or the Social Security Administration). Do not refer CADI applicants/enrollees who are certified disabled by SSA to SMRT. • Be screened by the Long Term Care Consultation (LTCC) team. • Have a determination from the LTCC team that, if not for the provision of waivered services, the person would reside in a nursing facility OR the person requires the level of care provided in a nursing facility. • Be under age 65 at the time of screening. A person is eligible for the CADI waiver through the month of the person's 65th birthday. If the person’s needs cannot be met by other programs, the person may continue on CADI after age 65, as long as the cost of services in the community does not exceed the cost of LTC care to MA. CADI Enrollees age 65 and over must enroll in managed care if they live in managed care counties. See §0914.03.03 (Managed Care Exclusions). • Be eligible for MA based only on the person's own income and assets. Exclude child support and RSDI payments received by or on behalf of children under age 18. • Choose home and community-based services. • Have anticipated costs to MA for community-based services that do not exceed the cost of services that are or would be provided in a health care facility. • Have a county service plan ensuring the person’s health and safety.

To determine the eligibility of an MA/CADI applicant:

1. Determine that the person has a disabled basis of eligibility.

2. Determine whether the person had a LTCC screening and was determined to need a nursing facility level of care.

3. Verify that the county case manager has determined the person to be CADI-eligible through developing a service plan and completing a cost determination.

The date of the LTCC screening is the earliest possible date of CADI eligibility. Coordinate the MA/CADI determination with the LTCC team and case manager.

4. Determine whether the person would be eligible for MA using only the person’s income and assets. Use a household size of 1. See §0908.05 (Determining MA/GAMC Household Size). Disregard the income and assets of spouses and parents in determining MA eligibility for the CADI program. See §0908.07 (Household Composition: Deeming).

Exclude child support and RSDI payments received by or on behalf of children under age 18.

Use Method B asset and income determination rules.

Asset limit: $3,000 for a household of 1. There is no asset limit for children under age 21.

CADI applicants and enrollees may transfer assets to their spouses without penalty. Other transfers may result in a period of ineligibility for CADI services. See §0909.27.11 (Improper Transfer Ineligibility).

If an adult is concurrently eligible for MA-EPD, use the MA-EPD asset limit. See §0909.05 (Asset Limits) and §0907.21.07.05 (MA for Employed Persons With Disabilities).

Income standard: 100% of FPG. See §0912.07.100 (100% of FPG). People with incomes over 100% of FPG must spend down to 75% of FPG (70% of FPG through 6-30-02). See §0912.07.075 (75% of FPG).

If the person is concurrently eligible for MA-EPD, there is no income limit. Follow MA-EPD rules to determine whether there is a premium. See §0907.21.07.05 (MA for Employed Persons With Disabilities).

If the person does not receive MA-EPD and income is over 100% of FPG, set the case up with a continuing monthly spenddown. See §0913.11 (Manual Monthly Spenddown Calculation) and §0913.09 (Automated Monthly Spenddown Calculation). Treat the projected amount of CADI services for the month as a medical bill incurred on the 1st of the month. The CADI enrollee is responsible for payment of the spenddown amount.

CADI enrollees who apply for QMB or SLMB must meet all requirements for those programs. Use the QMB or SLMB household size and count the income and assets of the CADI client’s spouse or parents if applicable. CADI enrollees who are not eligible for QMB or SLMB are not eligible for payment of Medicare premiums unless they also receive MA-EPD. See §0907.21.09 (MA Basis: Medicare Supplement Programs) and §0910.05.05 (Medicare Premium Payment).

Eligibility under CADI cannot begin until the person has been screened and approved to begin receiving CADI services. If the person is requesting retroactive MA for months before the screening and service begin date, deem spousal or parental income for those months if applicable.

EXAMPLE:

Harold applies for MA for his wife, Delores, on January 28. Delores has been hospitalized several times since November. Harold is requesting MA retroactive to November. Delores was screened by the LTCC team on January 15 and found eligible for CADI services. She receives RSDI based on her disability. Her assets are under $3,000 and she will be able to meet a monthly spenddown with the projected cost of CADI services. Check with the LTCC team and case manager to determine whether CADI can begin in January or February. Deem Harold’s income and assets for the months in the retroactive period before CADI begins.

CADI services are not available during periods of hospitalization.

Refer CADI enrollees under age 18 to DHS to determine and collect parental fees. If the child receives adoption assistance or the parents are enrolled in MA/GAMC, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance or who receive MA/GAMC for themselves are not liable for parental fees. See §0906.13 (Parental Fees).

GAMC:

No provisions.

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MA WAIVER PROGRAMS: MR/RC 0907.23.05

MinnesotaCare:

No provisions.

MA:

Certain people with mental retardation and related conditions may be eligible for additional home and community-based services in addition to regular MA services. Covered services under the Mental Retardation and Related Conditions (MR/RC) waivers include:

• Day training and habilitation services, including supported employment. • Supported living services for children. • Supported living services for adults. • Respite care. • Homemaker services. • Environmental modification. • Case management. • In-home family supports. • Adult day care. • Extended personal care attendant services after regular MA coverage is exhausted. • Personal support. • Assistive technology. • Caregiver and consumer training, education, and community supports. • Chore services. • Specialist services. • 24-hour emergency assistance.

To be eligible for MR/RC waivered services funding, a person must meet ALL the following conditions:

• Have mental retardation or a related condition. • Require a 24-hour plan of care. • Be eligible for MA. • Choose to participate in the waiver program as an alternative to receiving care in an ICF-MR services.

The average statewide cost to MA for MR/RC services must be less than the cost of providing the care in institutional settings. DHS makes this determination by averaging the cost of services for all eligible people. This cost requirement does NOT apply to each individual who receives MR/RC services.

There is no age limit for MR/RC. Enrollees age 65 and over must enroll in managed care if they live in managed care counties. See §0914.03.03 (Managed Care Exclusions).

To determine eligibility for MR/RC:

1. Determine whether the person has been determined to meet the conditions for the waiver. The county case manager makes this determination by verifying that the person has a diagnosis of mental retardation or related condition and requires 24-hour care. MR/RC does not require that the person be certified disabled by SSA or SMRT. The case manager’s waiver determination takes the place of the MA disability certification. This includes people who receive MA-EPD concurrently with MR/RC.

2. Determine whether the person is eligible for MA based on income and assets.

• The county agency must request written approval from DHS to disregard parental income and assets of waiver applicants under age 21 who live with their parents. If parental income makes the child ineligible or results in a spenddown, submit the Request to Suspend Medical Assistance Deeming Rules to DHS. Submit a separate request for DHS approval for each applicant child.

• Do not request a deeming suspension if the child is MA-eligible without regard to parental income due to receipt of SSI or adoption assistance, or if total household income is below the MA standard for the household size. If the parents report income orally or on the HCAPP that is less than the MA standard for the household size, request verification and determine eligibility based on household income. If the parents report income orally or on the HCAPP that would result in a spenddown, do not request verification. Do not send a denial notice. Submit the request to suspend deeming based on the parents’ statement.

Request a suspension of deeming for TEFRA children who transfer to the MR/RC waiver. Children cannot receive TEFRA and MR/RC at the same time.

• If the child is between 18 and 21, advise the client to apply for SSI.

Do not deem parental income if the child meets all conditions for the waiver, since this determination takes the place of a SSA or SMRT determination. MA does not deem the income of the parents of disabled children ages 18-21. Do not submit the Request to Suspend Medical Assistance Deeming Rules.

For married applicants, request suspension of deeming of spousal income (and assets for applicants age 21 and over). Note on the form that you are requesting suspension of spousal, rather than parental, deeming.

3. If DHS grants the suspension of deeming rules or no suspension is needed, determine MA eligibility using a household size of 1. Stop counting the parents’ (or spouse’s) income effective the 1st of the month waivered services begin. See §0908.05 (Determining MA/GAMC Household Size) and §0908.07 (Household Composition: Deeming).

Exclude child support and RSDI payments received by or on behalf of children under age 18.

If the MA case is closed, the county agency must request a new deeming waiver from DHS if the family reapplies.

Use Method B and a disabled basis of eligibility for all MR/RC clients.

Asset limit:

• $3,000 for a household of 1. There is no asset limit for children under age 21. If an adult is concurrently eligible for MA-EPD, use the MA-EPD asset limit.

See §0909.05 (Asset Limits) and §0907.21.07.05 (MA for Employed Persons With Disabilities). MR/RC applicants and enrollees may transfer assets to their spouses without penalty. Other transfers may result in a period of ineligibility for MR/RC services for adults subject to an asset limit. See §0909.27.11 (Improper Transfer Ineligibility).

Income standard: Effective 7-1-01, the income limit is 100% of FPG. See §0912.07.100 (100% of FPG). People with incomes over 100% of FPG must spend down to 75% of FPG (70% of FPG through 6-30-02). See §0912.07.075 (75% of FPG).

If the person is concurrently eligible for MA-EPD, there is no income limit. Follow MA-EPD rules to determine whether there is a premium. See §0907.21.07.05 (MA for Employed Persons With Disabilities).

If the person does not receive MA-EPD and income is over 100% of FPG, set the case up with a continuing monthly spenddown. Treat the cost of waivered services as a medical bill incurred on the 1st of the month. See §0913.11 (Manual Monthly Spenddown Calculation) and §0913.09 (Automated Monthly Spenddown Calculation).

MR/RC enrollees who apply for QMB or SLMB must meet all requirements for those programs. Use the QMB or SLMB household size and count the income and assets of the MR/RC client’s spouse or parents if applicable. MR/RC enrollees who are not eligible for QMB or SLMB are not eligible for payment of reimbursement of Medicare premiums. See §0907.21.09 (MA Basis: Medicare Supplement Programs) and §0910.05.05 (Medicare Premium Payment). To enter these cases correctly on MAXIS, follow the procedures for MA-EPD in POLI TEMP TE02.07.416 (Employed Person With Disabilities - Part 1).

MR/RC services are not available during a period of hospitalization or residence in an ICF-MR.

Refer MR/RC enrollees under age 18 to DHS to determine and collect parental fees. See §0906.13 (Parental Fees). If the child receives adoption assistance or the parents are enrolled in MA/GAMC, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance or who receive MA/GAMC for themselves are not liable for parental fees. See §0906.13 (Parental Fees).

GAMC:

No provisions.

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MA WAIVER PROGRAMS: CAC 0907.23.07

MinnesotaCare:

No provisions.

MA:

Community Alternative Care (CAC) is a federally approved home and community-based services waiver program for chronically ill people. CAC funds the following services in addition to those MA normally pays for:

• Case management. • Environmental adaptations and modifications. • Family counseling and training. • Foster care. • Homemaker services. • Respite care. • Extended coverage of certain normally covered MA services, such as home health care, personal care attendant services, physical, occupational, respiratory, and speech therapies, prescription drugs, and transportation. These services are available through CAC only after regular MA services are exhausted.

To be eligible for CAC funding, a person must meet ALL of the following conditions:

• Have a disabled basis of eligibility for MA (disability certification from either the State Medical Review Team (SMRT) or the Social Security Administration). Do not refer CAC applicants/enrollees who are certified disabled by SSA to SMRT. • Would require frequent or continuous hospitalization over a 12-month period if not for the provision of waivered services. • Have an interdisciplinary team assessment which recommends waivered services. The county case manager is responsible for obtaining the assessment. • Be eligible for MA based only on the person's own income and assets. • Exclude child support and RSDI payments received by or on behalf of children under age 18. • Have a cost to MA for community-based services that does not exceed the cost of hospital placement based on Diagnostic Rate Group (DRG) charges. • Choose home and community-based services. • Have a county services plan ensuring the person’s health and safety. • Be under age 65 at the time of screening. People who turn age 65 after the CAC screening may remain on CAC if they continue to meet all other eligibility factors. Enrollees age 65 and over must enroll in managed care if they live in managed care counties. See §0914.03.03 (Managed Care Exclusions).

There is no age limit for CAC. Enrollees age 65 and over must enroll in managed care if they live in managed care counties. See §0914.03.03 (Managed Care Exclusions).

To determine the eligibility of an MA-CAC applicant:

1. Determine that the person has a disabled basis of eligibility.

2. Determine whether the person had an interdisciplinary team assessment which recommended waivered services based on the person’s anticipated need for frequent or continuous hospitalization.

3. Verify that the county case manager has determined the person to be CAC-eligible through developing a service plan and completing a cost determination and that DHS has approved the recommendation and plan.

The date of the interdisciplinary team assessment is the earliest possible date of CAC eligibility. Coordinate the MA/CAC determination with the case manager.

4. Determine whether the person would be eligible for MA using only the person’s income and assets. Use a household size of 1. See §0908.05 (Determining MA/GAMC Household Size). Disregard the income and assets of spouses and parents in determining MA eligibility for the CAC program. See §0908.07 (Household Composition: Deeming). Exclude child support and RSDI payments received by or on behalf of children under age 18.

Use Method B asset and income determination rules.

Asset limit: $3,000 for a household of 1. There is no asset limit for children under age 21.

CAC applicants and enrollees may transfer assets to their spouses without penalty. Other transfers may result in a period of ineligibility for CAC services. See §0909.27.11 (Improper Transfer Ineligibility).

If an adult is concurrently eligible for MA-EPD, use the MA-EPD asset limit. See §0909.05 (Asset Limits) and §0907.21.07.05 (MA for Employed Persons With Disabilities).

Income standard:

100% of FPG. See §0912.07.100 (100% of FPG). People with incomes over 100% of FPG must spend down to 75% of FPG (70% of FPG through 6-30-02). See §0912.07.075 (75% of FPG).

If the person is concurrently eligible for MA-EPD, there is no income limit. Follow MA-EPD rules to determine whether there is a premium. See §0907.21.07.05 (MA for Employed Persons With Disabilities).

If the person does not receive MA-EPD and income is over 100% of FPG, set the case up with a continuing monthly spenddown. See §0913.11 (Manual Monthly Spenddown Calculation) and §0913.09 (Automated Monthly Spenddown Calculation). Treat the projected amount of CAC services for the month as a medical bill incurred on the first of the month. The CAC enrollee is responsible for payment of the spenddown amount.

CAC enrollees who apply for QMB or SLMB must meet all requirements for those programs. Use the QMB or SLMB household size and count the income and assets of the CAC client’s spouse or parents if applicable. CAC enrollees who are not eligible for QMB or SLMB are not eligible for payment of reimbursement of Medicare premiums. See §0907.21.09 (MA Basis: Medicare Supplement Programs) and §0910.05.05 (Medicare Premium Payment). To enter these cases correctly on MAXIS, follow the procedures for MA-EPD in POLI TEMP TE02.07.416 (Employed Person With Disabilities - Part 1).

Eligibility under CAC cannot begin until the person has been assessed and approved to begin receiving CAC services. If the person is requesting retroactive MA for months before the assessment and service begin date, deem spousal or parental income for those months if applicable.

CAC services are not available during periods of hospitalization.

Refer CAC enrollees under age 18 to DHS to determine and collect parental fees. If the child receives adoption assistance or the parents are enrolled in MA/GAMC, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance or who receive MA/GAMC for themselves are not liable for parental fees. See §0906.13 (Parental Fees).

GAMC:

No provisions.

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MA WAIVER PROGRAMS: TEFRA 0907.23.09

MinnesotaCare:

No provisions.

MA:

The TEFRA option provides MA eligibility to some disabled children who live with their families. It is commonly known as TEFRA because it was part of the Tax Equity and Fiscal Responsibility Act of 1982. Unlike the waivered services described in this chapter, TEFRA does not provide any additional MA covered services. It provides for the waiver of parental deeming requirements.

Count only the child's income when determining MA eligibility under TEFRA. Exclude child support and RSDI payments received by or on behalf of children under age 18. Use a household size of 1. Do not count the income or assets of the child's parent(s). See §0908.05 (Determining MA/GAMC Household Size) and §0908.07 (Household Composition: Deeming).

Asset limit:

There is no asset limit for children under age 21.

Income standard:

Effective 7-1-01, the income limit is 100 % of FPG. See §0912.07.100 (100% of FPG). Children with incomes over 100% FPG must spend down to 75% FPG (70% of FPG from 7-1-01 through 6-30-02). See §0912.07.075 (75% of FPG).

If the child’s income is over 100% FPG, set the case up with a continuing monthly spenddown. See §0913.11 (Manual Monthly Spenddown Calculation) and §0913.09 (Automated Monthly Spenddown Calculation). See §0913.21 (Allowable Medical Bills to Meet Spenddown) for expenses to apply toward meeting the spenddown.

Use Method B to determine TEFRA eligibility. To qualify for TEFRA, a child must meet ALL of the following conditions:

• Be under age 18. • Have a disability determination from the State Medical Review Team (SMRT). • Need a certain level of home health care to stay at home. That level would compare to the level of care provided in a hospital, nursing home or an intermediate care facility for the mentally retarded (ICF/MR). • The cost to MA for home care for the child must not be more than MA would pay for the child's care in a medical institution. • Live with at least one parent. • Be eligible for MA except for parental income and assets.

A child whose only disability is deafness or blindness could not qualify under the TEFRA Option because Minnesota has no medical facilities for the treatment of deafness or blindness enrolled as providers. Check with such applicants about any other disabilities they might have.

Because TEFRA does not provide any additional covered services, a child who is eligible for MA without a spenddown under another basis or waiver does not need a TEFRA certification. This includes:

• Children who are eligible for MA through TMA or TYMA See §0907.19.11 (Transitional/Transition Year MA). • Children who are eligible as auto newborns. See §0907.19.05.03 (MA Basis: Auto Newborn).• Children who are eligible for another waiver program described in this chapter, including CADI, MR/RC, CAC, or TBI. For information about these waiver programs, see:

§0907.23.03

MA Waiver Programs: CADI.

§0907.23.05

MA Waiver Programs: MR/RC.

§0907.23.07

MA Waiver Programs: CAC.

§0907.23.13

MA Waiver Programs: TBI.

• Children who are eligible for MA-only without a spenddown based on parental income and assets. • Children who receive SSI.

If children lose MA eligibility under 1 of the above bases, but appear to meet all of the conditions for TEFRA, request a TEFRA certification. Leave MA open while the SMRT determination is in process. If SMRT approves TEFRA, continue eligibility as a TEFRA case. If SMRT determines the child is ineligible for TEFRA and there is no eligibility when parental income is deemed, close MA for the first month for which you can give 10-day notice. If the family appeals the SMRT decision, follow §0917.11 (Continuation of Benefits).

EXAMPLE:

Mona is a disabled child who lives with her mother and brother. The family receives MA as a family with children. Mona’s mother begins employment. The family is no longer eligible for MA without a spenddown. All family members qualify for TYMA. When TYMA ends, Mona’s mother and brother no longer qualify for MA without a spenddown. Mona continues to require a level of home care comparable to what would be provided in a hospital, nursing home, or ICF-MR. Request a TEFRA certification from SMRT. Close TYMA and open Mona as a disabled child pending the SMRT decision.

EXAMPLE:

Chad, age 3, lives with his parents. He is disabled and needs a level of home care that meets TEFRA requirements. He is eligible for MA with his parents' income deemed. Do not request a TEFRA certification for Chad.

EXAMPLE:

Ashley is an infant who lives with her mother and is eligible for MA as an auto newborn. She needs community-based services that are not covered by MA. Consider eligibility under 1 of the other waiver programs. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility).

Refer TEFRA children who turn age 18 to SSI if they continue to have disabilities. Leave MA open as a disabled child ages 18-21 while the SSI determination is pending. If SSI determines that the child is not disabled and the child continues to live with the parent(s), determine eligibility based on parental income.

If a child is certified for TEFRA because parental income exceeds MA limits, do not require the parents to reverify their income at recertification unless the parents report an income decrease that would make the child eligible for MA without a spenddown with parental income deemed.

EXAMPLE:

Emily, age 6, is disabled and requires TEFRA-level home and community-based services. She does not require additional waivered services. Her parents' income exceeds MA limits. Emily is approved for a waiver of parental income and assets through TEFRA. On the annual recertification form, Emily's parents report decreased income. It appears Emily may now qualify for MA without a spenddown based on the decreased parental income. Request income verification. If Emily no longer requires a TEFRA waiver to qualify for MA, do not require a SMRT determination for continued TEFRA eligibility.

Also see §0907.23.09.03 (TEFRA--SMRT Procedures).

GAMC:

No provisions.

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TEFRA -- SMRT PROCEDURES 0907.23.09.03

MinnesotaCare:

No provisions.

MA:

Also see §0907.23.09 (MA Waiver Programs: TEFRA).

SMRT makes a disability and level of care determination for each TEFRA Option child. See §0906.15 (Disability Determinations). Only SMRT has the authority to evaluate disabilities for TEFRA certification.

Complete a Determination of Disability (DHS 1467A) for every submission to SMRT and attach documentation to support the client's physical, psychological and/or MR/DD condition. TEFRA Option referrals require physical and/or psychological evidence specific to the child's condition. The specific requirements for the three disability types, physical, developmental and mental health are listed on DHS 3854, DHS 3855, and DHS 3856, respectively. Referrals must include:

• A recent (within the past 3 months) routine physical examination performed by a licensed physician. • A Children’s Activities of Daily Living (CADL) Form (DHS 2904A) completed by the child's parent(s) or guardian(s).

Referrals must also include the following items depending on the child’s disability:

• The current Individual Educational Plan (IEP) with the Team Assessment Summary. If the child is not of school age, submit an Early Childhood Assessment. If the child receives other special services, provide reports of these activities. These reports can be obtained from the local school district as part of an Individual Family Service Plan (IFSP). • A Full Scale Intelligence Quotient (IQ) test or any other psychological evaluation that describes the mental functioning if there are problems related to Mental Retardation/Developmental Delay and the client is unable to be tested. • Results of a complete psychiatric/psychological examination performed by a licensed psychiatrist or psychologist within the last 12 months. Include an updated progress note if the evaluation is over 3 months old or the child’s condition has changed. See the Guide for Parents Applying for TEFRA (DHS 3368) for more information on what the evaluation must include.

SMRT may approve a TEFRA certification for up to a maximum of 4 years. SMRT's decision on the frequency of review of disability and level of care is not subject to administrative appeal. See §0917 (Appeals).

Fax or mail the documentation to SMRT. If the county agency chooses to mail the documentation, send only one-sided copies to SMRT retaining the originals with the case file. SMRT will shred the documentation after it is stored electronically. Once the review is complete, SMRT will fax the decision to the county. The fax number to submit SMRT documentation is (651) 296-7694.

Assist the client in gathering medical information and completing forms as needed. If an active client who would not qualify for MA without TEFRA certification fails to cooperate in submitting medical information by the due date, send a timely closing notice for failure to cooperate with the TEFRA certification process. If the client is cooperating but is unable to supply all medical documentation by the recertification due date, leave the case open until the information is received and SMRT has made a decision. You may use health care access funds to pay for testing required by SMRT to determine disability.

For current TEFRA cases, SMRT will send the documentation requirements forms (DHS 3854, DHS 3855, or DHS 3856) to county agencies 90 days prior to the end of a TEFRA recipient’s disability determination end date for recertification.

Parents of TEFRA-eligible children may be responsible to pay parental fees as partial reimbursement of the child’s MA costs. After approving eligibility for the child under the TEFRA Option, complete the County Parental Fee Referral (DHS 2982) to DHS. See §0906.13.09 (Parental Fees).

GAMC:

No provisions.

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MA WAIVER PROGRAMS: EW 0907.23.11

MinnesotaCare:

No provisions.

MA:

The Elderly Waiver (EW) provides MA funding for home and community-based services for people who would otherwise need nursing facility care. Covered home care services include:

• Adult day care. • Respite care. • Homemaker services. • Adult foster care (other than room and board costs). • Extended home health. • Case management. • Equipment and supplies not covered by MA, Medicare, or the client. The equipment and supplies must help keep the client out of a nursing facility. • Companion services. • Extended personal care. • Home-delivered meals. • Caregiver training and education. • Assisted living. • Residential care. • Extended transportation. • Chore services

To receive EW services, a person must meet ALL of the following conditions:

• Have a Long Term Care Consultation (LTCC) screening. • Require a nursing facility level of care (NF-I or NF-II). • Be able to remain in the community rather than a nursing facility. • Choose community care. • The cost to MA for community-based services must cost less than institutional care. • Be eligible for MA.

There are 2 income limits for EW. People with incomes equal to or less than the Special Income Standard (SIS) are eligible for EW without an MA spenddown. They must contribute any income over the maintenance needs allowance and other applicable deductions to the cost of services received under EW. This is known as the waiver obligation.

The SIS for 1-1-06 through 12-31-06 is $1,809 for all EW applicants or enrollees, regardless of marital status. The SIS for 1-1-05 through 12-31-05 is $1,737. The maintenance needs allowance for 7-1-06 through 6-30-07 is $816 regardless of marital status. Treat each person as a household of 1. The maintenance needs allowance for 7-1-05 through 6-30-06 is $789.

To determine eligibility for the SIS EW program, add together all monthly gross income of the applicant or enrollee before any exclusions. Do not include the income of the person’s spouse. If the applicant or enrollee’s gross income is equal to or less than the SIS, see §0913.13.05 (Waiver Obligation--SIS EW).

People with income equal to or less than the SIS but greater than120% FPG for a household size of 1 may choose to receive services through Alternative Care (AC) rather than through SIS EW if they meet the eligibility requirements for both programs. See §0918.05 (Alternative Care - AC). However, people in this category who choose AC are NOT eligible for MA with a spenddown, with one exception as described in §0913.13.07 (Relationship Between EW and AC).

If income exceeds the SIS, single people and married couples who both receive EW must qualify under the applicable Method B income standard. See §0912.07.100 (100% of FPG), §0912.07.075 (75% of FPG) and TE02.07.117 (Single Elderly Waiver). Use a household size of 1 and Method B budgeting when both spouses receive EW services (as well as for single EW clients). Set the case up using a community spenddown. Treat the projected amount of EW services for the month as a medical bill incurred on the 1st day of the month.

Use a household size of 1 for MA and the Medicare Supplement Programs for the non-EW spouse when one spouse receives EW and the other receives MA.

For more information on community spenddowns see

§0913.05.05 (Use of 6-Month and LTC Spenddowns)

§0913.05 (Which Spenddown Type to Use)

§0913.11 (Manual Monthly Spenddown Calculation)

§0913.09 (Automated Monthly Spenddown Calculation)

Use an LTC spenddown for people with a community spouse who does not receive EW. See §0913.05 (Which Spenddown Type to Use) and §0913.13.03 (LTC Spenddown--EW With Community Spouse). If the person's available income exceeds the monthly EW charges, determine eligibility using a combined LTC/Medical spenddown. See §0913.15 (Combination LTC/Medical Spenddown).

The asset limit for EW is $3,000 for a household of 1. When both spouses receive EW, each has an asset limit of $3,000. If one spouse has assets over $3,000 and the other spouse has assets under $3,000, the spouse with excess assets may transfer assets to the other spouse.

Consider people who receive home care services through EW and who have a community spouse not receiving EW to be long term care spouses. An LTC spouse or a community spouse can request an asset assessment to determine what amount of the couple's marital assets are protected for the community spouse and when MA eligibility may begin for the LTC spouse. The asset assessment can be completed when the following conditions occur:

• The LTC spouse has had a LTCC screening.

AND

• The LTC spouse requires a nursing facility level of care.

AND

• Home care services began prior to the LTCC date and are anticipated to continue for at least 30 consecutive days after the LTCC date.

OR

• Home care services which are anticipated to last for at least 30 consecutive days will begin within 90 days of the LTCC date.

The community spouse of a person receiving EW services is entitled to a community spouse asset allowance. See §0909.25 (Spousal Asset Assessments).

If a need exists, the community spouse and certain family members who live with the LTC and community spouse may be entitled to an allocation from the income of the LTC spouse. See §0912.05.25 (Allocations).

GAMC:

No provisions.

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MA WAIVER PROGRAMS: TBI 0907.23.13

MinnesotaCare:

No provisions.

MA:

People who suffer traumatic brain injuries may be eligible for additional covered services beyond what MA normally provides through the Traumatic Brain Injury (TBI) waiver. Covered services include:

• Case management. • Adult day care. • Assisted living. • Behavior programming. • Chore services. • Cognitive therapy. • Companion services. • Family counseling and training. • Foster care. • Extended home health care services, including LPN, RN, respiratory therapy, speech therapy, physical therapy, occupational therapy, and supplies and equipment. These services are available through TBI only after regular MA coverage is exhausted. • Homemaker services. • Independent living skills counseling, maintenance, and therapies. • Mental health psychological testing and explanation of findings. • Environmental modifications and adaptations. • Night supervision. • Residential care. • Respite care. • Structured day program. • Extended transportation services.

To be eligible for services under the TBI waiver, a person must meet ALL of the following conditions:

• Have a disabled basis of eligibility for MA (disability certification from either the State Medical Review Team (SMRT) or the Social Security Administration). Do not refer TBI applicants/enrollees who are certified disabled by SSA to SMRT. • Be eligible for MA based only on the person’s income and assets. • Be under age 65 at the time of screening. A person is eligible for the TBI waiver through the month of the person's 65th birthday. If the person’s needs cannot be met by other programs, the person may continue on TBI after age 65, as long as the cost of services in the community does not exceed the cost of LTC care to MA. TBI enrollees age 65 and over are not exempt from managed care enrollment if they live in managed care counties. See §0914.03.03 (Managed Care Exclusions). • Choose community-based services. • Have a county service plan ensuring the person’s health and safety. • Have a cost to MA for community-based services that does not exceed the cost of services provided in a health care facility. • Be diagnosed with a traumatic or acquired brain injury that is not degenerative or congenital. • Demonstrate significant cognitive and behavioral needs related to the brain injury. • Meet one of the following:
• If not for the provision of waivered services, the person would reside in or require the level of care provided in a specialized nursing facility, such as a unit designed to work with brain injury and/or behavioral management. Individuals in this category are known as TBI-NF (Traumatic Brain Injury--Nursing Facility Level) and must have a Long Term Care Consultation (LTCC) screening,

OR

• If not for the provision of waivered services, the person would reside in or require the level of care of a long term neurobehavioral hospital. Individuals in this category are known as TBI-NB (Traumatic Brain Injury--Neurobehavioral Hospital Level) and must have an interdisciplinary team assessment which recommends waivered services. The county case manager is responsible for obtaining the assessment.

To determine the eligibility of an MA-TBI applicant:

1. Determine that the person has a disabled basis of eligibility.

2. Determine whether the person had a LTCC which determined the person’s need for specialized nursing facility care OR an interdisciplinary team assessment which determined the person’s need for long-term neurobehavioral level of care.

3. Verify that the county case manager has determined the person to be TBI-eligible through developing a service plan and completing a cost determination and that DHS has approved the recommendation and plan.

The date of the LTCC or interdisciplinary team assessment is the earliest possible date of TBI eligibility. Coordinate the MA/TBI determination with the case manager.

4. Determine whether the person would be eligible for MA using only the person’s income and assets. Use a household size of 1. See §0908.05 (Determining MA/GAMC Household Size). Disregard the income and assets of spouses and parents in determining MA eligibility for the TBI program. See §0908.07 (Household Composition: Deeming). Exclude child support and RSDI payments received by or on behalf of children under age 18.

Use Method B asset and income determination rules.

Asset limit: $3,000 for a household of 1. There is no asset limit for children under age 21.

TBI applicants and enrollees may transfer assets to their spouses without penalty. Other transfers may result in a period of ineligibility for TBI services. See §0909.27.11 (Improper Transfer Ineligibility).

If an adult is concurrently eligible for MA-EPD, use the MA-EPD asset limit. See §0909.05 (Asset Limits) and §0907.21.07.05 (MA for Employed Persons With Disabilities).

Income standard:

100% of FPG. See §0912.07.100 (100% of FPG). People with incomes over 100% of FPG must spend down to 75% of FPG (70% of FPG through 6-30-02). See §0912.07.75 (75% of FPG).

If the person is concurrently eligible for MA-EPD, there is no income limit.

Follow MA-EPD rules to determine whether there is a premium. See §0907.21.07.05 (MA for Employed Persons With Disabilities).

If the person does not receive MA-EPD and income is over the 100% of FPG, set the case up with a continuing monthly spenddown. See §0913.11 (Manual Monthly Medical Spenddown Calculation) and §0913.09 (Automated Monthly Medical Spenddown Calculation). Treat the projected amount of TBI services for the month as a medical bill incurred on the 1st of the month. The TBI enrollee is responsible for payment of the spenddown amount.

TBI enrollees who apply for QMB or SLMB must meet all requirements for those programs. Use the QMB or SLMB household size and count the income and assets of the TBI client’s spouse or parents if applicable. TBI enrollees who are not eligible for QMB or SLMB are not eligible for payment of reimbursement of Medicare premiums. See §0907.21.09 (MA Basis: Medicare Supplement Programs) and §0910.05.05 (Medicare Premium Payment). To enter these cases correctly on MAXIS, follow the procedures for MA-EPD in POLI TEMP TE02.07.416 (Employed Person With Disabilities - Part 1).

Eligibility under TBI cannot begin until the person has been screened or assessed and approved to begin receiving TBI services. If the person is requesting retroactive MA for months before the assessment and service begin date, deem spousal or parental income for those months if applicable.

TBI services are not available during periods of hospitalization or nursing facility care.

Refer TBI enrollees under age 18 to DHS to determine and collect parental fees. If the child receives adoption assistance or the parents are enrolled in MA/GAMC, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance or who receive MA/GAMC for themselves are not liable for parental fees. See §0906.13 (Parental Fees).

GAMC:

No provisions.

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GAMC PROGRAM TYPES 0907.25

MinnesotaCare:

No provisions.

MA:

No provisions.

GAMC:

People who do not have a basis of eligibility for MA may be eligible for GAMC. This includes people who:

• Receive General Assistance (GA) and do not have an MA basis of eligibility. GA recipients who have an MA basis of eligibility receive MA instead of GAMC.

EXAMPLE:

Donald, age 19, receives GA. He has an MA basis as a child under 21. He is not eligible for GAMC because he is eligible for MA.

GA recipients with no MA basis do not have to accept automatic GAMC. They may decline health care coverage. They may apply for MinnesotaCare although they are not required to do so.

• Receive GRH payments and do not have an MA basis of eligibility. • Are adults between age 21 and age 65 who do not live with children who meet the definition of a dependent child. See §0902.29 (Glossary: Denial...). This includes parents whose only child(ren) are between ages 18 and 21, as well as adults with no children in the home and stepparents with no biological or adoptive children in the home.

People who are waiting for a disability determination for MA may receive GAMC while the determination is pending. See §0906.15 (Disability Determinations). If the disability is approved, they are eligible for MA back to the first day of the month in which GAMC was approved or the date the disability certification begins, whichever is later. They may be eligible for retroactive MA for the 3 months before the month of application if the disability certification includes those months.

There are 2 benefit sets for GAMC with different income and asset limits. People with incomes equal to or less than 75% FPG and assets equal to or less than $1,000 receive full GAMC benefits. People with incomes between 75% and 175% FPG and assets equal to or less than $10,000 for a household of 1 and $20,000 for a household of 2 or more may qualify for limited coverage while in the hospital through the GAMC Hospital Only (GHO) program. See §0907.25.03 (Full GAMC) and §0907.25.05 (GAMC Hospital Only).

Except for income, assets, and inpatient hospitalization, the eligibility requirements for full GAMC and GHO are the same. See §0906 (Technical Requirements) for information on technical requirements including citizenship and immigration status, Social Security Number, state residence, and specific program barriers such as drug convictions. See §0910 (Other Health Insurance) for requirements related to cost-effective health insurance and 3rd party liability.

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GAMC BASES: FAMILIES WITH CHILDREN 0907.25.03

MinnesotaCare:

No provisions.

MA:

No provisions.

GAMC:

People who do not have a basis of eligibility for MA and who meet the technical eligibility requirements for GAMC are eligible for all GAMC covered services if they meet the income and asset limits.

Asset limit:

• $1,000 per household. Follow MA Method B to determine which assets to exclude and how to evaluate countable assets.

See §0909.05 (Asset Limits).

Income standard:

• 75% of FPG for a 6-month budget period. See §0912.07.075 (75 Percent of FPG Standard). Use gross income. Follow Method B to determine what income is excluded.

There are no spenddown provisions. People with incomes between 75% FPG up to 175% FPG may qualify for GAMC Hospital Only (GHO) or MinnesotaCare. People with incomes greater than 175% FPG do not qualify for GAMC.

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GAMC HOSPITAL ONLY (GHO) 0907.25.05

MinnesotaCare:

No provisions.

MA:

No provisions.

GAMC:

People who do not have a basis of eligibility for MA and who meet the technical eligibility requirements for GAMC, but who have income or assets in excess of the limit for full GAMC benefits, may qualify for GAMC for inpatient hospitalization. Benefits are limited to inpatient hospital charges and physician’s services received during the inpatient hospitalization. Eligibility begins the date of application or the date of inpatient hospital admission, whichever is later, and ends effective the date of discharge from inpatient hospitalization. There are no reviews or renewals for GHO.

Asset limit:

• $10,000 for a household of 1 and $20,000 for a household of 2 or more. Follow MinnesotaCare to determine what assets to exclude and how to evaluate counted assets. There are no improper transfer provisions for GHO.

See §0909.05 (Asset Limits).

Income standard:

• More than 75% FPG but no more than 175% FPG for a 6-month budget period. See §0912.07.075 (75 Percent of FPG Standards) and §0912.07.175 (175 Percent of FPG Standards). Use gross income. Follow MA Method B to determine what income to exclude.

There are no spenddown provisions. GHO enrollees have a $1,000 co-payment for each inpatient admission, regardless of income. The co-payment may be applied against the spenddown for household members who receive or are applying for MA. No other medical expenses may be applied to reduce the GHO enrollee’s co-payment. MMIS will apply the co-payment to the claim automatically.

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STATE-FUNDED MA BASIS: VICTIMS OF TORTURE 0907.25.07

MinnesotaCare:

No provisions.

MA:

People receiving care and rehabilitation services from the Center for Victims of Torture (CVT) who do not meet MA eligibility criteria are eligible for state-funded MA (program NM) while they receive CVT services.

Do not require verification of receipt of CVT services for people who are otherwise eligible for federally-funded or state-funded MA. MA will pay for covered services received through CVT.

Determine MA eligibility for applicants receiving CVT services. If an applicant is ineligible for federally-funded or state-funded MA because of:

• Citizenship/immigration status

OR

• Assets

OR

• Income in excess of the standard to qualify without a spenddown

OR

• Lack of an MA basis of eligibility.

Request a copy of the CVT acceptance letter dated within the past 30 days. If the applicant submits an acceptance letter more than 30 days old, request updated verification to determine if the applicant is still receiving services. Approve program NM for the period of CVT services.

Verify continued receipt of CVT services at each income review and recertification. If services end and the person is not otherwise eligible for MA, terminate program NM.

EXAMPLE:

Raoul submits a HCAPP. He includes a CVT acceptance letter dated within 30 days of the date of application. He is undocumented and ineligible for MA. Approve program NM for the period in which he receives CVT services. Verify continued receipt of CVT services at each income review and recertification.

EXAMPLE:

Olga submits a HCAPP She includes a CVT acceptance letter dated within 30 days of the date of application. She meets all eligibility requirements for federally-funded MA. Approve MA. If MA eligibility ends due to immigration status, assets, income or lack of an MA basis, verify whether she continues to receive CVT services. If so, approve program NM for the period in which she receives the services.

If current enrollees indicate they have begun receiving CVT services, take no action if they remain eligible for MA. If MA eligibility ends, request verification of continued CVT services. Approve program NM while the CVT services continue.

EXAMPLE:

Keisha receives MA. At the time of her annual renewal, she reports increased income. She is unable to meet a spenddown for continued eligibility. She submits a current CVT acceptance letter. Approve program NM for the period of CVT services.

Use MAXIS eligibility type GS with income standard X for people who are eligible for program NM only because they receive CVT services.

When you identify a case as receiving CVT services, contact the MAXIS Help Desk to request security. Once the Help Desk has established security, the primary worker may add a secondary worker. In SPEC/XFER, select "Transfer Information" or "Transfer County to County" and transmit. PF9 to edit the panel. Add the secondary worker number after the "Servicing Worker" number. Only the primary and secondary workers, mentors, and supervisors will have access to these cases. The security will remain as long as the case is active on MAXIS, regardless of whether the person continues to receive CVT services.

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GAMC: MANDATORY MINNESOTACARE REFERRALS 0907.25.09

MinnesotaCare:

No provisions.

MA:

No provisions.

GAMC:

GAMC applicants and enrollees who do not meet an MA basis of eligibility must be referred to MinnesotaCare if they are:

• Stepparents and spouses of non-parent caretakers with gross family incomes equal to or less than 75% FPG. See §0912.07.075 (75 Percent of FPG Standards).

• Adult caretakers with gross family incomes equal to or less than 75% FPG if no child in the home meets the MA definition of a dependent child. See §0902.09 (Glossary: Denial...). This includes: • Caretakers of children age 18 who are not in high school or are not expected to graduate by the 19th birthday. • Caretakers of children ages 19 and 20.

Caretakers of children who meet the dependent child definition have an MA basis of eligibility and are not mandatory MinnesotaCare referrals.

Do not refer GAMC-eligible people to MinnesotaCare if they:

• Receive GAMC automatically with GA. • Have a pending disability status from SSA or SMRT. If they are found disabled, they meet an MA basis. If they are determined not to be disabled, refer them to MinnesotaCare if they appear to meet all requirements. • Appear ineligible for MinnesotaCare due to
• Current health insurance. • Lack of state residence. • Immigration status. • Residence in Group Residential Housing (GRH) or an Institution for Mental Diseases (IMD).
• Have incomes between 75% and 175% FPG and are eligible for GAMC Hospital Only (GHO). Determine MinnesotaCare eligibility when GHO ends. However, GHO enrollees are not required to accept MinnesotaCare as a condition of future GHO eligibility.

People who meet the mandatory referral criteria may receive GAMC if otherwise eligible while a MinnesotaCare determination is pending if they cooperate with the referral process.

NOTE: These instructions do not apply to people who are ineligible for GAMC. Refer people whose GAMC is denied or terminated for a MinnesotaCare determination. See §0904.09 (Shared and Transferred Applications) and §0904.09.05 (Transfers from MA/GAMC to MinnesotaCare).

When you determine that people who meet the mandatory referral criteria are eligible for GAMC, complete the Screening Tool and Transfer Document (STTD) (DHS 3392) to screen for potential MinnesotaCare eligibility. Do not refer people who do not meet MinnesotaCare criteria. Continue GAMC if otherwise eligible and rescreen for potential MinnesotaCare eligibility at each income review, annual renewal, and when people report changes that may result in MinnesotaCare eligibility.

When people meet MinnesotaCare criteria:

Determine MinnesotaCare eligibility if your county is a MinnesotaCare enrollment site unless the client asks to have MinnesotaCare eligibility determined at MinnesotaCare Operations. See §0904.03.03 (MinnesotaCare Enrollment Sites). If your county is not an enrollment site or the client requests service at MinnesotaCare Operations, transfer the complete application to MinnesotaCare Operations with the STTD (DHS 3392). Send or give the Mandatory Referral Form Letter (DHS 3398) to the client. Leave GAMC open during the MinnesotaCare determination.

Monitor for MinnesotaCare eligibility. If you are not processing the MinnesotaCare application, check the MMIS RELG screen monthly.

When MinnesotaCare is approved, terminate GAMC for the first month for which you can give 10-day notice.

Terminate people who fail to cooperate with the MinnesotaCare application process for the first month for which you can give 10-day notice. This includes people who fail to cooperate with pursuing the application or who fail to make the first premium payment.

Disqualify people who fail to cooperate with MinnesotaCare or who voluntarily request termination of MinnesotaCare once approved from receiving GAMC. These people remain ineligible for GAMC at all future applications unless they no longer meet MinnesotaCare eligibility criteria.

EXAMPLE:

Paul applies for GAMC and meets the mandatory MinnesotaCare referral criteria. He is approved for MinnesotaCare but fails to make his first premium payment. GAMC is terminated. He reapplies for GAMC 6 months later and now has private health insurance. Approve GAMC if he is otherwise eligible.

If Paul did not have private health coverage and continued to meet other MinnesotaCare mandatory referral criteria, he would be ineligible for GAMC.

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MA/GAMC BASIS: IMD RESIDENTS 0907.27

MinnesotaCare:

No provisions.

MA:

The following people who live in an Institution for the Treatment of Mental Diseases (IMD) have a basis of eligibility for MA:

• Children up to age 21 who are living in an IMD certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). See §0907.19.03 (Families and Children Bases - Child Under 21). • People up to age 22 who have received inpatient psychiatric hospital services continuously since before their 21st birthday and who were eligible for MA on their 21st birthday while living in an IMD certified by JCAHO. • People who receive MA, are enrolled in managed care, and were placed in an IMD by the health plan, or for whom the health plan pays court-ordered costs. See §0914 (Service Delivery). These people remain enrolled in the health plan with the same budget as they had before placement. • People age 65 and over. See §0907.21.03 (MA/Medicare Supplement Basis: Age 65 & Over).

Use Method B for all IMD residents who are eligible for MA.

Asset limit for people age 21 and over who are not on MA-EPD:

• $3,000 for a household of 1. • $6,000 for a household of 2. • $200 for each additional household member.

MA-EPD:

- $20,000

No asset limit for children under 21.

Income standard for people who are not on MA-EPD:

100% of FPG. See §0912.07.100 (100 Percent of FPG Standards).

People with incomes greater than 100% FPG may be eligible by spending down to 75% FPG (70% FPG through 6-30-02). See §0912.07.075 (75 Percent of FPG Standards).

MA-EPD:

No income limit. People with incomes equal to or greater than 100% FPG must continue to pay the MA-EPD premium while residing in an IMD.

Except for enrollees whose IMD costs are the responsibility of a health plan (including court ordered placements for which the health plan is responsible), use a long term care spenddown if MA is paying the cost of care in the IMD. See §0913.13 (Long Term Care Spenddown Calculation).

People who are eligible for MA while living in an IMD are eligible for all MA covered services. If MA is not paying the cost of care in the IMD, the person is eligible for all MA covered services incurred in addition to facility costs, such as doctor and dental visits.

MA pays the cost of care for individuals up to age 21, or up to age 22 if they meet the conditions earlier in this section, only in the state Regional Treatment Centers (RTCs).

People who meet an MA basis of eligibility but are ineligible for MA solely because they live in an IMD are eligible for state-funded MA benefits, except for coverage of nursing homes that are IMDs. Use major program I/IM on MAXIS and MMIS. Determine eligibility using MA income and asset limits. Determine the MA basis of eligibility and apply the appropriate income standard, asset limit, and method. See §0907.19 (MA Families and Children Bases), §0907.21 (MA Basis: Age 65 and Over/Blind/Disabled), and §0909.05 (Asset Limits).

EXAMPLE:

Mary, age 35, receives MA for herself and 2 children. She is placed in an IMD for an estimated stay of 3-4 months. She is ineligible for MA solely due to IMD residence. Determine eligibility for program IM eligibility using the MA Parent/Caretaker asset limit ($20,000 for Mary and 2 children) and income limit (100% of FPG). Use Method A.

People who are eligible for program IM are eligible for MA if they have been discharged from the IMD or are on convalescent or conditional leave. See §0906.09.01 (Institutional Residence --MA/GAMC).

People who are enrolled in program IM solely due to IMD residence are also ineligible for the Medicare Supplement Programs. Reimburse cost-effective Medicare premiums for this group.See §0910.05.05 (Medicare Premium Payment).

People who are otherwise eligible for MA-EPD but cannot get MA due to residing in an IMD may be eligible for program IM. Use MA-EPD asset limits and premium determination rules. See §0907.21.07.05 (MA for Employed Persons with Disabilities). Recalculate the premium if the MA-EPD enrollee is on a medical leave from employment of up to 4 months or has decreased wages while residing in the IMD. See §0907.21.07.06 (MA-EPD Employment Definition) and §0913.01.03 (MA-EPD Premiums).

GAMC:

People who reside in an IMD and do not have a basis of eligibility for MA are eligible for GAMC. Use gross income. Follow MA Method B to determine what income to exclude.

Asset limit:

• $1,000 per household.

See §0909.05 (Asset Limit).

Income standard:

75% FPG See §0912.07.075 (75 Percent of FPG Standards).

EXAMPLE:

Peter, age 40, resides in an IMD. He is single with no children and is not blind or disabled. Determine GAMC eligibility.

People who qualify for GAMC under a GAMC-only basis of eligibility are eligible for all GAMC covered services. The IMD costs are not a GAMC covered service and will be paid through other funding, such as GRH, other state programs, or private pay. The IMD resident is eligible for GAMC services such as doctor and dentist visits that are not included in the IMD treatment plan.

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EMERGENCY MEDICAL ASSISTANCE-EMA 0907.29

MinnesotaCare:

No provisions.

MA:

People who are not otherwise eligible for MA because of immigration status or deemed income and assets of a sponsor who is not a household member may be eligible for emergency MA (EMA, program code EH) if they have a medical emergency. DHS may be able to claim federal reimbursement for people enrolled in program NM who have medical emergencies.

To be eligible for EMA, people must:

• Meet 1 of the MA bases of eligibility described in sections §0907.19 through §0907.23 of this chapter. • Meet MA income and asset limits. See §0912.07 (Income Standards) and §0909.05 (Asset Limits). • Have a medical emergency. • Be ineligible for regular MA solely due to their immigration status or deeming of sponsor income and assets. See §0906.03 (Citizenship and Immigration Status).

A medical emergency for EMA purposes occurs when a person meets any of the following 3 circumstances:

• Has a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to:

- Place the person's health in serious jeopardy.

OR

• Cause serious impairment to bodily functions.

OR

• Cause serious dysfunction of any bodily organ or part.

Accept the client's statement that the client was in severe pain at the time of treatment. Verify medical service dates and open EMA or EGAMC only from the date the medical emergency begins until the medical emergency ends.

Examples of such conditions include stroke, heart attack, abscessed teeth, broken bones, ear infections, and kidney failure.

• Has a chronic medical condition which, if left untreated, could reasonably be expected to:
• Place the person's health in serious jeopardy.

OR

• Cause serious impairment to bodily functions.

OR

• Cause serious dysfunction of any bodily organ or part.

Examples of such conditions include insulin dependent diabetes, HIV positive with complications, cancer, kidney disease, and tuberculosis.

Verify with a physician's statement confirming both the condition and the consequences if left untreated. Open Emergency MA for as long as the chronic condition persists. Reverify the condition and consequences of not receiving medical treatment at each recertification, or sooner if the client's health is expected to improve.

Gives birth.

Pregnant women who are ineligible for MA solely due to their immigration status are eligible for program NM for the duration of the pregnancy and the 60-day postpartum period. EMA will cover the labor and delivery costs. MMIS will identify these costs and seek federal reimbursement through EMA. It is not necessary to change pregnant women’s eligibility from program NM to EH for labor and delivery.

For pregnant women who are requesting EMA for labor and delivery costs only, approve EMA for the period from the onset of labor through delivery. EMA will not cover prenatal or postpartum care. If the woman is open on program NM, leave program NM open throughout pregnancy and postpartum period. Program NM will cover prenatal and postpartum care. The MMIS claims system will automatically seek federal reimbursement for labor and delivery costs.

EMA is available for the duration of the medical emergency. People with chronic conditions as described in §0907.29 (Medical Emergency Programs) may be eligible indefinitely if the condition persists. EMA does not cover preventive care, organ transplants, or home and community based waivered services. See the DHS Provider Manual for more information on covered services.

Children who are ineligible for MA due to immigration status may receive EMA under the TEFRA option if they have a medical emergency. See §0907.23.09 (MA Waiver Programs: TEFRA).

GAMC:

No provisions.

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