Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 20 - Division of County Operations › Rule 016.20.97-017 - Medical Services Policy Manual - New Policy: The list of individuals eligible for Medicaid has been updated. The section regarding Stepparent Income Disregard has been replaced by Transitional Employment Assistance (TEA) Related Medicaid.

Current through Register Vol. 49, No. 6, June, 2024
2000
Individuals Eligible for Medicaid
The following categories of individuals are eligible for
				Medicaid:
1. Individuals eligible for
			 Supplemental Security Income (SSI) benefits (i.e., recipients of straight SSI
			 benefits, mandatory state supplements, SSI conditional payments and SSI
			 presumptive disability payments). Re. MS 2010;
2. Blind or disabled individuals with
			 converted cases who are not considered to be blind or disabled under SSI
			 criteria. Re. MS 2020;
3.
			 Individuals eligible for Medicaid as essential spouses in December 1973 and who
			 continue to meet that eligibility criteria. Re. MS 2025;
4. Medical Only Individuals who are current
			 recipients of SSA; who were previously eligible for and received SSA and SSI
			 concurrently in at least one month after April 1977; and who would now be
			 eligible for SSI if all COLA increases received since they last received SSA
			 and SSI concurrently were deducted from current income. Re. MS 2030;
5. Medical Only Individuals whose assistance
			 payments were terminated due to the 20% increase in Social Security benefits in
			 September 1972, and who would be currently eligible for assistance payments if
			 the 20% increase in Social Security benefits in September 1972 were
			 disregarded. Re. MS 2040;
6.
			 Disabled widows and widowers who were entitled to SSA for December 1983; who
			 received SSA disability for January 1984; who lost SSI after January 1984, due
			 to elimination of a benefit reduction factor previously applied; who would be
			 SSI eligible if the 1984 reduction factor increase and all COLA's since 1984
			 were disregarded; and who applied and were found eligible for Medicaid benefits
			 between July 1, 1986, and June 30, 1988. Re. MS 2045;
7. Disabled widows and widowers who were at
			 least age 60 on or after 4/1/88, were not yet age 65 on 4/1/88, formerly
			 received SSI benefits which were terminated due to entitlement to SSA widow's
			 or widower's benefits, currently receive SSA widow's or widower's benefits, are
			 not currently eligible for Medicare, would be eligible for SSI if ALL SSA
			 benefits were disregarded, and are otherwise income and resource eligible for
			 Medicaid. Re. MS 2046;
8. Disabled
			 widows, widowers and disabled surviving divorced spouses who lost their SSI due
			 to receipt of SSA benefits based on a less restrictive definition of disability
			 that was used prior to 0BRA of 1990. Re. MS 2049;
9. Qualified Medicare Beneficiaries who
			 qualify under the Medicare Catastrophic Coverage Act of 1988, and whose
			 benefits are limited to Medicare cost-sharing. Re. MS 2047;
10. Specified Low Income Medicare
			 Beneficiaries whose income is between 100% and 120% of the Federal Poverty
			 Level and who meet all other requirements for the Category will be eligible for
			 payment of their Medicare Part B Premium. Re. MS 2051;
11. Qualified Disabled and Working
			 Individuals who lost Medicare Part A entitlement solely due to Substantial
			 Gainful Activity. Medicaid coverage for these individuals is limited to payment
			 of their Part A premium. Re. MS 2048;
12. Disabled Adult Children (DAC) who are age
			 18 or older, who became disabled or blind before age 22, who were receiving SSI
			 based on disability or blindness, and who lost SSI on or after July 1, 1987 due
			 to a DAC entitlement or a DAC increase. Re. MS 2050;
13. Individuals who were eligible for
			 Medicaid in Title XIX institutions in December 1973. Re. MS 2044.3;
14. Families who lose TEA related Medicaid
			 eligibility due to increased wages and who qualify for up to 12 months of
			 transitional Medicaid. Re. MS 2061;
15. Families who lose TEA related Medicaid
			 eligibility due to collection of child support payments and who qualify for up
			 to 3 months of extended Medicaid. Re. MS 2063;
16. Eligible individuals under age 21 and
			 individuals age 65 and older who are receiving inpatient psychiatric care in
			 the Arkansas State Hospital or the George W. Jackson Center. Re. MS
			 2070.
17. Developmentally Disabled
			 Individuals who qualify for Home and Community Based Services. Re. MS
			 2075;
18. Aged Individuals who
			 qualify for Home and Community Based Waiver Services. Re. MS 2076;
19. Newborn infants born to women determined
			 to be Medicaid eligible when the infant was born. Re. MS 2080;
20. Individuals who qualify for services
			 under the Alternatives for Adults with Physical Disabilities Waiver. Re. MS
			 2078;
21. Disabled children
			 eligible for Medicaid under TEFRA. Re. MS 2090;
22. Illegal aliens who are eligible for
			 emergency services only. Re. MS 2095;
23. Individuals who qualify for retroactive
			 Medicaid eligibility. Re. MS 2100 (applies to all categories except Newborn
			 Infants, PW-PE, QMB, SMB, QDWI, and Waiver Categories. Re. MS 2080, MS 5600, MS
			 2047, MS 2051, 2048, 2075, and 2076);
24. Individuals in Title XIX Long Term Care
			 Facilities who are eligible according to LTC criteria. Re. MS 3000;
25. Women eligible as Pregnant Women who meet
			 the AFDC or Medically Needy standards of need. Re. MS 5000, 7000;
26. Pregnant women, infants and children (up
			 to age 6) whose income does not exceed 133 percent of the Federal Poverty
			 Level, and children ages 6 and older, who were born after September 30, 1983,
			 whose family income does not exceed 100 percent of the Federal Poverty Level.
			 Re. MS 5600;
27.
Pregnant
			 Women found presumptively eligible by a Qualified Provider for ambulatory
			 prenatal care. Re. MS 5600;
28.
Individuals eligible for the U-18
			 category. Re. MS 6000;
29.
Title IV-E and other Foster Children. Re. MS 6000 and
			 7000;
30.
Non-Title
			 IV-E Adoptive Children with Special Needs. Re. MS 6590;
31.
Individuals eligible for the
			 Medically Needy Program. Re. MS 7000;
32.
Refugees eligible for Medicaid
			 under "special eligibility period" criteria of the Refugee Resettlement
			 Program;
33.
Women
			 found eligible for Family Planning Waiver services and whose benefits are
			 limited to family planning services only; and
34.
Individuals found eligible for
			 Transitional Employment Assistance related Medicaid. Re. MS 2085.
2005
Date Specific
				Eligibility
With date specific eligibility, for most Medicaid
				categories, an individual's or family's eligibility may begin or end on any day
				of a month.
When eligibility is established, eligibility will begin
				on the day the application was registered, unless retroactive coverage is
				needed. If retroactive coverage is needed and if eligibility is established for
				a retroactive period, eligibility can begin up to 3 months prior to the date of
				application (but not on the first day of the third retroactive month unless the
				application was filed on the first day of a month).
Eligibility for most Medicaid categories under date
				specific eligibility may be terminated at any time. The end date of eligibility
				will be the last day of the 10 day advance notice period, unless a recipient
				requests a hearing within the advance notice period.
There are some Medicaid categories in which eligibility
				may
not
begin or end on any day of a month. These
				categories are: QMB (MS 2047), SMB (MS 2051), QDWI (MS 2048), and TM (MS 2061).
				Information about the begin and'end dates for these categories is found in the
				eligibility section for each category.
2010
Supplemental Security Income
			 (SSI) Eligibles
Individuals who have been determined eligible for SSI benefits
				by the Social Security Administration (SSA) are eligible for Medicaid (i.e.,
				recipients of straight SSI benefits, Mandatory State Supplements, SSI
				conditional payments and SSI presumptive disability payments).
The County Office is notified of SSI eligibles by printout as
				SSA makes information available to the Office of Information Systems (OIS). OIS
				will mail Medicaid ID cards to all SSI eligibles at certification.
SSA will notify OIS via the State Data Exchange system of
				changes for this group of eligibles. The County Office will notify the local
				SSA District Offices by means of a lead form, RVI-302, regarding current
				changes reported by/for individuals within this group (e.g., SSI recipient
				enters a nursing home).
2010.1
National Correction Procedure
The National Correction Procedure is a process for notifying
				the Social Security Administration (SSA) of changes that could affect
				SSI/Medicaid eligibility and/or the amount of State supplementation
				payments.
When information is received that is not reflected on the
				latest "SSI Recipient" printout, the County Office will submit the information
				to SSA via the SSA-3911, Report of Change-SSI Data. The following information
				can be reported:
Recipient's Name
Resources
Sex
Unearned Income Type
Date of Birth
Unearned Income Stop Date
Payee Name, Mailing Address, Zip Code
Unearned Income Amount
SSI Living Arrangement
Unearned Income Frequency
Date of Death (month, year)
Unearned Income Claim/ID Number
Marital Status
Earned Income Period
Residence Address, Zip Code
Earned Income Wage Estimate
State, County of Jurisdiction
Net Self-Employment Income Estimate
In addition, the County Office will properly identify the
				recipient and/or any other individual, the reason for submittal, and the County
				Office Worker requesting the change. Supporting documentation will be submitted
				if available.
The county officer worker will complete Parts I and II of the
				SSA-3911. Completion and routing are self-explanatory with the following
				exceptions:
Item 8. - Enter Bureau of Supplemental Security Income, 1200
				Main Tower Bldg., Dallas, TX 75202,
Item 10. - Enter the information from the "SSI Recipient"
				printout that needs correction,
2085
Transitional Employment
			 Assistance (TEA) Related Medicaid
The Personal Responsibility and Work Opportunity Reconciliation
				Act of 1996 (
				P.L.
				104-193 ) replaced the Aid to Families with
				Dependent Children (AFDC) program with the Temporary Assistance for Needy
				Families (TANF) program. In Arkansas, the TANF program is known as Transitional
				Employment Assistance (TEA).
Low income families and children who receive cash assistance
				are no longer automatically entitled to Medicaid. Certain individuals may be
				Medicaid eligible in the TEA category if their net income and countable
				resources do not exceed the AFDC income and resource limits which were in
				effect on July 16, 1996, and if there is deprivation of parental support. An
				individual need not be receiving TEA cash assistance to be eligible for
				Medicaid in this category.
2085.1
Extent of Services
Individuals approved for TEA Medicaid will be eligible for the
				full range of Medicaid services, including services under the Children's Health
				Services Program.
2086
Eligibility
			 Requirements
1.
Citizenship or Alienage
- The individual must be
			 either a United States citizen or qualified alien (Re. TEA 2220).
2.
Social Security Number
(SSH)
Enumeration
- Requirements at
			 TEA 2110 must be met.
3.
Mandatory Assignment of Rights to Medical Support
-
			 Assignment of rights to medical support/third party liability is required (MS
			 1350).
4.
Cooperation
			 with the Office of Child Support Enforcement(OCSE)
- An OCSE
			 referral must be made any time there is an absent parent, and, if both parents
			 are in the home, whenever paternity has not been established (TEA
			 2140).
5. '
Residency
- The individual must be an Arkansas
			 resident (TEA 2250).
6.
Relationship and Living with Specified Relative
- A
			 dependent child must be living with his/her specified relative in the
			 relative's home (TEA 2210).
7.
Deprivation of Parental Support
- The dependent child
			 must be deprived of parental support or care by reason of the unemployment,
			 death, continued absence, or physical or mental incapacity of a parent (FA
			 2240).
8.
Standard of
			 Need
- In determining eligibility, parents will be included in the
			 need standard with their natural/adopted children. Normally, all of the full
			 siblings in the household will be included in the budget with their
			 natural/adoptive parents. However, a parent may choose to exclude a child and
			 that child's income and resources if inclusion of that child would cause
			 ineligibility for the other children. Children may also be excluded for other
			 reasons, and the parent need not state the reason. Stepparents will not be
			 budgeted with their stepchildren.
9.
Resources
- The
			 total equity value of all countable resources available to the assistance unit
			 cannot exceed $1000. Resources are determined and verified as specified at TEA
			 2270 - 2277.6. Resources available only to a stepparent will be disregarded in
			 determining eligibility for the stepchildren and their natural/adoptive parent
			 (the stepparent's spouse).
10.
Income
- Net countable income will be compared to the
			 AFDC Reduced Standard of Need for the unit size. Income limits are those which
			 were in effect on July 16, 1996. Income is determined and verified as specified
			 at TEA 2300-2353.2.
Income available only to a stepparent will be disregarded in
				the eligibility determination of the stepchild. Eligibility for the parent can
				be determined in TEA related Medicaid only if the stepparent has no income. If
				the stepparent has income, eligibility for the parent will have to be
				determined in another category (e.g., AFDC-MN) with the stepparent's income
				deemed to the parent (Re. FA 2377.1).
Income Limits
Unit Size
Countable Income Limit
1
$ 81
2
162
3
204
4
247
5
286
6
331
7
373
8
415
9 or more
457
2086.1
TEA Requirements Not Applicable to TEA Related
			 Medicaid
The following TEA cash assistance eligibility factors are not
				required for TEA related Medicaid eligibility:
1. Personal Responsibility Agreement
			 Requirement-
2. TEA Minor Parent
			 Requirements as outlined at TEA 2120 - 2123
3. Time Limit Requirement
4. Work Participation Requirement
2086.2
Application
			 Process
Initial eligibility for TEA related Medicaid will be determined
				at the same time that eligibility for TEA cash assistance is determined.
				Initial applications may be made on the DCO-180, Application for Transitional
				Employment Assistance. Other forms needed for new applicants are the DC0-96,
				DCO-86, DCO-662, and DCO-7. If additional information is needed, the county
				worker will also complete Form DCO-002 and give it to the applicant during the
				initial interview.
2086.3
Time Limit on Disposition nf Applications
The county office worker will have a maximum of 30 days from
				the date of application to dispose of the application by one of the following
				actions: approval, denial, or withdrawal.
2087
Authorization of
			 Eligibility
When all eligibility requirements have been met, the county
				office worker will complete Form DC0-56 for a Category 20 approval (Action
				Reason 100). The begin date of Medicaid eligibility will be the date of
				application, unless retroactive coverage is needed. Retroactive coverage may
				begin up to three months prior to the application date. The applicant will be
				notified by DCO-55 or DCO-700.
2087.1
Denial and Withdrawal
The county worker will complete the following tasks when
				denying an application:
1. Record
			 pertinent information in the case narrative.
2. Complete denial data on'Form DCO-180 and
			 submit for data entry on WIMA.
3.
			 Notify applicant by DC0-55 or DC0-700.
4. For withdrawal, obtain a signed statement
			 from the applicant that he/she wishes to withdraw the application.
2088
Reevaluation and Changes
Cases will be reevaluated every twelve months. Medicaid
				revaluations should be scheduled to coincide with the TEA cash assistance
				reevaluation, if applicable to the household.
Recipients are required to report changes within ten days after
				the change occurs. If a reported change will result in adverse action, a ten
				day advance notice via Form DCO-700 will be given, if required (Re. MS 7840).
				All changes will be documented in the case record. Changes will be entered on
				Form DCO-56 and submitted for entry into the ACES system.
2090
Home Care for
			 Children/TEFRA
Section 134 of the Tax Equity and Fiscal Responsibility Act of
				1982 (TEFRA), as amended by OBRA of 1987, provides for coverage of certain
				disabled children in the home if they would qualify for Medicaid as residents
				in a Title XIX Institution (e.g. Nursing Home, ICF-MR, etc.). Arkansas has
				elected to cover this group.
TEFRA is a category of Medicaid eligibility that enables
				children to have care in their homes rather than in an institution. Children
				who live in institutions or receive extended care in institutions are not
				eligible in the TEFRA category.
2090.1
Eligibility Requirements
1. Age - The child must be 18 or under (Re.
			 MS.3321);
2.
Disability
- The child must be disabled according to
			 SSI definition. If disability has not been established by SSA and if MRT is to
			 establish the disability, medical and social information will be sent to MRT
			 for determination of disability (Re. MS 2090.4 and MS 3322);
3.
Citizenship or Alien
			 Status
- The child must be a citizen, an alien lawfully admitted
			 for permanent residence, or permanently residing in U.S. under 'Color of the
			 Law' (Re. MS 3324);
4.
Residency
- The child must be an Arkansas resident
			 (Re. MS 2200);
5.
Resources
- The child's countable resources cannot
			 exceed $2,000.00 (Re. MS 3330). No period of ineligibility will be imposed for
			 transfers with uncompensated value;
6.
Income
- The
			 child's gross countable income must be less than the current LTC income limit,
			 i.e. the child would be Medicaid eligible if institutionalized (Re. MS 3340 -
			 3348.1). In-Kind Support and Maintenance is not considered income in TEFRA
			 cases. SSI exclusions are not allowed;
7.
Medical Necessity
- The child must meet the medical necessity requirement for institutional care
			 (Re. MS 3350), i.e., the child requires a level of care that would be provided
			 in a hospital, nursing facility or ICF/MR;
8.
Appropriateness of
			 Care
- Medical services must be available to provide care to the
			 child in the home (RE. MS 2090.5), and it must be appropriate to provide such
			 care outside an institution;
9.
Cost Effectiveness
- The estimated cost of care for
			 the child in the home cannot exceed the estimated cost of care for the child in
			 an institution (Re. MS 2090.5);
10.
Child Support Enforcement Referral
(Re. MS 1310);
			 and
11.
Social Security
			 Enumeration
- The individual must meet the Social Security
			 Enumeration requirements specified in MS 1390.
2090.2
Application
			 Process
Application will be made by the adult responsible for care of
				the child in the child's county of residence.
Forms to be completed at the application interview are the
				DC0-777, DCO-86, DCO-87, DC0-662, DC0-707, DC0-769, sections
				I and
				II of the DCO-2603, and the first
				three lines of the DCO-2602. When the parent's or guardian's signature has been
				obtained at the bottom of Page 1, DC0-2602, the Physician Assessment form will
				be given to the individual to be completed by the child's physician. Forms
				DCO-106, DC0-107 and/or DC0-81, and DCO-108 will also be completed if the
				disability is to be established by MRT.
Applications will be registered on WIMA in Category 49.
2090.3
Eligibility
			 Determinations
With the exception of the Appropriateness of Care and Cost
				Effectiveness requirements, eligibility determinations for TEFRA cases will be
				conducted in the same manner as AD Long Term Care cases.
A child who would not be eligible for Medicaid in an
				institution cannot be considered for eligibility under TEFRA.
If a child's countable income is less than the current LTC
				income limit and the child's countable resources are less than $2,000.00,
				he/she will meet the TEFRA i ncome and resource requirements. Parental i ncome
				and resources wi 11 be disregarded.
Alternating TEFRA and SSI
				Eligibility
Some children who receive SSI may intermittently lose their SSI
				due to fluctuating parental income and may be TEFRA eligible in the non-SSI
				months. In these cases, the county must redetermine TEFRA eligibility for each
				month in which the child is not SSI eligible.
If fluctuating parental income causes a child's SSI eligibility
				status to change from month to month and less than 10 months have passed since
				the last full TEFRA certification or reevaluation (Re. MS 2093), only DCO-777
				and redetermination of income and resource eligibility are required to reopen
				the TEFRA case; redetermination of other eligibility factors will not be
				required.
2090.4
Disability Determinations
SSA Disability Determination
- In
				order to qualify for TEFRA, a child must be considered disabled under the SSI
				regulations that govern children's disabilities. If a child received SSI within
				one year prior to making TEFRA application, but was terminated for reasons
				other than cessation of a disability (e.g., parental income), documentation
				will be obtained for the case record and the child will be considered disabled
				based on the previous SSA disability
				determination.