Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 20 - Division of County Operations › Rule 016.20.18-003 - AR Works Program Updates

Current through Register Vol. 49, No. 6, June, 2024
A-100 General Program Information
The Medicaid Program is a Federal-State Program designed to
				meet the financial expense of medical services for eligible individuals in
				Arkansas. The Department of Human Services, Divisions of County Operations and
				Medical Services have the responsibility for administration of the Medicaid
				Program. The purpose of Medical Services is to provide medical assistance to
				low income individuals and families and to insure proper utilization of such
				services. The Division of County Operations will accept ad applications,
				verification documents, etc. and will make eligibility determinations.
Benefits for the Arkansas Medicaid and ARKids Programs include,
				but are not limited to the following:
* Emergency Services
* Home Health and Hospice
* Hospitalization
* Long Term Care
* Physician Services
* Prescription Drugs
* Transportation-Refer to Appendix B for a description of
				TransportationServices
Generally, there is no limit on benefits to individuals under
				age 21 who are enrolled in the Child Health Services Program (EPSDT). There may
				be benefit limits to individuals overage 21. Consult "Arkansas Medicaid, ARKids
				First & You, Arkansas Medicaid Beneficiary Handbook" (PUB-040) for specific
				information and covered services.
The Adult Expansion Group coverage for most individuals will be
				provided through a private insurance plan, i.e., a Qualified Health Plan (QHP).
				QHP coverage will include:
* Outpatient Services
* Emergency Services
* Hospitalization
* Maternity and Newborn Care
* Mental Health and Substance Abuse
* Prescription Drugs
* Rehabilitative and Habilitative Services
* Laboratory Services
* Preventive and Wellness Services and Chronic Disease
				Management
* Pediatric Services, including Dental and Vision Care
Exception:
Individuals eligible for
				the Adult Expansion Group who have health care needs that make coverage through
				a QHP impractical, overly complex, or would undermine continuity or
				effectiveness of care, will not enrol! in a private QHP plan but will remain in
				Medicaid.
A-105 Nondiscrimination
MS Manual 08/15/14
No person will be prevented from participating, denied
				benefits, or subjected to discrimination on the basis of race, color, national
				origin, age, religion, disability, sex, veteran status, or political
				affiliation. The Agency will be in compliance with the provisions of the Civil
				Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the
				Americans with Disabilities Act of 1990, and regulations issued by the
				Department of Health and Human Services.
The Agency has the responsibility for informing applicants and
				recipients that assistance is provided on a nondiscriminatory basis and that
				they may file a complaint with the Agency or federal government if it is
				thought that discrimination has occurred on the basis of race, color, national
				origin, sex, age, sexual orientation, gender Identity or disability.
A-110 Cost Sharing Coinsurance/Copayment
MS Manual 05/01/18
The types of cost sharing In the Medicaid Program are
				coinsurance, co-payment, deductibles and premiums. Medicaid recipients are
				responsible for paying a coinsurance amount equal to 10% of the per diem charge
				for the first Medicaid covered day per inpatient hospital admission. Medicaid
				recipients are also responsible far paying a copayment amount per prescription
				based on a graduated payment scale, not to exceed $3.00 per
				prescription.
The coinsurance and copayment policy does not apply to the
				to-towing tecipients and/or services:
1. Individuals under the age of 18 receiving
			 coverage through ARKids A orNewborn
2. Pregnant women
3. Individuals residing in a nursing or
			 ICF/IID {Intermediate Care Facilities/Individuals with Intellectual
			 Disabilities) facility who are approved for vendorpayment
4. Emergency services
5. Health Maintenance Organization (HMO)
			 enrollees
6. Services provided to
			 individuals receiving hospice care
7. Adult Expansion Group enrollees with
			 household income up to and including 100% of the FPL for their household size
			 are not required to pay co-pays or other cost-sharing.
A-115 Cost Sharing for Workers with Disabilities
MS Manual 08/15/14
Recipients of Medicaid for Workers with Disabilities with gross
				income under 100 percent (100%) of the Federal Poverty Level for their family
				size will be subject to the usual Medicaid co-pays. Recipients with gross
				income equal to or greater than 100 percent (100%) of the FPL will be assessed
				co-payments at the point of service for medical visits and prescription drugs
				according to the following schedule:
1.
			 Physician's visits - $10.00 per visit;
2. Prescription drugs - $10.00 for generic,
			 $15.00 for brand name;
3. Inpatient
			 Hospital - 25% of the first day's Medicaid per diem rate;
4. Orthotic appliances, prosthetic devices
			 and augmentative communication devices -10% of the Medicaid maximum allowable
			 amount,
5. Durable medical
			 equipment -20% of Medicaid maximum allowable amount peritem;
6. Occupational, physical and speech therapy,
			 & private duty nursing - $10.00 per visit, with a cap of $10.00 per day.
After certification, any increases in income that will cause
				the individual to exceed 100% of the FPL and possibly cause revision to the
				individual's cost sharing amount wilt not be processed until the next
				reevaluation. If the individual reports a decrease in income that puts him
				under
A-330 Adult Expansion Group Identification Cards
MS Manual 05/01/18
For those individuals who are enrolled in a Qualified Health
				Plan through auto assignment or by their own selection, an Identification card
				will be mailed directly to the individual by the insurance carrier. For those
				individuals who are enrolled in Medicaid through the Adult Expansion Group
tMS-C-150
). a Medicaid card will be mailed within 5
				business days of the individual being found eligible for traditional
				Medicaid.
A-340 Reissuance of Identification Cards
MS Manual 05/01/13
Replacement cards will be authorized through the system. The
				procedures are the same for SSI and non-SSI recipients.
1. Review recipient's case information in the
			 system to verify that correct information [e.g., name, date of birth, mailing
			 address, etc.) has been updated.
2.
			 Select the ID button on the Budget Summary and then check the "Replace" box by
			 the member(s) who needs the replacement card and then click the Save button.
If the recipient is SSI eligible, locate the SSI case number in
				the system. If there is no record of the case, or the SSI recipient is not
				receiving a check, refer him or her directly to the local SSA Office. If the
				SSI recipient has been approved for 30 days or less, inform him or her that it
				is too early to have received a Medicaid card. It takes Social Security 30 days
				or more from the date of approval to forward the eligibility date through
				SDX.
If the SSI case record is located on WA5M, but information on
				the record is incorrect (e.g., wrong address), the caseworker should contact
				System Support or Client Assistance for correction(s) to the case.
Note:
Adult Expansion Group recipients
				enrolled in a Qualified Health Plan will contact their insurance provider for
				answers to plan questions. Contact information will be printed on the insurance
				card and on the carrier information included with the card.
The purpose of this group is to provide pre-natal care to the
				unborn child who is expected to be born in the United States. As this coverage
				is intended to benefit unborn children who will be U.S. citizens at birth, the
				pregnant woman will not qualify for this coverage if she intends to leave the
				U.S. before *he baby is born.
This group is also different from the other Pregnant Women
				groups in that it receives an enhanced federal match rate under the Children's
				Health Insurance Program (CHIP). The CHIP enhanced funding coverage is
				available only to pregnant women who have no other insurance that covers
				pregnancy related services.
The non-citizen pregnant woman will receive postpartum
				coverage. Postpartum coverage is through the end of the month in which the
				60th day from the date of delivery falls.
B-260 Former Foster Care Adults
MS Manual 06/08/16
This group consists of adults up to age 26 who aged out of
				foster care in Arkansas. There is no income or resource test. Other than the
				general Medicaid eligibility requirements that all Medicaid eligibles must meet
(MS D-100
), the requirements for eligibility in this
				group are that the adult was in foster care in Arkansas, was enrolled in
				Medicaid when aging out of foster care at age 18-21 depending on the individual
				circumstances and is currently underage 26.
Individuals in this group receive the full range of Medicaid
				benefits.
B-270 Adult Expansion Group (Arkansas Works Program)
MS Manual 05/01/18
The Health Care Independence Program was amended to become the
				Arkansas Works Program starting January 1,2017. Throughout this policy manual
				the Arkansas Works Program will be referred to as the Adult Expansion
				Group.
This group consists of adults who are 19 through 64 years of
				age with household income equal to or below 133% {138% with 5% disregard
				applied) of the applicable federal poverty level (
MS
				E-110}
and are not eligible in either the Parents/Caretaker
				Relatives group (
MSB-230
) or Former Foster Care group
				(
MS B-260)
. Adults who are blind or who have a
				disability may be covered in this group unless they are determined eligible for
				coverage in another group on the basis of the need for long term care services
				(facility or waiver) or other disability related services.
A woman who is pregnant at the time of application cannot be
				included in this group until after the postpartum period. She must be enrolled
				in one of the pregnant women groups or in the parents/caretaker relatives group
				if eligible. However, a woman who becomes pregnant after enrolling in this
				adult group may remain in the adult group throughout her pregnancy.
Individuals eligible in this group will participate in the
				Arkansas Works Program authorized by the Arkansas Works Act of 2016 and its
				amendment in 2017, The Arkansas Works Program provides Medicaid funding in the
				form of premium assistance to enable individuals to enroll in private health
				insurance plans.
Exception:
Individuals eligible for
				the Adult Expansion Group, who have health care needs that make coverage
				through the Health Insurance Marketplace impractical, overly complex, or would
				undermine continuity or effectiveness of care, will not enroll in a private
				Qualified Health Plan (QHP) but will remain in Medicaid
				[Re.
MSA-100
1,
NOTE:
If an individual in this group
				has a child(ren) under age 18 living in the home, the child(ren) must be
				covered in Medicaid or have other health insurance coverage.
Unless exempt, all Arkansas Works enrollees between the ages of
				19 through 49 will be required to comply with the work and community engagement
				requirement for the Arkansas Works Program (Re.
MS F-200 and
				F-201
). All Arkansas Works Program recipients will be referred to
				the Arkansas Division of Workforce Services for free job assistance services to
				assist them in complying with the work and community engagement
				requirement.
NOTE:
Individuals enrolled in the
				Arkansas Works Program are required to have a valid email address.
Medical Services Policy Manual, Section D
D-500 Mandatory Assignment of Rights to Medical Support/Third
				Party Liabilities
MS Manual 05/01/18
As a condition of eligibility for Medicaid, recipients are
				required to assign their rights to Medical Support/Third Party Liability
				payments to the Department of Human Services. This means that any funds
				settlements or other payments made by or on behalf of third parties should be
				paid directly to the Arkansas Medicaid Program. In Arkansas, Third Party
				Liability payments are automatically assigned by state law.
The Medical Assistance Program ts required by Federal and State
				Regulations to utilize all Third Party sources and to seek reimbursement for
				services which have been paid by both a Third Party and Medicaid.
Private insurance and Medicaid are complementary. A recipient's
				Medicaid eligibility, except for an ARKids B recipient, is not affected by
				having Third Party coverage (
Re. M5 F-180
).
When a recipient has Third Party coverage in addition to
				Medicaid, which can be used for medical expenses, Third Party coverage must be
				utilized first. Medicaid will pay up to the Medicaid allowable charge. For
				example: A Medicaid recipient has insurance which paid 80%, or $80 of a $100
				medical bill. The Medicaid allowable charge for the bill was only $60.00. A
				Medicaid payment was not due since the Medicaid allowable charge was less than
				the insurance payment. Third Party sources whose payments Medicaid will
				retrieve include private health insurance, automobile liability insurance where
				applicable, workmen's compensation, settlements for injuries, etc.
Tri-Care is considered to be a Third Party source. Whenever a
				Tri-Care beneficiary is also eligible for Medicaid, Tri-Care is in every
				instance the primary payer. This applies to all classes of Tri-Care
				beneficiaries, i.e., dependents of active duty members, retirees, dependents of
				retirees, dependents of deceased active duty members, and dependents of
				deceased retirees.
V
Mote:
The Third Party Liability
				policy does not apply to individuals enrolled in a private Qualified Health
				Plan through the Adult Expansion Group, however Assignment of Rights to Medical
				Support does apply.
Medical Services Policy Manual, Section E
E-100
Financial Eligibility
MS Manual 10/26/15
Each individual applying for or receiving Medicaid benefits
				must have a financial eligibility determination made at application and, if
				eligible, on an on-going annual basis or when a change affecting eligibility
				occurs. Financial eligibility consists of an income test and if
				the-category requires, a resource or asset
				test.
Most Medicaid eligibility groups have an income limit which an
				individual's countable income must fall under in order to be eligible for
				coverage in that group. Income limits and the manner in which countable income
				is determined vary by eligibility groups. The groups to which an income limit
				does not apply, and therefore no income determination is made, are the
				following:
* Newborns
(MS B-220
):
Former Foster Care Adults
(MS
				B-2E0
):
* Workers with Disabilities
(MS
				B-330
).
*f NOTE: For the Workers with Disabilities category, before
				determining eligibility, the applicant must pass a pre-test screening to ensure
				his/her unearned income does not exceed the SSI individual benefit plus $20. If
				the applicant meets this criteria, all income is disregarded in the financial
				eligibility determination. However, both unearned and earned income will be
				used to determine cost sharing. See
MS A-115
.
A resource limit applies to most of the eligibility groups that
				do not use MAGI methodologies for financial eligibility. For these groups, the
				value of an individual's countable resources must be determined. There is no
				resource limit, and therefore no resource determination is made, for the
				following groups:
* Those using MAGI methodologies (
MS
				E-110)
:
* Newborns (
MS B-220J
;
* Former Foster Care Adults (
MS
				B-2601
;
* Workers with Disabilities (
MS
				B-330)
.
E-110
Income and Resource Limits for MAGI and Non-MAGI
				Groups
MS Manual 05/01/18
Below are the income and resource limits for all Medicaid
				groups. When the income limit is based on a percentage of the federal poverty
				level (FPl), the countable household income will be compared to the FPL for the
				applicable household size. Refer to
Append ices F and
				S
for the specific income level amounts.
Category
Income Limit
Resource
Limit
ARKidsA
142%
of FPL *
No Resource Test
ARKids B
211%
of FPL*
No Resource Test
Newborns
No Income Test
Eligibility is based on mother's
Medicaid eligibility at child's birth
No Resource Test
Pregnant Women:
Full Medicaid Pregnant Woman
1 person: $124.00
2 person: $220.00
3 person: $276.00
4 person: $334.00
5 person: $388.00
See Appendix F for household sizes over 5.
No Resource Test
Limited Medicaid Pregnant Woman
209% of FPL *
Unborn Child
209% of FPL*
Parent and Caretaker Relative
1 person: $124.00
2 person: $220.00
3 person: $276.00
4 person: $334.00
5 person: $388.00
See Appendix F for household sizes over 5.
No Resource Test
Adult Expansion Group
133% of FPL *
No Resource Test
Medically Needy:
Exceptional (EC)
EC - may not exceed the monthly income limit
SD - may exceed the quarterly income limit
See MS 0-710 for the monthly and quarterly income
						  limit
1 person: $2,000
2 person: $3,000
3 person: $3,100
Spend Down (SD)
TEFRA
3 times the SSI Payment Standard Appendix S
$2000
Autism
3 times the SSI Payment Standard Appendix S
$2000
Long-Term Services
&.
Supports:
3 times the SSI Payment Standard
Individual $2000
Nursing Facility, DDS, ARChoices,' Assisted Living and
						  PACE
Appendix S
Couple $3000
Medicare Savings:
ARSeniors
QMB
5MB
OJ-1
QDWI
Equal to or below 80% FPL
100% FPL
Between 100% & 120% FPL
120% but less than 135% FPL
200% FPL
ADDendix F
ARSeniors, QMB, SMB&QI-l: Individual $7,560 Couple
						  $11,340
QDWI:
Individual $4000 Couple $6000
Workers with Disabilities
Unearned income may not exceed SSI individual benefit
						  plus $20
No resource test
PICKLE
Under the current SSI/SPA level Appendix S
Individual $2000
Widows & Widowers with a Disability (COBRA and OBRA
						  '87)
Under the current SSI/SPA level Appendix S
Individual $2000
Widows & Widowers with a Disability and Surviving
						  Divorced Spouses with a Disability (OBRA '90)
Under the current SSt/SPA level Appendix S
Individual $2000
Disabled Adult Child (DAC)
Under the current SSI/SPA level Appendix S
Individual $2000
*May be eligible
for
an additional
5%
disregard, MS E-26S.
E 200 Determining Financial Eligibility Under the MAGI
				Methodology used to determine the monthly income. If the most recent tax data
				is not available or does not reflect current income, the individual's income
				will be determined by other means as determined appropriate by the caseworker,
				such as sales receipts, business records, etc.
Costs directly related to producing the income are subtracted
				from the self-employment annual gross before the monthly earnings are included
				in the budget. See Schedule C in
Appendix Q
for all
				allowable costs associated with self-employment income.
After allowable deductions from annual income, the remainder is
				then divided by 12 to determine the monthly income.
E-267 Comparing Income to Income Standard for Appropriate
				Household Size
MS Manual 01/01/14
After the Medicaid household composition, size and countable
				current income have been established, the Medicaid household's countable income
				will be compared to the household size income standard for the appropriate
				eligibility group to determine whether an individual is income eligible. Income
				eligibility wilt first be determined in the eligibility group the individual
				falls into with the lowest income standard, e.g., eligibility for a parent
				would first be determined in the Parent/Caretaker Relative group before a group
				with a higher income standard.
E-268 The 5% Gross Income Disregard
MS Manual 05/01/18
Each individual will be allowed a general gross income
				disregard in the amount of 5% of the Federal Poverty Level for the household
				size.
The five percent (5%) disregard will be applied only to the
				Families and Individuals category that has the highest income level in which an
				individual could be eligible. For example, if an individual is not income
				eligible in the lowest income level group (eg., Parents/Caretaker Relatives),
				the five (5%) disregard will be applied to the higher income group (e.g., Adult
				Expansion Group). However, if the individual is eligible in the higher income
				group without applying the five percent (5%) disregard, the disregard will not
				be applied.
When applied, the 5% disregard effectively raises the income
				limits for the applicable eligibility group by five (5) percentage points. For
				example, the income limit for the Adult Expansion Group rs 133%
				(
MSE-110)
. To apply the 5% disregard, add 5% to 133%
				to raise the income limit to 138% of FPL. The eligibility groups with dollar
				amounts for income limits are not the highest income limit groups for the
				individuals that fall into them. Therefore, the 5% disregard will never be
				applied to the dollar amount income limits.
Application of the 5% Disregard in the ARKids First
				eroups
The 5% disregard is applied to the ARKids A income limit only
				if the child who would otherwise be ineligible without the disregard is covered
				by a health insurance plan. Since eligibility tn ARKids B is not available to a
				child with health insurance, ARKids A is the eligibility group with the highest
				income limit available to an insured child and therefore, the 5% disregard can
				be allowed.
The 5% disregard is not applied to the ARKids A income limit if
				the child is uninsured and ineligible for ARKids A without application of the
				disregard. ARKids B is the eligibility group with the highest income limit for
				uninsured children and therefore, the 5% disregard ts applied only if needed to
				achieve ARKids B eligibility.
Refer to
MS F-180
for exceptions to
				health insurance coverage for ARKids B eligibles.
E-269 Who Is Eligible-Example Scenario
MS Manual
				05/01/18
Continuing the example of Bertha, Audrey and Chloe to show
				whose income will be counted and who is eligible for Medicaid.
Bertha and Audrey's household are the same which includes
				Bertha, Audrey & Chloe.
[GREATER THAN] Bertha earns $8,000.00 per month, which equals
				$96,000 annually.
[GREATER THAN] Audrey earns $314.22 per month, which equals
				$3,770.64 annually.
[GREATER THAN] Audrey is the child and tax dependent of Bertha.
				Audrey is not required to file taxes; therefore, her income does not count.
				Bertha's income is counted.
[GREATER THAN]
Bertha's household size is
				3.
[GREATER THAN]
Compare the $8,000 00 monthly
				income to the 133% + 5% = 138% standard for a household size of 3,
				$1,345.96.
[GREATER THAN] Bertha and Audrey are not eligible for Medicaid;
				therefore, the agency will electronically transfer their account to the FFM for
				possible eligibility for Advanced Premium Tax Credits and cost sharing
				reductions.
Chloe's household includes Chloe and her mother, Audrey.
[GREATER THAN]
Audrey earns $314.22 per month,
				which equals $3,770.64 annually. Audrey's income will be counted because
				neither her mother, nor father is included in this household. Chloe's child
				support income is disregarded.
[GREATER THAN] Chloe's household size is 2.
[GREATER THAN] Compare the $314.22 monthly income to the ARKids
				A standard of 142% for 2, $1,948.24.
Note:
The 5%
				disregard was not needed for ARKids A eligibility and therefore was not
				applied.
[GREATER THAN]
Chloe is eligible for ARKids
				A.
Medical Services Policy manual, Section F
F-200 Work and Community Engagement Requirement for the Adult
				Expansion Group
MS Manual 05/01/18
The Arkansas Works Program requires certain recipients of the
				Adult Expansion Group to meet the requirement of working 80 hours or more per
				month. Unless exempt, Adult Expansion Group recipients are ineligible to
				receive Medicaid benefits if, during any 3 months of the calendar year, they
				failed to meet the work and community engagement requirement. Adult Expansion
				Group recipients will fait in one of five categories for the work and community
				engagement requirement:
1. Enrollees
			 age 50 or older-Work and community engagement requirement does not apply for
			 this age group;
2. Enrollees age
			 19-49 that are employed or self-employed at least 80 hours per month on an
			 ongoing basis - Exempt from the work and community engagement
			 requirement;
3. Enrollees age 19-49
			 that are employed or self-employed on a one-time, not ongoing monthly basis -
			 Complying with the work and community engagement requirement;
4. Enrollees age 19-49 that are not employed
			 or self-employed at least 80 hours per month but meet an exemption to the work
			 and community engagement requirement. Exemptions are:
a. Currently receiving an exemption to the
			 SNAP Requirement to Work;
b.
			 Receiving TEA Cash assistance;
c.
			 Receiving unemployment benefits;
d.
			 Has been determined medically frail;
e. Caring for an incapacitated
			 person;
f. Living in home with a
			 dependent minor;
g. Being
			 pregnant;
h. Experiencing a
			 short-term incapacitation; is medically certified as physically or mentally
			 unfit for employment; or has an acute medical condition validated by a medicat
			 professional that would prevent complying with the requirements,
i. Participating in an alcohol or drug
			 treatment program; or
j. Enrolled
			 in full-time education, job training or vocational training;