Child Health Assurance Program (CHAP)

Transcription

1 Child Health Assurance Program (CHAP) 300 THE CHAP provides medical assistance to children under the age of 19 and pregnant women. 315 ELIGIBLE CATEGORIES - PREGNANT WOMEN AND CHILDREN Pregnant Women Description Two categories of pregnant women may be eligible for CHAP. One category is eligible for all Medicaid covered services and one is only eligible for pregnancy-related services. The categories are Pregnant women with countable income below the TANF limits, and pregnant minors with countable income below the 100% poverty limits are eligible for all Medicaid services. Pregnant women with income over the TANF limits but equal to or below 133% of the poverty level are eligible for pregnancy-related services only, including postpartum services. Note: Pregnancy-related and postpartum services are those medically necessary Medicaid services, including family planning, provided to a pregnant woman which promotes her systemic well-being. MAPS Nov 01 MTL 10/06 The Child Health Assurance Program (CHAP)

2 315.2 Verification Pregnancy must be verified in writing, with the verification provided by a qualified medical professional. Once verified, eligibility begins the month of application (or up to three months prior to the month of application when prior medical coverage is requested) provided applicant was pregnant at the time and all other eligibility requirements are met Eligibility Women who, while pregnant, apply for and are eligible for medical assistance are eligible for pregnancy-related medical and postpartum services. Postpartum services are provided for two months following the child s birth month. Pregnant women must apply for assistance while pregnant to receive postpartum services. An eligible Medicaid woman who becomes pregnant is considered to have applied for assistance while pregnant and is eligible for postpartum services. Once initial eligibility is established, a pregnant woman remains eligible for pregnancyrelated medical coverage throughout the pregnancy and postpartum period regardless of changes in countable income. The pregnant woman must still meet residency requirements. Example: A pregnant woman applies for medical assistance in April. In May, Medicaid is approved effective April. In June, the woman reports an increase in income. If the income results in ineligibility, the woman will remain eligible for pregnancy-related services throughout her pregnancy and postpartum period. Example: A pregnant woman applies for medical assistance in July. She is not eligible in July due to excess income. However, she applied for medical assistance while pregnant, is under the income limits and meets all other prior medical eligibility for May. She is eligible for pregnancy-related services effective May and throughout her pregnancy. She is eligible for postpartum services once the baby is born. Example: In November, a woman applies for medical assistance to cover pregnancy related services and the birth of her baby in September. She may be eligible for Medicaid in September and ongoing. However, she is not eligible for postpartum services, as she did not apply while pregnant. If the assistance unit becomes ineligible due to excess income, the pregnant woman s eligibility is reduced to pregnancy-related services only. The assistance unit is notified of the termination of Medicaid for other household members and of the continuing Medicaid eligibility of the pregnant woman. MAPS Verification MTL 10/06 01 Nov 10

3 Once a woman is reduced to pregnancy-related services, due to excess income, a review of eligibility is not required during the remainder of her pregnancy and post partum period. At the end of the post partum period, assistance is terminated for the woman, and only the newborn remains eligible under OBRA (see MAPS 515). Examples: 1. A pregnant woman receiving assistance with other dependent children reports income which makes the assistance unit ineligible. The assistance unit is notified of the termination of the children s Medicaid and the change in the pregnant woman s Medicaid coverage to pregnancy-related and postpartum medical services. 2. A pregnant woman receiving assistance with other dependent children all move together out of state. The assistance unit is no longer eligible due to loss of residency. 3. A pregnant woman receiving pregnancy-related Medicaid moves out of state. The pregnant woman is no longer eligible due to loss of residency. When the child is born, evaluate for newborn (OBRA) coverage and notify the mother of the newborn s eligibility and when her postpartum coverage ends. Postpartum coverage ends the last day of the second month immediately following the month the pregnancy ended. Example: If the pregnancy ends June 3rd the postpartum period ends the last day of August. 320 CHILDREN Description Children under the age of 19 who are 1. Age six (6) or older with income above TANF limits but equal to or below 100% of poverty are eligible. Note: These children are ineligible upon reaching age nineteen. However, if the child is in a medical facility when they reach the maximum age, the child remains eligible for Medicaid until discharge. OR 2. Under age six (6) with income above TANF limits but equal to or below 133% of poverty. Note: These children are only eligible upon reaching age six if their income is below 100% of poverty. However, if the child is in a medical facility when they reach the maximum age, the child remains eligible for Medicaid until discharge. Eligible children receive full Medicaid service. Income eligibility for the pregnant woman and children may be determined separately based on the household composition. See MAPS to determine whose income is counted towards the pregnant woman and children. MAPS Nov 01 MTL 10/06 Eligibility

4 320.1 Nevada Check Up Referrals for Children Ineligible for Medicaid Children ineligible for Medicaid due to income requirements may be eligible for the Nevada Check Up Program. Cases denied or terminated for Division of Welfare and Supportive Services medical programs are screened and electronically referred to Nevada Check Up for eligibility consideration. The Nevada Check Up Program provides low-cost, comprehensive health care coverage to uninsured children 0-18 years of age who are not covered by private insurance or Medicaid. It is possible for one child in a household to be covered by Medicaid, while another child in the same household is eligible for Nevada Check Up. Example: A household s income may fall between the 100% and 133% of poverty income range. Children under the age of six would be eligible for Medicaid, while those over the age of six would be ineligible for Medicaid. The older children may be eligible for Nevada Check Up and must be referred to the program CHAP Referrals from Nevada Check-Up Nevada Check-Up applicants are screened for Medicaid eligibility prior to approval. Applicants identified as potentially eligible for CHAP are referred to DWSS by the Division of Health Care Financing and Policy (DHCFP). Nevada Check-Up referrals are sent to the Carson City district office for processing if the household has no open case and to the appropriate district office if an open case exists. Nevada Check-Up referrals are treated as an application for CHAP if there is no open medical case, or as a request to add child(ren) if the household has an open medical case. Application date is the date the district office receives the referral. Households must complete and sign form 2902-EG, CHAP Addendum and provide all other necessary verifications for a CHAP eligibility determination. 321 CHAP APPLICATION Application Follow application procedures in manual section A-100 for pregnant women and children applying for CHAP. A face-to-face interview is not required for Medicaid. If an interview is not requested by the client or the client fails to keep an interview appointment, request verification for Medicaid applications and/or review of eligibility in writing through the mail allowing ten (10) days for submitting the specified information. MAPS Nevada Check Up Referrals for Children Ineligible for Medicaid MTL 10/06 01 Nov 10

5 322 DISPOSITION When processing applications, determine eligibility for each month using the policy in effect for that month. Assistance unit groups may be eligible for some months and ineligible for others. Approval - assistance is approved when eligibility requirements are met. Withdrawal - applications are withdrawn when the applicant or representative requests withdrawal. Denial - assistance is denied when: - written information which indicates ineligibility is provided by the applicant; or - verification is received through any other source; or - information essential in determining eligibility is not provided; or - the division loses contact with the applicant before eligibility is determined. Reinstatement - reinstatements are made at the discretion of the office manager or supervisor. Send a Notice of Decision to the applicant and the authorized representative. The notice(s) advises the household: the reason the application was denied, or benefits were reduced, terminated or reinstated. the effective date of denial or benefit reduction, termination or reinstatement. the right to appeal, and available free legal representation. If the household is eligible, the notice advises them: the date benefits begin, amount and type of benefits, who is eligible, the right to appeal, and where free legal assistance is available. Note: Households in which the only approved individual is a pregnant woman should be approved for CHAP eligibility. The case manager should future action the case to process a REHA and evaluate under TANF Related Medicaid (TRM) in the sixth month of pregnancy. NOTE: Household s, applying for TRM who are ineligible due to excess income in the initial month but eligible for CHAP (through the trickle down process in NOMADS) whose income decreased in the second month and are eligible for TRM ongoing are not required to complete a new application for assistance. 323 PROCESSING LIMITS Eligibility must be determined and the household notified within 45 days from application unless unusual circumstances exist. The reason for the delay must be documented. In addition, if there is a legal guardian or authorized representative they are also notified. MAPS Jul 01 MTL 12/04 Disposition

6 324 SNAP JOINT PROCESSING These applicants are not entitled to joint processing and are not categorically eligible. 325 NON-FINANCIAL REQUIREMENTS Identity: Verify identity through sources such as, birth records, other public agency or school records, etc. 326 ASSISTANCE UNIT/GROUP COMPOSITION The following are examples of assistance unit compositions and are not all inclusive. 1. A pregnant woman with no other children is an assistance unit group. 2. A pregnant woman with one or more of her own natural or adoptive children are included in the same assistance unit group. 3. A pregnant woman with children who are not natural or adoptive are separate assistance unit groups. 4. An individual child is a single assistance unit group. 5. A married woman, under the age of 19, with one or more of her own natural children, is included in the same assistance unit group. 6. Two or more children who are not siblings are separate assistance groups. 7. Two or more sibling children, one of whom is pregnant. (The appropriate poverty level must be used to determine eligibility, based on age or pregnancy. The needs of the unborn would also be considered in determining the eligibility of the pregnant child.) 327 CITIZENSHIP Follow TANF citizenship requirements in A-400. An individual must be a U.S. citizen or an eligible non-citizen legally admitted to the U.S. in one of the eligible categories in manual section A-400. Non-citizens not admitted in this manner are ineligible. However, these persons may be eligible for Emergency Medical Assistance (EM). Documentation of citizenship and identity must be received on all household members whose income or needs are used in the CHAP determination. MAPS-324 SNAP Joint Processing MTL 12/04 12 Jul 01

7 328 AGE/RELATIONSHIP A pregnant woman may be eligible as: an adult on their own case; or a dependent child if living with her parent(s) and still a minor or a minor (under 18 years of age) on their own case, if not living with her parent(s). Update the case to an adult case status the month following a pregnant child s 18 th birthday. However, if an 18 year old is living with her parent(s) after the birth of her child, even though she is no longer a minor, she remains a dependent child under CHAP criteria until reaching age 19. To be eligible for CHAP, a child may live with one or both parents; live with a husband; live with a relative; or live with a person who is not a relative (e.g.; friend/neighbor). Relationship is not a requirement for CHAP. 329 RESIDENCE/DOMICILE If the children reside equally with both parents at separate addresses, the parent applying for assistance, must sign the application for medical assistance, rights and obligations, and other forms. Budget income from the parent requesting assistance to determine CHAP eligibility. The parent requesting assistance is responsible for reporting changes. Children may be out of the home (i.e., hospitalization, rehabilitation facility), as long as the parent/caretaker relative maintains a home for them. Children must be residents of Nevada. See residency requirements in manual section A-900. Verify household composition for children in the budget. 330 SOCIAL SECURITY NUMBER Pregnant women and/or children in the assistance unit group must meet Social Security enumeration requirements, with the exception of OBRA babies during the first year of deemed eligible. Follow TANF policies and procedures in manual section A FINANCIAL MANAGEMENT Follow TANF policies and procedures in manual section A-1400 for exploring financial management. MAPS Jul 01 MTL 12/04 Age/Relationship

8 332 MEDICAID ELIGIBILITY 1. Medicaid eligibility begins the first day of the first eligible month. 2. Prior Medicaid eligibility (up to three months prior to Medicaid application month) can begin the first day of the month or months the assistance unit group has evidence medical services were provided in the month(s) for which Medicaid is requested, and meets all eligibility criteria. Women found eligible for Medicaid while pregnant in a prior medical month remain eligible for pregnancy-related and postpartum medical coverage throughout the pregnancy and postpartum period even if they are ineligible due to excess income in the month of application. Pregnant women must apply for assistance while pregnant or be Medicaid eligible at the time pregnancy occurs to receive postpartum services. Newborns are eligible for one year from the month of birth when born in a prior medical month in which the mother was determined eligible. 3. Newborns are eligible for one year from the month of birth when born in a month in which the mother was determined eligible. Newborns being adopted, pending adoption or pending relinquishment are deemed eligible for the birth month if born to an eligible Medicaid mother whether or not they go home with the birth mother. The newborn is deemed to have filed a Medicaid application through the birth mother. Once the birth mother legally relinquishes control or the child is released from the hospital to someone else s care, reevaluate eligibility for future months based on the child s change of circumstances Inmates of Public or Penal Institutions An inmate of a public institution is ineligible for Medicaid, UNLESS the institution is a medical institution. An inmate of a penal institution is never eligible for Medicaid while in the custody of law enforcement officials, UNLESS admitted as an inpatient to a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility. This individual is eligible for Medicaid and any Medicaid covered services provided to them while an inpatient in these facilities as long as all other eligibility criteria is met. Maps-332 Medicaid Eligibility MTL 12/04 12 Jul 01

9 333 MEDICAID HEALTH CARE CHOICES Refer to manual section M-100 for health care options available to Nevada Medicaid CHAP recipients. 334 THIRD PARTY LIABILITY (TPL) Follow TANF policies and procedures for TPL requirements. 335 EDUCATIONAL LEVEL There are no requirements to provide educational level; however, the information should be obtained when available. 336 CHILD SUPPORT ENFORCEMENT PROGRAM REQUIREMENTS Follow TANF policies and procedures except for the following: Do not require the client to remit child support payments received. The Medicaid only client may refuse support services and still receive medical assistance for a CHAP child or pregnancy. Note: Pregnant women who fail to cooperate with the Child Support Enforcement Program (CSEP) for the unborn or other children receiving CHAP assistance are eligible only for pregnancy-related medical services. Do not obtain or send the Non-Custodial Parent (NCP) Form 2906-EG for children who reside with both parents. 337 FINANCIAL REQUIREMENTS - RESOURCES There is no resource test for households applying for CHAP. All CHAP assistance unit groups must still report their resources; however, there is no requirement to obtain verification of the value of a household s resources for determining eligibility for CHAP. If the client provides verification of their resources, document the case based on the verifications provided. However, the client s statement is acceptable. DO NOT pend the client for verification of resources. MAPS May 01 MTL 09/03 Medicaid Health Care Choices

10 Countable resources are entered in the system only for the purpose of identifying households that are determined eligible solely due to the elimination of the CHAP asset test. Follow TANF rules in manual section A-500 to determine countable resources. NOMADS will evaluate the case applying the resource test solely for the purpose of tracking the number of households made eligible for Medicaid as a result of eliminating the asset test. This information has a direct impact on the level of funding received from the federal government. The system will make a final determination for CHAP excluding the resources. 338 FINANCIAL REQUIREMENTS - INCOME Income Evaluation 1. Use TANF definitions of countable and exempt income with the following exceptions. Count TANF payments as income. Exception: A returned out-of-state TANF check is not budgeted, whether or not correctly paid. 2. Use TANF budgeting policies and procedures. CHAP applicants must be required to pursue all sources of available income, except as provided for in manual section A Disregards are allowed if the wage earner is entitled to the deductions Budgeting 1. Pregnant Women Income from the following sources is used in determining eligibility for a pregnant woman. Income of the pregnant woman for whom assistance is requested; and Income of the pregnant woman's spouse living in the home. If he is a stepparent of the unborn, his income is not used to determine the child's eligibility, once born. If the spouse is an ineligible or undocumented noncitizen, their income is budgeted but their needs are not included and earned income deductions are not allowed; and If any blood related or adoptive dependent children of the pregnant woman living in the home have income, determine eligibility using MAPS-600, Sneede v. Kizer policy. If the pregnant woman is a minor living with her parent(s), the parents income and needs are included when determining eligibility. Budget the income of both the pregnant woman and her parents and compare the net income to the poverty level. MAPS-337 Financial Requirements Resources MTL 09/03 01 May 09

11 2. Children Under the Age of 19 Income from the following sources is used to determine eligibility for children under the age of 19. Income of natural/adoptive parent(s) living in the home. If the parent is an ineligible or undocumented non-citizen, their income is budgeted; however, do not include their needs or allow earned income deductions; If the children reside equally with both parents at separate addresses, income from the parent requesting assistance must be budgeted to determine CHAP eligibility. Income of the child s spouse living in the home. If the spouse is an ineligible or undocumented non-citizen, their income is budgeted; however, do not include their needs or allow earned income deductions; Income of the child, if the child is the only one being applied for. If any blood-related or adoptive brothers and sisters of a child being applied for who are dependent children living in the home have income, regardless of citizenship status, determine eligibility using manual section MAPS-600, Sneede v. Kizer policy Best Estimate Eligibility is determined using the best estimate of income and expenses Overpayments Medicaid overpayments caused by the clients or their representative must be calculated for each month the recipient was determined to be ineligible. Do not calculate agency error overpayments. Overpayments associated with the best estimate policy are classified as "agency errors." See manual section F for additional information. MAPS May 01 MTL 13/03 Budgeting

12 338.5 Income Limits Net countable income may not exceed the following limits for the applicable household size. Household Size 7/1/07 TANF Limits 100% of Poverty 4/13 133% of Poverty 4/13 1 $253 $ 958 $1, $1,293 $1, $1,628 $2, $1,963 $2, $2,298 $3, $2,633 $3, $2,968 $3,947 8* 708 $3,303 $4,392 *Add $65 for each additional person (TANF Limits). *Add $335 for each additional person (100% of poverty). *Add $445 for each additional person (133% of poverty). Note: The 100% of poverty income figures are rounded to the nearest dollar. The 133% of poverty figures were determined using 100% of poverty and then rounded to the nearest dollar. 339 FINANCIAL DETERMINATION Pregnant Women The needs of the following individuals are included in the financial determination (do not include the needs of persons receiving SSI): The pregnant woman for whom assistance is requested; and Each unborn of the pregnant woman (the pregnant woman and the unborn are two persons or, if she is carrying twins, three persons, etc.); and The spouse of the pregnant woman living in the home. Exception: Ineligible non-citizen spouse s needs are not included although their income is countable. MAPS Income Limits MTL 13/03 13 May 01

13 The blood-related or adoptive siblings of the unborn who are themselves dependent children living in the home regardless of citizenship status. The responsible parent(s) living in the home when the pregnant woman is age 17 or younger and the needs of any dependent siblings of the minor mother living in the home. Income of the dependent siblings is excluded Children Under the Age of 19 The following individual's needs are included when determining eligibility (do not include persons receiving SSI): The child for whom assistance is requested; and The natural/adoptive parents of the child living in the home. (Do not count the needs of a stepparent.) The spouse of a married minor for whom assistance is requested, if living in the home. Exception: Ineligible non-citizen parent's or spouse s needs are not included although their income is countable. The blood-related or adoptive siblings of the child who are themselves dependent children living in the home regardless of citizenship status. Note: The needs of each unborn of a pregnant woman are not included in determining eligibility of children under the age of 19. In cases where a pregnant woman is applying for herself and a child under the age of 19, two determinations are made. 1. One for the child excluding the needs of the unborn(s), and 2. One for the pregnant woman including the needs of the unborn(s). 340 BUDGET COMPLETION A CHAP budget is completed when: evaluating Medicaid eligibility for pregnant women and children who have been determined ineligible for cash benefits, or evaluating eligibility for pregnant women and children who have applied only for CHAP benefits. MAPS May 01 MTL 09/03 Pregnant Women

14 340.1 Eligibility Determination Pregnant women and children under age six are eligible if the total net income is equal to or below 133% of poverty. If the total net income is equal to or below the 133% poverty level but exceeds the TANF payment allowance, a pregnant woman will be eligible for pregnancy-related medical benefits. If the total net income is under the TANF payment allowance, a pregnant woman will be eligible for full medical benefits. (The net income will always be under 133% of poverty level in this instance.) Children age six or older, under the age of 19, are eligible if the total net income is equal to or below 100% of poverty. 350 CHAP EARNED INCOME DISREGARDS An individual is eligible for the earned income disregard if: The net income is less than the appropriate 100/133% poverty level (compared to the size of the household whose needs are included); and They are a citizen or eligible non-citizen who is a: - a pregnant woman eligible to receive CHAP assistance, or - a spouse of a pregnant woman or child eligible to receive CHAP, or - a (natural/adoptive) parent of a child eligible to receive CHAP, or - a child eligible to receive CHAP; and The disregard has not previously been allowed up to two times under applicable medical categories (TRM, CHAP). An individual will remain eligible to receive the earned income disregard for CHAP if they are sanctioned for noncompliance with the terms of their Agreement of Cooperation or Personal Responsibility Plan (PRP), or disqualified for an intentional program violation (IPV). MAPS Eligibility Determination MTL 09/03 01 May 09

15 Note: When a CHAP family requests an eligibility determination (upgrade) under another Medicaid category, the adult(s) in the household must meet applicable income tests. When a case closes due to the end of OBRA and the family applies for CHAP, the earned income disregards are not automatically applied. The household must meet applicable income tests Applying the Disregard If a member is eligible for the earned income disregard, apply the disregard effective the first medical month. If the individual is not eligible for the earned income disregard during the initial eligibility determination or exhausts the disregard, apply the work-related expense deduction. (See manual section A-620.1) Application of the earned income disregard will not allow a child who was ineligible for CHAP during the initial eligibility determination to become eligible. Example: A household consisting of a pregnant woman and an 8-year-old child has income less than the 133% poverty level, but greater than the 100% poverty level, making the 8-year-old child ineligible for CHAP. When the earned income disregard is applied the first medical month, the 8-year-old child will not become CHAP eligible. Refer to manual section A for additional information on applying, tracking and removing the earned income disregard. MAPS May 09 MTL 09/03 CHAP Earned Income Disregards