Missouri TANF/Medicaid Eligibility Review Conducted September 1999

Missouri TANF/Medicaid Eligibility Review Conducted September 1999 I. INTRODUCTION The HCFA Regional Offices (ROs), in collaboration with various other Department of Health and Human Services (DHHS) agencies, have conducted reviews of State Medicaid eligibility and enrollment processes. The primary area of inquiry was the implementation of the delinking of the Temporary Assistance to Needy program (TANF) from the Medicaid program. The review protocol contained seven core areas: eligibility and enrollment, maintaining coverage for families leaving Medicaid, reaching families outside of Medicaid, Child Health Insurance Program, administration and efficiency, and computer systems. Federal representatives conducted an on-site review of certain aspects of the Missouri (MO) Medicaid program the week of September 20, 1999. The review team consisted of Federal Health Care Financing Administration (HCFA), Administration for Children and Families (ACF) and Office for Civil Rights (OCR) staffs. This report contains information gathered through review of the State s documents, policies and procedures, case reviews and discussions with State Medicaid and Division of Family Services representatives as well as consumer advocates. Subsequent to the review, State and local advocacy groups were given the opportunity to comment on the review team s findings. This report may reflect these comments in whole or in part as well as information that updates the findings to reflect actions the State has taken since the review. I. Description of the Review Process The Missouri (MO) TANF/Medicaid eligibility review team was comprised of six staff. There were four HCFA Regional Office staff and a representative from both the Office of Civil Rights (OCR) and the Administration for Children and Families (ACF). The team visited the Single State Agency, the Missouri Department of Social Services (DSS), on September 20-21, 1999, to discuss the issues reflected in the HCFA Review Protocol Guide. Over the course of the next three days, September 22-24, 1999, the six-member team split into Team A and Team B. Both teams A and B interviewed county Income Maintenance (IM) staff and reviewed a sample of approximately 38 cases from each county office. The cases were identified for selection by the State and were pulled from each county s universe of active and closed TANF and active and closed Medicaid and SSI related cases. A sample of individuals whose SSI was closed but were entitled to section 4913 mo14.doc- final report 1

protection and were receiving Medicaid were pulled. There were no closed section 4913 cases in the sample reviewed. At the time of this review, September 1999, there were 13,449 Medical Assistance for Families (MAF) cases Medicaid only, no cash, for parents, and 21,502 MAF cases- Medicaid only, no cash, for children. The selection of the six counties sampled was based on the counties with the highest percentage of TANF case closures. County selection was also based on the county s geographical proximity to other potential counties of selection. This helped to plan travel in a more time efficient and cost effective manner. The overall focus of the case file reviews was to determine if families had been offered and/or provided Medicaid. Special focus was on those families denied or terminated from TANF and/or Medicaid. Further discussion of the cases reviewed can be found in Section III. The State s comments to the initial draft report are incorporated throughout the body of the report and in the Areas of Concern section of the report. Additionally, advocates comments regarding the State s operation of the Medicaid Program were provided during the initial September 1999 review and are found in Section V. Comments from Local Organizations and throughout the body of the report. Advocates were also provided an opportunity to review the draft report containing comments and corrective actions supplied by the State. Comments from Legal Services of Eastern Missouri, Inc. were submitted in October 2000 and those that are relevant to the report s Areas of Concern are reflected in the body of the report, primarily in Section IX. Follow-up: Areas of Concern. II. Background The MO Department of Social Services has under its administrative purview both the Medicaid and the TANF Programs. The Medicaid Program is administered statewide and is under State supervision. County office caseworkers (also called Income Maintenance (IM) workers), accept and process various types of applications, including TANF, Medicaid, childcare, food stamps, general assistance and state supplements for the aged, blind, and disabled. Caseload size is based on the number of families or individuals applying or determined eligible for benefits. The mix of programs in a worker s caseload also affects the caseload size. Those with TANF cases carry a smaller caseload due to the amount of work this type of case typically requires. Typically IM workers with family caseloads are responsible for the processing of all programs (TANF, Medicaid, Food Stamps, childcare, etc.) related to the family unit. County offices decide if their caseloads will be generic or dedicated as far as caseload mix. The type of cases carried by a worker, adult versus family, does mo14.doc- final report 2

affect the number of cases in a caseload, although workers typically carry around 250 cases at a time. County office staff supplied this information. MO State Child Health Insurance Program (SCHIP) is a Medicaid expansion administered under the authority of the DHHS 1115 demonstration waiver. The State elected to call all of its Medicaid programs for families MC+ (children, parents, pregnant women). This includes individuals eligible under regular Medicaid and those eligible under the 1115 waiver expansion. Previously, the State had used MC+ as the name for their Medicaid managed care program. Outreach materials refer to the SCHIP group as MC+ for Kids. MO was approved in 1998 for the 1115 demonstration waiver expanding Medicaid eligibility to a larger group of individuals than routinely was covered under the regular Medicaid Program. Specifically, this waiver permits children up to 300% of the Federal Poverty Level (FPL) starting in September 1998, to receive identical Medicaid benefits, excluding only Non-Emergency Medical Transportation services. Five new groups of adults were also added by the 1115 waiver: custodial parents, noncustodial parents (those with current child support and those participating successfully in a specific work/training program), those transitioning off of Transitional Medical Assistance (TMA), and pregnant women exhausting their 60 days postpartum care. Not all regions of the State have enrolled managed care organizaions; therefore, certain regions of the State are only fee-for-service. Under the SCHIP, a Medicaid 1115 expansion, a child receives Medicaid State Plan services except for Non-Emergency Medical Transportation (NEMT) and may have to pay a premium or cost sharing. Payment of cost sharing or a premium is based on the Federal poverty level (FPL) of the family. State Agency staff indicated that under the Medicaid Program MO also covers unemployed parent families with a less restrictive definition of what constitutes unemployed and offers presumptive Medicaid for pregnant women. State Agency staff stated that there are more than 150 providers that participate in presumptive eligibility determinations. Currently MO does not elect to provide family coverage under SCHIP. MO has a Health Insurance Premium Payment (HIPP) program that covers both Medicaid and SCHIP eligibles. The HIPP program allows a State to pay the private health insurance premium for a recipient and or family eligible for Medicaid or SCHIP. This is permitted if the cost of this health insurance premium is determined to be more cost effective than providing Medicaid coverage. mo14.doc- final report 3

III. Analysis of Documentation and Case Reviews Approximately 38 case files per county were reviewed. The content of the case files varied little from county to county. Specific sections were designated for the Income Maintenance case file: for TANF and Medicaid, for Child Support Enforcement, for Food Stamp, for Child Care, and often a Services section. From our review there were a number of cases closed for a recipient s refusal to cooperate. A refusal to cooperate could be the result of a recipient s failure to provide income and or resource data, a required SSN, or information on living arrangements for those included in the assistance group. From the content of certain files reviewed, it was not possible for the review team to ascertain the exact nature of the refusal to cooperate and whether families had been terminated or denied Medicaid correctly. However, there were no case files reviewed by the team that provided evidence of incorrect determinations. The opinion of the advocate community is that the extensive use of refusal to cooperate could be affecting the quality of closings and terminations. The State is aware of the issues surrounding refusal to cooperate. The State has taken actions to educate staff to these issues. The State has developed a two step review process to be used for TANF/1931 cases that are potential closures. This process was begun July 1999. If the client does not return the required information for the TANF portion of the case, then the case can be closed. The 1931 case will remain open. A form pertaining to 1931 is sent to the individual. This form explains the difference between cash and Medicaid and outlines specific eligibility criteria. If this form is not returned with the required information then the 1931 case can be closed. The process employed by the State staff to record the specific eligibility group to which an individual should be assigned is based on a Level of Care code. Codes are also used to describe specific case actions such as to deny, close, or reinstate. The IM worker enters the appropriate codes into the state computer system. MO uses a number of forms in the processing of its Medicaid program. The IM-1 is a one-page application used for multiple programs such as TANF, Medicaid, spenddown, nursing care, QMBs, SLMBs, Food Stamps, General Relief, Blind supplements, refugee assistance and QDWIs. The IM-2 is a six-page eligibility statement used to apply for the multiple programs. The IM-1 and IM-2 are companion forms. The IM-1UA is a twopage Medicaid only application used for all family related Medicaid categories including the 1115 expansion. The MC-1UA application is used for outreach and contains addresses for the seven phone centers and is designed to be mailed. The IM-1UA and the MC-1UA are available in Spanish. mo14.doc- final report 4

Eligibility for Medicaid is not tied to TANF or Food Stamp eligibility. However, workers frequently determine eligibility for multiple programs at the same time. According to State Agency staff, if an issue exists that affects the TANF, Food Stamp or other program s eligibility, then Medicaid is processed separately and not delayed. State Agency staff indicated that an individual or family could request to apply for Medicaid only. The State indicated that workers are instructed to advise individuals of this option. The team reviewed Medicaid applications for conformance to the policy addressing the collection of social security numbers (SSN) and information on household members required to be shown for the processing of eligibility. Our comments are as follows: Form: Observations: 1. IM-1 (effective 10/98) The IM-1 is an application for multiple programs. It has a section To be completed by county office only which requests the applicant and spouse s SSN. Not noted on the form but in the instruction is the notation that there can be optional disclosure of this information for those not applying for Medicaid. This form does not ask information about other household members except for the number of children or persons applying for or receiving benefits. This form is not available in Spanish. 2. IM-2 (effective 3/95) This eligibility statement is used for multiple programs. It states, You must provide SSN of all persons applying for or receiving public assistance. It then asks for the SSN for all persons in the home and for children away at school (for a child where there is maintained care, custody and control). This form is not available in Spanish. 3. IM-1UA (effective 6/00) This form is used to apply for family related Medicaid. It requests the name and SSN of the applicant and all other household members. Not noted on the form but in the instruction is that it is optional to disclose the SSN or household member(s) not applying for benefits. This form is available in Spanish. mo14.doc- final report 5

4. MC-1UA (effective 5/00) This form is used for family related Medicaid and is designed for outreach activities. It contains information on the seven phone centers and is designed to be mailed. This form is available in Spanish. MO uses an IM-80, an Adverse Action Notice, for multiple State programs, e.g., TANF, Food Stamps, etc. including Medicaid. This form was revised in 11/99 to make clearer that case action(s) is specific to eligibility for cash assistance, and/or Medicaid and/or Food Stamps. MO also uses an IM-33MAF, a Notice of Case Action for section 1931 cases (with and without cash.) The IM-32 MAF is an approval notice designed for TANF or Medicaid. The IM-32MC notice was added 05/00 to address specific issues pertinent to the 1115 waiver (Medicaid expansion) population. These notices were reviewed to determine how well they recognize the need for TANF and Medicaid to be treated as two separate programs. Notices: Observations: 1. IM-80 (effective 11/99) This form is designed to record information separately for multiple programs, such as TANF, Food Stamps, and Medicaid. This form is not available in Spanish. 2. IM-33MAF (effective 08/00) This form is designed to record TANF and Medicaid case actions separately. This form explains that a hearing is available. This form is not available in Spanish. 3. IM-32MAF (effective 12/99) This approval notice is designed for the TANF and/or Medicaid Programs. This form is not available in Spanish. 4. IM-32 MC (effective 05/00) This approval notice applies to the 1115 waiver expansion population. It provides for cost sharing information and other program limitations. The notices are manually produced. Overall, the review team thought the notices were personalized, easy to read, and well written. However, it is recommended that the State consider making all forms available in Spanish. mo14.doc- final report 6

Program Assurances A comprehensive State training module began in July 1999 and was completed in October 1999. This training focused on issues arising from TANF/Medicaid delinking, the implementation of SCHIP and the 1115 waiver expansion. Training materials reviewed contained TANF/Medicaid delinking policies and procedures in accordance with Federal requirements. The State has routinely issued policy memorandums that cover a variety of topics relating to TANF/Medicaid delinking issues, TMA, and the need for workers to determine individuals continued Medicaid eligibility under 1931 or other applicable Medicaid categories. Department of Social Services Memorandums and Missouri Medicaid Provider Bulletins covering these and other Medicaid and SCHIP related topics are forwarded on a flow basis to all county offices and to the HCFA Regional Office. The review team scanned these documents and found them to contain policies and procedures addressing TANF/Medicaid delinking in accordance with Federal requirements. To further educate families on the differences between TANF and Medicaid, the State sent a letter and a brochure produced by the Southern Institute of Families and Children to current TANF and Medicaid eligible families. This information explained the relationship between TANF and Medicaid eligibility. Also, workers were instructed to provide a copy of this information to each new TANF and Medicaid applicant and to individuals at the time of redeterminations. Additionally, the State sent a cover letter and an MC+ (the MO Family Medicaid Program) application to all households who during 11/98 through 10/99 received TANF but were not currently receiving Medicaid. This was to further educate individuals that eligiblity for Medicaid is not tied to TANF eligibility and to provide them an opportunity to apply for Medicaid. MO also issued a memorandum, dated 2/1/00, to county staff pertaining to the development of a brochure produced by the Southern Institute to be shared with employers. This brochure, entitled Employers Connecting Employees to Benefits for Low Income Working Families, was to be shared with employers so that they could share with their employees the various benefits that were available from the State. This included Medicaid as one of the benefits. IV. Analysis of Findings from On-site State and Local Office Reviews Application and Enrollment State Agency and county staffs stated that county offices employ income maintenance (IM) workers to take and process all types of applications. Therefore, an individual or family applying for TANF, Medicaid, childcare and food stamps may have the same worker processing all benefits for which they apply. In MO when an individual is mo14.doc- final report 7

applying for TANF s/he is also applying for Medicaid. Similarly, if an individual is found eligible for TANF s/he is also eligible for Medicaid. Medicaid income and resource limits are more liberal than those for TANF eligibility. The IM-1UA and MC- 1UA are used to apply for family categories of Medicaid. The IM-1 and IM-2 are used in the application process for various programs such as TANF, childcare, Medicaid, food stamps, etc. The State indicated that if a family elects to apply for more than Medicaid they would complete an IM-1/IM-2, otherwise, they could just complete the IM-1UA. Coverage of the Section 1931 Eligibility Group The welfare reform provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) amended title IV-A of the Social Security Act (the Act) by eliminating the Aid to Families with Dependent Children (AFDC) program and replacing it with a new program, known as the Temporary Assistance to Needy Families (TANF). Prior to the enactment of PRWORA, receipt of AFDC conferred automatic eligibility for Medicaid. PRWORA severed the link between receipt of AFDC cash assistance and Medicaid. Section 114 of PRWORA added a new Section 1931 to the Act. Under Section 1931 of the Act, States are required to extend Medicaid eligibility to low-income families who meet the pre-welfare reform AFDC income and resource standards, and certain other AFDC requirements in effect under the July 16, 1996 State AFDC Plan. Under Section 1931 of the Act, States have the option to lower their income standards, but not below the AFDC standards in effect as of May 1, 1988. States also have the option to increase their income or resource standards based on a percentage that does not exceed the percentage increases in the Consumer Price Index that have occurred since July 16, 1996. Section 1931(b) of the Act also gives States the option to use income and resource methods that are less restrictive than the methods used under the AFDC State plan as of July 16, 1996. Missouri s State Plan Amendment, (SPA) # 97-8, approved January 07, 1999, effective 10/1/97 covers the 1931 group. This SPA permits the State to cover low-income families and children under Section 1931 of the Act. The group included in the AFDC State Plan effective July 16, 1996 includes AFDC children age 18 who are full-time students in secondary school or in the equivalent level of vocational or technical training. Under the approved State plan, the State uses certain AFDC standards and methodologies under the AFDC State plan in effect as of 7/16/96, and less restrictive income and/or resource methodologies than those in effect as of July 16, 1996. Procedures Related to Denials/Terminations State Agency staff stated that any change reported by a family potentially affecting TANF or Medicaid eligibility could trigger a redetermination. MO currently does not have 12 months of continuous Medicaid eligibility. mo14.doc- final report 8

Medicaid redeterminations are required annually. TANF redeterminations are required every six months. For a Medicaid-only individual an initial application or redetermination can be done by mail. If an individual does not comply with a TANF redetermination requirement their TANF case can be terminated. According to State Agency staff, this termination would not terminate the Medicaid case. It is State policy to require a separate annual review of section 1931 Medicaid if the TANF case is closed. This two step process took effect in July 1999. The case files sampled did not indicate that Medicaid cases were being closed based on a reason(s) specific only to TANF. State Agency staff explained that IM workers are instructed to re-evaluate an individual s eligibility when a family member leaves the household. IM workers are instructed to evaluate and to re-evaluate an individual or a family for all categories of Medicaid. The worker would analyze income, eligible household members, age of child, and relationship of child to caretaker. This can be done face-to-face, by phone or by mail. The State has instructed staff to routinely use available case file information in order to determine if an individual or family is or could be eligible for some category of Medicaid when there is a denial or termination. The review team did not find evidence in the cases sampled that the State is making or not making ex-parte redeterminations. The State indicated in its comments to this report that the following information was drawn from an internal review done for training purposes. Review findings were not finalized. Raw data had not been validated prior to the being made available to HCFA or local organizations. Therefore, the validity of the data is questionable. The advocate community takes exception to the State s assertion. Their comments are shown in Section IX. Follow-up: Areas of Concern. The State conducted a focused program evaluation review on TANF cases closed in February 1999. The review was conducted in April 1999. They reviewed 3,793 closed or denied TANF cases. The State found in their review that in 45% of these cases, TMA or Medicaid had not been opened. Furthermore, a large percent of these cases were closed for a client s failure to cooperate. Other trends provided by the 2/99 review were: Many clients did not have a good understanding of MC+ eligibility versus TANF. Forms could be revised to be clearer as to the effect on the client's TANF vs. MC+. Training for staff was needed regarding all the family healthcare programs, especially since the new CHIP (implemented 9-98) and 1115 waiver (implemented 2-99). These two programs were implemented without formal training being provided to workers. Many clients were not completing the joint TANF and MAF review of eligibility process and thus their cases were being closed. State Quality Assurance staff also reviewed 809 closed TANF cases that did not have Medicaid opened. They found that of the 809 cases: 59% indicated both cash and Medicaid were closed; 12% explained Medicaid options to the client at the time of closing; mo14.doc- final report 9

42% of the closings indicated possible Medicaid eligibility; 37% of the closings were based on client failure to return cash reinvestigation forms; and 12% of the closings were based on voluntary closings. These figures imply, for the time frame reviewed, that Medicaid eligibility had not always been delinked from cash assistance eligibility. Also, a client survey conducted by the State indicated that 98 of 99 clients whose Medicaid case had been closed stated that Medicaid was important to them. However, the State believes that the construction of the survey questions did not always produce reliable, meaningful statistics. The results of the survey provided the following: 50% stated they did not realize their Medicaid case would be closed; 48% stated they did not understand why their Medicaid benefits were closed; 89% stated their caseworker did not explain that they might be eligible for Medicaid benefits under a different program; and 57% stated they were not aware they could continue to receive Medicaid benefits if they went to work. The State expressed to the review team that they were aware that IM workers needed further training on the issue that TANF and Medicaid, for both the initial and continued eligibility, did require independent consideration. The State recognized that a refusal to cooperate for a denial or a termination of TANF may or may not be applicable for the Medicaid portion of the TANF/Medicaid related case. Once an individual is determined not eligible for Medicaid the State has instructed workers to review case files for eligibility criteria for all other categories of Medicaid. As a result of this worker review, the State has instructed workers to counsel clients regarding potential eligibility for other Medicaid. The State responded that a number of corrective steps have been taken to assist in remedying the issues raised by their 2/99 study. Some of these corrective activities are: (1) In July 1999, they issued a memorandum that changed the procedure to follow when a Temporary Assistance/Medical Assistance for Families (MAF) recipient failed to cooperate with a review of their eligibility. The process provides families the opportunity to complete an MAF review after the cash benefits end for failure to complete a review. This process change helps families understand that their medical benefits may continue after non-cooperation on their cash benefits. This change was also addressing the number of failure to cooperate closings. (2) All Income Maintenance staff received comprehensive training on the MAF, Transitional Medical Assistance (TMA), and MC+ programs during July through October 1999. This included the state's new SCHIP mo14.doc- final report 10

provisions (implemented September 1998) and 1115 waiver parent groups (implemented February1999.) (3) In October 1999, Area management staff was instructed to conduct a review of closed Temporary Assistance cases and establish appropriate corrective actions based on those reviews. (4) In December 1999, the Family Healthcare Program manual was issued and placed on-line in the DFS computer system. This included the MAF, TMA and MC+ healthcare programs. This manual is available to field staff. (5) In December 1999, an educational letter was issued to all active Temporary Assistance recipients explaining the separation of cash and medical eligibility. A pamphlet developed by the Southern Institute on Children and Families was included which explains many of the support services available to working families. The State also instructed field staff to use the Southern Institute pamphlets to educate Temporary Assistance applicants and recipients about the difference in cash and medical eligibility. (6) Notices used to inform recipients about actions taken on their cases were modified to provide better communication to Temporary Assistance/MAF recipients about the effect actions have on their cash and their medical benefits. Forms IM-32MAF, IM-33MAF and IM-80 were revised. (7) The form used for annual reviews of healthcare benefits was modified to include a cover letter with the MC+ income guidelines. This was to help ensure that families understand the higher income limits used for medical benefits. (8) During January 2000, a letter was sent to families whose Temporary Assistance/MAF benefits were terminated during November 1, 1998 through October 31, 1999 to educate them as to the difference in cash and medical eligibility and to encourage them to apply for healthcare coverage. MC+ income guidelines and an application were included. (9) During February 2000, the State provided follow-up training on MAF, TMA and MC+ to supervisory staff. According to HCFA guidance issued in a Dear State Medicaid Director letter dated April 22,1997, when an individual is about to lose Medicaid because of the loss of eligibility for cash assistance (such as the loss of AFDC benefits through the transition from AFDC to the State's TANF program, or the loss of SSI benefits in States that provide Medicaid to individuals because they receive SSI), the State is required to make an ex-parte mo14.doc- final report 11

redetermination of the individual's Medicaid eligibility under any other eligibility group. The term "ex-parte redetermination" means a redetermination made by one party, the State, without the involvement of any other party such as the recipient. Thus, an ex-parte redetermination is to be based to the maximum extent possible on information contained in the individual's Medicaid file including information available through the SDX or BENDEX. If the State is able to make a decision that the individual continues to be eligible for Medicaid, the beneficiary should be notified. The review team found no evidence in the cases sampled that the State was or was not routinely doing ex-parte redeterminations in accordance with these requirements. According to one local organization, the State has no policy regarding ex-parte requirements. However, the State indicated that they routinely instruct staff to use whatever eligibility information is available in the case file to determine or redetermine an individual s or family s eligibility. The State indicated that their ex-parte policy is woven into its redetermination process even though it is not referenced as ex-parte. State Agency staff stated that newborn Medicaid cases have one year of continuous Medicaid eligibility and that the State s system uses a newborn indicator. When a mother s Medicaid case is closed an alert shows for the newborn so that the case can be evaluated for the child s own Medicaid eligibility. Section 1925 Transitional Medicaid Also covered by State memorandums and bulletins is the enrolling of families in TMA after they have lost Medicaid eligibility under the 1931 category based on too much earned income. The loss of Medicaid under section 1931 based on an increase in child support would result in extended Medicaid for four months. The same rules or process as that applicable to TMA does not govern extended Medicaid. According to State policy obtained through interviews with State Agency and county staff, if a family loses section 1931 Medicaid based on increased earned income, the parent(s) is placed on TMA. The child(ren) is reviewed for eligibility under other Medicaid categories, for example, the Poverty Level program. If the child(ren) is not eligible for another category of Medicaid, s/he is also placed on TMA. The review for placement of the child(ren) into another Medicaid categories is to maintain continuity of health care for the child(ren). This is important because the non-compliance of a family with the TMA reporting requirements could adversely affect a child s continued receipt of TMA. If the family or child(ren) lose eligibility for section 1931 Medicaid and they do not qualify for other categories of Medicaid or for TMA, then the worker reviews the parents for coverage under the 1115 waiver expansion and or the child(ren) for SCHIP. This process is a manual process requiring proper case adjudication and coding to the computer system by the worker. County supervisors stated that they review this area in their routine case reviews. mo14.doc- final report 12

The State indicated that once an individual is determined eligible for TMA, a letter is sent notifying the family that Medicaid will continue for another six months and possibly 12 if the recipient fulfills TMA requirements. At the same time, an information sheet is provided to the recipient explaining requirements and benefits that are available under TMA. This sheet explains that if earned income remains under 185% of the Federal poverty level (FPL) minus childcare and the required quarterly report form is submitted timely, then the individual can receive the last six months of TMA. The IM worker must input a code for the 1st and 2nd periods of TMA. The receipt of the first six months of TMA is automatically given to eligible individuals regardless of changes in earnings. If after the first six months of TMA, the information form shows income over 185% of the FPL then the family cannot receive the second six months of TMA. Once the worker receives the report form it is coded as received. The individual then starts the 2 nd 6-month period of TMA. If there is income in the 2 nd 6-month period that exceeds 185% of the FPL the worker must take another action to terminate the TMA. If the last six months of TMA is terminated for the non-receipt of a quarterly report form, a family can be reinstated and covered retroactively if good cause exists for the nonreturn of the form. Good cause is a reason that is acceptable to the State for the nonreturn of the form in a timely manner. Termination from TMA could also be based on the child leaving home, the family moving out of State, a child aging out, or a return to section 1931 eligiblity. State Agency and county staff stated that when a person loses TMA for the last six months the worker is instructed to explore other Medicaid eligibility categories. State policy provides that an individual could be eligible for numerous TMA periods. This depends on how the months of employment and unemployment fall. The State system can switch from the end of the 12 months of TMA to a two-year period of continued eligibility for certain uninsured parents transitioning off of TMA. These individuals become eligible for Medicaid with certain service restrictions. The authority for this expanded Medicaid Program is provided through the 1115-demonstration waiver. The State notifies individuals of their eligibility by letter. State Agency and county staffs stated that caseworkers are instructed to explore the enrollment of families into TMA any time a 1931 Medicaid case is closed based on excess earned income. In MO, to close a 1931 Medicaid only case and to open a TMA case requires manual input into the computer system by the IM worker. Coverage of Disabled Children Protected under Section 4913 of the Balanced Budget Act Section 211 of the PRWORA revised the definition of childhood disability under the Supplemental Security Income (SSI) program. The new SSI childhood disability definition is more stringent than the old definition and resulted in the loss of SSI benefits mo14.doc- final report 13

for some children. Under Section 4913 of the Balanced Budget Act (BBA), States must provide Medicaid to children who were receiving SSI benefits on August 22, 1996, and lost SSI benefits on or after July 1, 1997 due to the new disability definition provided they continue to meet current SSI income and resource standards and the definition of childhood disability in effect prior to the 1996 revised definition. A 1902(f) State of which Missouri is one, employs eligibility criteria for the aged, blind and disabled which are more restrictive than the eligiblity criteria used in the SSI program. Section 4913 of the BBA-1997 permits but does not require that 1902(f) states provide Medicaid to disabled children who lost their SSI by virtue of the 1996 change by PRWORA to the SSI disability definition for children. States were encouraged to provide Medicaid to children in this category if the state used the SSI childhood disability rules in effect on August 21, 1996 for determining the Medicaid eligibility for these children, and the child meets the State's other Medicaid eligiblity criteria under its State plan. According to State Agency staff, Missouri conducted in January 1998 a search for individuals who would fall into the section 4913 eligibility group. A tape match was performed between the Social Security Administration (SSA) data and the MO DSS data. The SSA tape contained identifying information on MO children who were Supplemental Security Income (SSI) eligible as of a certain date. There were 4,575 names on the tape. From this MO matched 3,349 names to their records. From the 3,349 names, 318 were not Medicaid active and were forwarded to workers to determine if the individuals could be reinstated to Medicaid. Time Frame for Eligibility Determination Federal Regulations 42 CFR 435.911 require that Medicaid eligibility for families and children must be determined within 45 days from the date of application. State staff indicated that workers routinely process 90% of the cases within 30 days. This is supported by the State s monthly statistical report and by the cases reviewed. Additionally, State Agency staff and county supervisors informed us that applications for Medicaid that are part of TANF applications are not held back for the processing of the TANF portion of the application. The Medicaid portion of the joint TANF/Medicaid application is processed within the required time frame. This means that if a delay in TANF eligibility is experienced the worker is instructed to continue the processing of the Medicaid portion of the application. Reviewed case files did not indicate a problem with timely processing of applications. In fact, most files reviewed were processed in less than 30 days. Outstationing Section II of the MO State Plan indicates that the State meets the outstationing requirements of 42 CFR Part 435-Subpart J (42 CFR 435.904). This is reflected in the State Plan, 2.1d, page 11 a, per SSA 1902 (a) (55). Information provided by the State indicated that the State is outstationing workers at Disproportionate Share Hospitals mo14.doc- final report 14

(DSH) and Federally Qualified Health Centers (FQHCs) as required by regulation. Individuals can be served by any outstation location. Applications from outstation locations are forwarded for processing to the county office that is specific to the applicant s residency. Applications can be processed at any of the 115 county offices. Also the seven Phone/Service Centers can mail and receive Medicaid only applications. The seven Phone/Service Centers also have a toll free number to answer questions on the State s Medicaid expansion. The elderly and disabled can receive home visits for completion of Medicaid applications. All applications are forwarded to the correct county office for processing. The following section on Outreach describes how MO has utilized an agreement with the Department of Health to increase the number of State staff that can accept and assist in the Medicaid enrollment process. State Agency staff stated that there are 14 FQHCs and 25 + DSHs in the State. All of these provide assistance to complete Medicaid applications. Public Charge At the time of this review MO had not issued a clarification on the Public Charge issue, as it relates to Medicaid, to providers or as part of the Medicaid expansion outreach effort as suggested by a May 26, 1999, State Medicaid Directors Letter. The State, however, does include a copy of an Immigration and Naturalization Service (INS) letter explaining Public Charge in its MC+ outreach package. This package is made available to community organizations where the State believes that the Public Charge message is best delivered. They also plan on including information on this issue in the State s policy manual. Outreach MO has an agreement with a number of entities to perform outreach, as well as to take applications for their Medicaid expansion. They have agreements with 52 county Department of Health (DOH) offices to accept and assist in the completion of Medicaid applications. All other county DOH offices provide some type of application assistance to clients. The State is also working with a statewide coalition, Caring Communities, to assist in outreach for the Medicaid expansion. The State has focused outreach on children potentially eligible for the expansion group. However, in the process they have been reaching and enrolling a large number of children that are Medicaid eligible under pre-expansion Medicaid standards. This information was provided by the State. Computer Systems State Agency staff stated that the computer system utilized by the MO Department of Social Services for its Medicaid Program is able to calculate Medicaid budgets. This computer system also handles other State specific programs; General Relief, Blind mo14.doc- final report 15

Pension, State Supplement, etc. Workers must manually input codes into the State computer system to reflect the proper Medicaid category for an individual or family. If an individual or family is no longer eligible for Medicaid, the worker must explore the individual s or family s continued eligibility for Medicaid whether related to section 1931 or other categories. Once eligibility is determined for a specific category of Medicaid the worker must input the code into the computer system. County supervisors interviewed stated that in their case reviews they do review for correct code input. It was the opinion of the review team that the State s computer system could benefit from being updated. For example, a system that could generate more forms and notices could be more efficient for workers. Certain manual processes that State workers are currently using in the eligibility determination process increase the likelihood that errors are more likely to occur. V. Comments from Local Organizations The following are comments that have been summarized from those provided by local organizations representing various groups that attended an initial September 1999 meeting. This meeting was to discuss issues pertinent to the delinking of TANF and Medicaid. An attempt has been made to record the comments as provided except for minimal rewrite for clarity. These comments were provided by individuals based on their or others experiences and or opinions. Therefore, the review team saw no reason to provide editorial comments to these statements. The comments are grouped by the HCFA recommended areas of discussion. Local organizations concerns are also noted throughout this report. Groups represented at this meeting were Legal Services, YWCA, Reform Organization of Welfare, Missouri Association of Social Welfare, Citizen s for Missouri s Children, and The Health Care WATCH. Also in attendance at this meeting was a representative of the MO Department of Social Services, Division of Family Services. Subsequent advocates comments were provided in October 2000 to the corrective actions and comments supplied by the State. The comments relevant to the Areas of Concern are reflected in Section IX. Follow-up: Areas of Concern of this report. Delay or Diversion from Medicaid The nature of the Medicaid program is so complex that it is doubtful if anyone could implement it well. Many of the Division of Family Services (DFS) county offices don t understand the (TANF/Medicaid) program. There are 115 county offices and the programs are administered differently from county to county. The benefit of the doubt is not given to the poor person. The nature of the name "Work First" gives the idea that other needs are secondary to work. mo14.doc- final report 16

Some caseworkers don t understand the difference between SCHIP, Transitional Medicaid and regular Medicaid. There are delays in Medicaid processing because of Child Support Enforcement (CSE) investigations. They make modifications on people s child support. People pay for their own Medicaid because child support decreases. This child support issue needs further exploration. Applications are taking longer than 30 days to process. One applicant applied over a year ago and just received her card. Her child support decreased as well. What level of income triggers a child support investigation? Families transitioning off welfare are not told about SCHIP There is a lack of providers, especially for dental care. There needs to a national policy for dental. The Dental Industry is not strong enough to fight alone. Even when people are able to secure a job and the job provides insurance, it often does not cover dental. MC+ for Children (SCHIP) poster mentions the requirement of being uninsured for 6 mos. This is a way to discourage up front because this is not a requirement for regular Medicaid. There are not enough caseworkers. The TANF/Medicaid delinking did not happen up front. Workers were given the wrong information. Caseloads are too high. Training is done by e-mail or memos and the caseworker s manuals are not being updated. MO is not accessing the $500 million Federal (TANF) money to assist with the delinking process. Termination or Denial of Benefits Advocates felt that there are inappropriate Medicaid denials and terminations. TANF gets closed and Medicaid gets closed as well. Workers make people come in for redeterminations, which is not required, and if they don t they close their case. One case was closed and the client has one child with cerebral palsy. She is working and has no insurance. She tried five different workers to reschedule her reinvestigation. The ex-parte redetermination is not being done. People are not aware that they can remain on Medicaid if they ask for their TANF case to be closed. The notices do not advise the client of Transitional Medicaid. The political culture encourages loss of Medicaid. The cultural change is to ask the client what they think they need, as they do not want people to be dependent. There is a State law, SB 387, requiring workers to tell the client all that they are eligible for. The State has not implemented this law. Notices are still a problem. HCFA informed the State that they must inform people that they are denied for regular Medicaid when found eligible for SCHIP. Every MO divorce decree requires that the case have a medical support order. This often slows down TANF/Medicaid case processing. mo14.doc- final report 17

TANF/Medicaid cases closed on failure to cooperate need further exploration by the caseworker. The issue in question may or may not affect continued Medicaid, however the total case is being closed. The State is not supposed to sanction Medicaid if you close TANF. Mandatory supervisory reviews should be done on all closed Medicaid cases. Client Education Advocates contended that we couldn t expect caseworkers to do anymore. They are already overburdened. They need more caseworkers and more training. The State needs to use the $500 million (TANF funds) to hire more caseworkers and to do more outreach. They need to give grants to community organizations to do outreach. Head Start is a great place for outreach. There is reluctance on the part of the State to access its share of the $500 million in delinking funds. There is uncertainty and confusion about the use of this money. People do not understand about their right to a fair hearing. Clients think that decisions on their case are fair and don t pursue further. Not all denial notices tell about the right to a fair hearing. Clients fear providing Social Security Numbers (SSN) and therefore do not apply for themselves or their children. The State needs to indicate that the name and SSN are only needed for those applying for assistance. This statement needs to be part of the application. Beneficiary Education of Transitional Medicaid Advocates believed that notices do not include understandable Transitional Medicaid language. People are not aware of the delink. There is misleading information in the outreach packet. The name of the program is MC+. The State has called the regular Medicaid and the expanded Medicaid program, including SCHIP, MC+. The outreach information addresses the expansion population. There was a big campaign that if clients go to work that they will still be eligible for Medicaid. The correction of the outreach materials needs to be included in the State s corrective action plan. With TANF numbers decreasing, TMA should be increasing. This is not happening. There is a question of whether individuals are being properly assigned to the correct medical program. Outstation Eligibility Workers Advocates suggested that the State should outstation workers at Head Start centers. Caseworkers that are knowledgeable are needed. People get lost in the application process and are not placed in the right category. Spanish applications are not readily available. mo14.doc- final report 18

State s allocation of FTEs need to be re-evaluated. Caseload size and complexity have increased. The number of workers is not keeping pace. Workers were told that the addition of the Medicaid expansion and SCHIP would not add to their workload. This has not been the case. Many caseworkers are carrying in excess of 250 cases or families. Additional Advocate Comments Advocates believe that there are some fundamental steps that the State must take to correct or reduce barriers to families and children from being able to apply for and receive Medicaid. These necessary steps are: 1. Revising regulations, manuals and policies to fully and to completely reflect Medicaid delinking and ex-parte redeterminations; 2. Revising State policies and procedures to ensure that new mothers receive the full Medicaid coverage for which they are eligible; 3. Training and retraining workers and supervisors regarding all of the issues pertinent to delinking; 4. Conducting regular quality control audits of the issues high lighted in this report to evaluate the effectiveness of State policies, procedures and practices; 5. Adopting policies that would alleviate the impact of local officials misapplication of delinking requirements. This would include presumptive eligibility, 12 months continuous eligibility, expanded coverage to adults under 1931, etc; 6. Adopting mandatory supervisory review of all closed TANF cases; 7. Revising all notices and forms so that they are clearly understandable and meet the legal requirements of the Medicaid Program; 8. Making necessary computer or other system changes to ensure that Medicaid and TANF are properly delinked; 9. Making compliance with Medicaid delinking and ex-parte redeterminations requirements a mandatory component of workers and supervisors performance evaluation; 10. Broad reinstatement of families that lost Medicaid when they left TANF; 11. Ensuring that the State s notices, forms, and practices and procedures fully compy with Title VI of the Civil Rights Act and the new OCR policy guidance. mo14.doc- final report 19