The following categories of individuals are eligible for Medicaid:

1. Individuals eligible for Supplemental Security Income (SSI) benefits (i.e., recipients of straight SSI benefits, mandatory state supplements, SSI conditional payments and SSI presumptive disability payments). Re. MS 2010;
2. Blind or disabled individuals with converted cases who are not considered to be blind or disabled under SSI criteria. Re. MS 2020;
3. Individuals eligible for Medicaid as essential spouses in December 1973 and who continue to meet that eligibility criteria. Re. MS 2025;
4. Medical Only Individuals who are current recipients of SSA; who were previously entitled to SSA and eligible for and received SSI concurrently in at least one month after April 1977; and who would now be eligible for SSI if all COLA increases received since they were last entitled to SSA and received SSI concurrently were deducted from current income. Re. MS 2030;
5. Medical Only Individuals whose assistance payments were terminated due to the 20% increase in Social Security benefits in September 1972, and who would be currently eligible for assistance payments if the 20% increase in Social Security benefits in September 1972 were disregarded. Re. MS 2040;
6. Disabled widows and widowers who were entitled to SSA for December 1983; who received SSA disability for January 1984; who lost SSI after January 1984, due to elimination of a benefit reduction factor previously applied; who would be SSI eligible if the 1984 reduction factor increase and all COLA's since 1984 were disregarded; and who applied and were found eligible for Medicaid benefits between July 1, 1986, and June 30, 1988. Re. MS 2045;
7. Disabled widows and widowers who were at least age 60 on or after 4/1/88, were not yet age 65 on 4/1/88, formerly received SSI benefits which were terminated due to entitlement to SSA widow's or widower's benefits, currently receive SSA widow's or widower's benefits, are not currently eligible for Medicare, would be eligible for SSI if ALL SSA benefits were disregarded, and are otherwise income and resource eligible for Medicaid. Re. MS 2046;
8. Disabled widows, widowers and disabled surviving divorced spouses who lost their SSI due to receipt of SSA benefits based on a less restrictive definition of disability that was used prior to OBRA of 1990. Re. MS 2049;
9. Qualified Medicare Beneficiaries who qualify under the Medicare Catastrophic Coverage Act of 1988, and whose benefits are limited to Medicare cost-sharing. Re. MS 2047;
10. Specified Low Income Medicare Beneficiaries whose income is between 100% and 120% of the Federal Poverty Level and who meet all other requirements for the Category will be eligible for payment of their Medicare Part B Premium. Re. MS 2051;
11. Qualified Disabled and Working Individuals who lost Medicare Part A entitlement solely due to Substantial Gainful Activity. Medicaid coverage for these individuals is limited to payment of their Part A premium. Re. MS 2048;
12. Disabled Adult Children (DAC) who are age 18 or older, who became disabled or blind before age 22, who were receiving SSI based on disability or blindness, and who lost SSI on or after July 1, 1987 due to a DAC entitlement or a DAC increase. Re. MS 2050;
13. Individuals who were eligible for Medicaid in Title XIX institutions in December 1973. Re. MS 2044.3;
14. Families who lose TEA related Medicaid eligibility due to increased wages and who qualify for up to 12 months of transitional Medicaid. Re. MS 2061;
15. Families who lose TEA related Medicaid eligibility due to collection of child support payments and who qualify for up to 3 months of extended Medicaid. Re. MS 2063;
16. Eligible individuals under age 21 and individuals age 65 and older who are receiving inpatient psychiatric care in the Arkansas State Hospital or the George W. Jackson Center. Re. MS 2070.
17. Developmentally Disabled Individuals who qualify for Home and Community Based Services. Re. MS 2075;
18. Aged Individuals who qualify for Home and Community Based Waiver Services. Re. MS 2076;
19. Newborn infants born to women determined to be Medicaid eligible when the infant was born. Re. MS 2080;
20. Individuals who qualify for services under the Alternatives for Adults with Physical Disabilities Waiver. Re. MS 2078;
21. Disabled children eligible for Medicaid under TEFRA. Re. MS 2090;
22. Illegal aliens who are eligible for emergency services only. Re. MS 2095;
23. Individuals who qualify for retroactive Medicaid eligibility. Re. MS 2100 (applies to all categories except Newborn Infants, PW-PE, QMB, SMB, QDWI, and Waiver Categories. Re. MS 2080, MS 5600, MS 2047, MS 2051, 2048, 2075, and 2076);
24. Individuals in Title XIX Long Term Care Facilities who are eligible according to LTC criteria. Re. MS 3000;
25. Women eligible as Pregnant Women who meet the AFDC or Medically Needy standards of need. Re. MS 5000, MS 7000;
26. Pregnant women, infants and children (up to age 6) whose income does not exceed 133 percent of the Federal Poverty Level, and children ages 6 and older, who were born after September 30, 1982, whose family income does not exceed 100 percent of the Federal Poverty Level. Re. MS 5600;
27. Pregnant Women found presumptively eligible by a Qualified Provider for ambulatory prenatal care. Re. MS 5600;
28. Individuals eligible for the U-18 category. Re. MS 6000;
29. Title IV-E and other Foster Children. Re. MS 6000 and MS 7000;
30. Non-Title IV-E Adoptive Children with Special Needs. Re. MS 6590;
31. Individuals eligible for the Medically Needy Program. Re. MS 7000;
32. Refugees eligible for Medicaid under "special eligibility period" criteria of the Refugee Resettlement Program;
33. Women found eligible for Family Planning Waiver services and whose benefits are limited to family planning services only. Re. MS 5900;
34. Individuals found eligible for Transitional Employment Assistance related Medicaid. Re. MS 2085;
35. A Qualifying Individual - 1 whose income is at least 120% but less than 135% of the Federal Poverty Level and who meets all other requirements for the category will be eligible for payment of the Medicare Part B premium. Re. MS 2073;
36. A Qualifying Individual - 2 whose income is at least 135% but less than 175% of the Federal Poverty Level and who meets all other requirements for the category will have a portion of the Medicare Part B premium paid. Re. MS 2074; and
37. Children who lost their eligibility for SSI because they did not meet the new definition of disability established by Sec. 211 of P.L. 104-193 (The Welfare Reform Act). Re. MS 2036.

With date specific eligibility, for most Medicaid categories, an individual's or family's eligibility may begin or end on any day of a month.

When eligibility is established, eligibility will begin on the day the application was registered, unless retroactive coverage is needed. If retroactive coverage is needed and if eligibility is established for a retroactive period, eligibility can begin up to 3 months prior to the date of application (but not on the first day of the third retroactive month unless the application was filed on the first day of a month).

Eligibility for most Medicaid categories under date specific eligibility may be terminated at any time. The end date of eligibility will be the last day of the 10-day advance notice period, unless a recipient requests a hearing within the advance notice period.

There are some Medicaid categories in which eligibility may not begin or end on any day of a month. These categories are: QMB (MS 2047), SMB (MS 2051), QDWI (MS 2048), and TM (MS 2061). Information about the begin and end dates for these categories is found in the eligibility section for each category.

Individuals who have been determined eligible for SSI benefits by the Social Security Administration (SSA) are eligible for Medicaid (i.e., recipients of straight SSI benefits, Mandatory State Supplements, SSI conditional payments and SSI presumptive disability payments).

The County Office is notified of SSI eligibles by printout as SSA makes information available to the Office of Information Systems (OIS). OIS will mail Medicaid ID cards to all SSI eligibles at certification.

SSA will notify OIS via the State Data Exchange system of changes for this group of eligibles. The County Office will notify the local SSA District Offices by means of a lead form, RVI-302, regarding current changes reported by/for individuals within this group (e.g., SSI recipient enters a nursing home).

The National Correction Procedure is a process for notifying the Social Security Administration (SSA) of changes that could affect SSI/Medicaid eligibility and/or the amount of State supplementation payments.

When information is received that is not reflected on the latest "SSI Recipient" printout, the County Office will submit the information to SSA via the SSA-3911, Report of Change-SSI Data. The following information can be reported:

In addition, the County Office will properly identify the recipient and/or any other individual, the reason for submittal, and the County Office Worker requesting the change. Supporting documentation will be submitted if available.

The county officer worker will complete Parts I and II of the SSA-3911. Completion and routing are self-explanatory with the following exceptions:

Item 8. - Enter Bureau of Supplemental Security Income, 1200 Main Tower Bldg., Dallas, TX 75202,

Item 10. - Enter the information from the "SSI Recipient" printout that needs correction,

Item 11. - Enter the information (i.e. requested change) being reported, and

Item 12. - Enter the effective date of the requested change.

Upon receipt, SSA will investigate the reported change, take any necessary corrective action, and notify the Service Representative of the result by completing Part III of the SSA-3911 and returning the form to the County Office.

Upon receipt, the Service Representative will take any necessary corrective action indicated in Part III of the SSA-3911.

An aged, blind or disabled individual who is the spouse of another aged, blind or disabled individual who has not lived apart from said individual for more than six months. To be considered eligible, an individual must, in addition to meeting other eligibility criteria, file an application.

An unmarried eligible individual who is not the head of household and who is:

Consider a couple to be husband and wife if they are:

1. legally married under State law, or
2. either determined to be the spouse of a Title II (Social Security) recipient or
3. living together and holding out to the community as husband and wife.

Spouses have to be separated six months before they can be considered as individuals for SSI purposes unless they are separated at the time of application. Divorced couples are considered as individuals immediately. When both spouses are eligible and one enters an LTCF, spouses are generally considered as individuals after the month of separation.

2014 Definition of Living Arrangements

Individuals, who applied for Aid for the Blind (AB) or Aid for the Disabled (AD) from July through December 1973 and were certified for AB or AD, were converted to SSI with the understanding that SSI would review the cases for blindness and disability determination under Title XVI (SSI) definition of blindness or disability. Converted cases not blind or disabled under Title XVI criteria were closed. The State must provide Medicaid to those individuals, if any, who were closed if they:

1. were eligible for Medicaid in December 1973 as blind or disabled individuals, whether or not they were receiving cash assistance in December 1973, and
2. for each consecutive month after December 1973, continue to meet the criteria for blindness or disability and the other conditions of eligibility used under the Medicaid plan in December 1973, and
3. meet all current conditions for Medicaid eligibility except the current SSI definition for blindness or disability.

Reevaluation for converted cases not blind or disabled under SSI criteria is required every twelve months.

An essential person (EP) is an individual who:

1. for the month of December 1973 was an individual whose needs were taken into account in determining the needs of a qualified individual (QI) for aid or assistance under the policy in effect for June 1973;
2. lives in the home of a qualified individual (ownership of the home is immaterial but the QI and EP must reside together);
3. is not eligible in his own right, or as the eligible spouse of the QI or any other individual (to be considered eligible an individual must, in addition to meeting other eligibility criteria, file an application); and
4. does not have income or resources in an amount that causes the QI to lose eligibility for SSI payment.

A qualified individual is a person who:

1. for the month of December 1973 was a recipient of aid or assistance under the policy in effect in December 1973, and

2. in determining the recipients need for such aid or assistance for December 1973 there was taken into account the needs of another person who was living with the recipient and who was not eligible for aid or assistance for December 1973 under the policy in effect.

Simply stated, a QI is a person who was a recipient in December, 1973 and who had an EP.

In accord with Section 503 of P.L. 94-566, Unemployment Compensation Amendments of 1976 (commonly known as the Pickle Amendment), AABD No-grant Medicaid eligibility was extended to include individuals who become ineligible for SSI payments due to Social Security cost of living adjustment (COLA) increases.

The above group of Medicaid eligibles was broadened by a 1984 decision in the case of Lynch vs. Rank in the U.S. District Court, District of Northern California, which altered the interpretation of the Pickle Amendment, to provide Medicaid to former SSI recipients who lost SSI, not solely to a COLA increase, but lost SSI for ANY reason, if the individual would be SSI eligible today by disregard of all COLA's received on their SSA since the loss of SSI.

A clarification by the Health Care Financing Administration (HCFA) in 1997 broadened the Pickle Amendment to include those persons who were entitled to SSA and received SSI in the same month. This would allow potential eligibility to persons who lose eligibility for SSI due to an SSA entitlement.

Individuals who remain eligible for Medicaid under provisions of the Act, as amended by Lynch vs. Rank, will not be included in the family count for TEA (nor will their income and resources be included) when they are members of a household with a related TEA case. However when a spouse or child of a Lynch vs. Rank eligible applies for AABD Medicaid, the Lynch vs. Rank eligible will be considered as a household member and his/her income and resources considered.

The initial group of individuals becoming eligible for continued Medicaid under provisions of the Act resulted from the July 1, 1977, SSA cost of living increase. Under provisions of the law, additional individuals will become eligible at each SSA cost of living increase.

The following procedures will be completed to insure that closed SSI recipients will continue to receive Medicaid.

1. Converted Cases

From a special lead file provided by the Social Security Administration, Baltimore, the Central Office will identify individuals losing SSI eligibility due to COLA increases. These individuals will be converted to the AABD No-grant category at the end of each calendar year, with a reevaluation due the following year in January.

At the time Central Office converts the individuals entitled to No-grant categories, they will produce a listing of the converted individuals by county entitled "SSI COLA Cases Converted to No-Grant Categories" and generate a DCO-57 for each individual converted.

2. Annual System Review of Medically Needy Cases

1. Converted Cases

2. Medically Needy Cases

In order for individuals or couples to qualify for continued Medicaid coverage under provisions of the Pickle Amendment, as amended by Lynch vs. Rank, they:

1. must be current recipients of SSA;
2. must have been previously entitled to SSA and eligible for and received SSI concurrently in at least one month after April, 1977; and

would now be eligible for SSI if all SSA COLA increases received since they were last entitled to SSA and received SSI concurrently were deducted from current income.

The following are examples of possible eligibles under the Pickle Amendment, as amended by Lynch vs. Rank:

Example #1: An individual applies for Medicaid in August 1998. The individual's only income is $580.00 SSA. The County Office verifies through query that the individual last received SSI in May 1994. The query establishes the individual became entitled to SSA in May 1994 and received the first SSA payment in June 1994 which caused SSI ineligibility. The County Office verifies the individual received $70.00 in COLA increases since 1994. They deduct the COLA increases and the $20.00 general exclusion ($580.00 - $70.00 - $20.00 = $490.00) and compare the result of $490.00 to the current (1998) SSI/SPA of $494.00. The individual is income eligible.

Example #2: An individual applies for Medicaid in September 1998. The individual's only income is $520.00 SSA. The County Office determines that the individual lost SSI in October 1996 due to excess resources. The individual is now resource eligible. The County Office verifies $22.00 in COLAs received since 1996. Deducting the COLAs and the $20.00 general exclusion ($520.00 - $22.00 - $20.00 = $478.00) and comparing the $478.00 net to the current (1998) SSI/SPA of $494.00, the individual is income eligible.

Determination will be made by personal interview with the recipient or person acting on their behalf in the County Office unless other arrangements are determined to be necessary. The recipient will complete and sign Form DCO-777.

If the individual is not currently open, the application will be registered in Category 11, 31, or 41, as appropriate.

If an ineligible spouse or other family member (e.g. parent of a disabled child) has income that must be deemed to the applicant, their COLA increases since the applicant lost SSI will also be disregarded. (For deeming procedures, refer to MS 2111 section.)

After all COLA disregards and SSI exclusions have been deducted from current income, the net countable income will be compared to the current SSI SPA. If the individual's income is under the SPA, he/she is eligible for continuing Medicaid benefits.

If the individual has an ineligible spouse, countable income will be determined according to MS 2111.1, allowing COLA disregards, and the net income compared to the couple's SPA.

If eligibility is to be determined for both members of a married couple, total their current income, subtract their combined COLA disregards, a $20 exclusion per couple and other applicable SSI exclusions to arrive at their countable income. This income will be compared to the couple's SSI SPA to determine Medicaid eligibility.

The income calculations will be entered on Form DCO-707. Only Sections 1, 2, 4, and 5 will be completed.

Reevaluations of eligibility will be made every twelve-(12) months. Data Processing will prepare preprinted DCO-75's for subsequent reevaluations.

Former SSI recipients who are not converted open and found eligible will be reopened in Category 11, 31, or 41, using the old SSI case number and a "B" action type. The begin date of coverage will be the date of application unless retroactive coverage is needed. If needed, retroactive coverage up to three months prior to the date of application may be given.

The unit size will be entered, and the current income will be entered in the corresponding fields. In the Unearned Exclusion Field enter a total of all COLA disregards and SSI exclusions. A "Y" will be entered in the MU field, and the current SSI SPA (individual or couple, if there is an eligible or ineligible spouse) in the MNIL field. The net income, after disregards and exclusions, will be entered in the Net Countable Field.

If certifying an eligible couple, a separate DCO-57 will be completed for each individual, with separate case numbers. On the DCO-57 for each, a unit size of "2" and their combined income will be entered. The combined COLA disregards and SSI exclusions (only one $20 exclusion) will be entered in the Unearned Exclusion field, and a "Y" entered in the MU field. The couple's SSI SPA will be entered in the MNIL field, and the net income in the Net Countable Field.

To complete a reevaluation of an open converted case or for subsequent yearly reevaluations, only the minimum record entries are required (i.e., "O" action, action date, worker number, action reason "201" and reevaluation date).

If a converted AABD No-Grant case is found ineligible (converted in error), advance notice of closure will be given on the DCO-700 or DCO-55 and the case will be closed, using closure code "39".

The Social Security Administration will notify Central Office of any individuals who qualify for continued Medicaid coverage under the Pickle Amendment who were not identified on the lead file transmitted from Baltimore.

As these individuals are identified to the Central Office, a notification will be sent to the County Office which services the county of their residence.

Upon receipt of notification from the Central Office, the County Office will contact the identified individuals, advise them of their potential Medicaid eligibility, and arrange for an application interview. Application will be taken on Form DCO-777, and registered on WIMA in the appropriate AABD category.

Eligibility will be established in the same manner as outlined in MS 2034. Once eligibility is established, certification will be made by the DCO-57 and the client notified via the DCO-700 or DCO-55. The starting date for Medicaid eligibility will be the first day of the month following the month of SSI closure.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193) changed the way childhood disability is determined. Some children lost their eligibility for SSI due to a redetermination of their disability pursuant to that legislation. The Balanced Budget Reconciliation Act of 1997 (P.L. 105-33), enacted on August 5, 1997, mandates the continuation of Medicaid eligibility for any of these children under age 18 who were receiving SSI on August 22, 1996, and who would have remained eligible for SSI had it not been for the change in disability criteria.

Children approved under these provisions are eligible for the full range of Medicaid services, including the Children's Health Services Program (EPSDT).

County offices received a list of potentially eligible children in December 1997, and some counties received an additional list in March 1998. It is possible, however, that some potentially eligible children are not included on either list. Therefore, any child who meets the following two conditions must also be considered for possible continued Medicaid eligibility:

1. The child was receiving SSI payments on August 22, 1996; and
2. SSI was terminated on or after July 1, 1997, because the child did not meet the new definition of disability established by Sec. 211 of P.L. 104-193.

In most cases, both conditions can be verified by a WTPY Response. The Current Pay Status field in the SSI section of the Response should indicate code N07 (not SSI eligible-cessation of recipient's disability). If the WTPY Response is inconclusive for either condition, the county should contact the Social Security Administration for clarification.

Determine whether the child is an eligible member of a Medicaid case.

If the child is currently open in category 45 (possibly pending the resolution of an appeal), no action is necessary. If the child is open in another category, see item 6.

If the child is not currently open in category 45, has never been opened in any other category, and the effective date of his or her SSI termination is within the last 6 months, create a new case record. A new application form is not required, but include copies of the WSSN and WASM screens.

After certification, send a manual notice of approval, along with instructions to report any changes to the county office.

1. If the child is currently Medicaid eligible in any category other than 45 (except ARKids First -- see item 7), it is not necessary to complete the steps in item 4 at this time. However, "Disabled Child" should be written in red on the upper right hand corner of the case record face sheet (DCO-86).
2. If the child should lose Medicaid eligibility in the non-SSI or non-ARKids First case for any reason other than turning age 18, the county should automatically determine eligibility in a category 41, using SSI income and resource methodology. The income limit is the SSI standard payment amount -- with parental income deemed (Re. MS 2111.2). The resource limit is $2000 -- with parental resources also deemed (Re. MS 2112.2). If the child is eligible, the county should prepare Form DCO-57 and key the certification, using the minimum record requirements listed in item 4b.

If the child is currently open in an ARKids First case (category 01), and it appears that he or she may be eligible in category 41 (i.e., is under age 18 and meets the SSI income and resource criteria), the county will contact the family or responsible individual, and ask if he or she wants an eligibility determination for the child.

1. If the answer is yes, the county will provide the family or responsible individual with a DCO-777 and proceed with the determination. If eligible, the county should advise the ARKids First Unit and request that the child's eligibility be ended. Once ARKids First eligibility ceases, the child may be certified in category 41, using the minimum record requirements in item 4b.
2. If the answer is no, the county will forward copies of the WACE and WAFM screens to the ARKids First Unit, and identify the child so that "Disabled Child" can be written in red on the ARKids First record face sheet as explained in item 6.

Reevaluations will be completed annually for all eligibility factors other than disability. No redetermination of disability will be required at any time to maintain eligibility for the child in category 41.

To be Medicaid eligible due to the 20% Social Security increase, an individual must meet the following criteria:

To determine current eligibility, the County Office must subtract the 20% Social Security increase from the current Social Security amount. If the 20% increase is not known, it must be calculated by subtracting the August, 1972 benefit amount from the September, 1972 benefit amount or calculating 20% of the August, 1972 benefit amount. Subtract only the 20% increase of the eligible individual(s); do not subtract the 20% increase of an ineligible spouse or any subsequent increases of any individual(s) included in the assistance unit.

The adjusted Social Security amount will be compared to current payment standards in the Financial Assistance Manual for AFDC or current SSI payment standards contained in MS 2034 (SSI exclusions are allowed for AABD). Resources and other income will also be evaluated against current AFDC or SSI criteria. Individuals who would be eligible for AFDC or SSI on this basis will be certified as AFDC, AA, AB or AD No-Grant.

Reevaluation of individuals who are Medicaid eligible due to the 20% Social Security increase will be conducted every twelve months and will involve the same procedures as outlined for determination of current eligibility. Form EMS-57 will be submitted to data entry when the reevaluation is completed. Subsequent EMS-57's will be generated by Data Processing.

Individuals who fail to meet the eligibility criteria will be closed by EMS-57. Advance notice will be given by EMS-700.

This section applies only to those individuals, if any, who were in Title XIX institutions in August 1972 and who were ineligible for cash assistance for that reason.

Individuals who would have been eligible under the August, 1972 AFDC criteria and who are making their initial applications, will be evaluated against the following:

Individuals who would have been eligible under the August, 1972 AABD criteria and who are making their initial applications, will be evaluated against the following:

1. Categorical Relatedness - age 65 or over, blind or disabled.
2. Citizenship - citizen of the United States or a lawfully admitted alien intending to permanently reside.
[MS 6700]
3. Residence - resident of Arkansas (i.e., must intend to reside in Arkansas).
4. Maximum limitation on net equity in a homestead - $7,500 and maximum limitation on other real or personal property - $1,500 for a married couple, if both are categorically eligible; $750 for an individual. The value of resources will be determined and treated in the same manner as outlined in the FA Manual with the exception of net equity in a motor vehicle. Net equity in a motor vehicle must be determined by obtaining the current assessed value from the tax assessor, or a current tax assessor's manual, multiplying by five and subtracting the value of any liens or encumbrances.
5. Budgetary Deficit - A standard budget must be calculated by subtracting income from budgetary allowances. Spouses will be budgeted together unless one spouse received AFDC or was in a nursing home. Budgetary allowances are:

1. Summary allowance for each eligible - $100 (food - $45, clothing - $15, personal and medical supplies - $40).
2. Summary allowance for ineligible persons (ineligible spouse, needy essential or needy dependent) - $30 (food - $25, clothing - $5).
3. Shelter and utility allowances - same as AFDC allowances listed in Section 2244.
4. Allowances for special living arrangements - $5 if applicant was required to eat meals away from home, up to $120, as paid, for home nursing care when found necessary by a physician, up to $150, as paid, for room and board (applied in place of allowances for food, shelter and utilities). Maximum Total Allowance - $210.

Earned income disregards - $50 for earned income over $80, for income under $80, the first $20 and one-half the remainder. In addition, a $20 allowance for each employed person will be subtracted for work related expenses. (Mandatory deductions and work related expenses above $20 may not be deducted). Only the $20 allowance for work related expenses will be subtracted from the earnings of the ineligible spouse.

The remaining income and all unearned income will be subtracted from the total requirements or maximum total allowance ($210), if applicable. There must be a deficit of at least $5 ($10 for spouses who are both applicants) to be determined eligible.

Individuals who were eligible for Medicaid in Title XIX institutions in December 1973 may continue to qualify for Medicaid. The State must provide Medicaid to those individuals, if any, who:

1. for each consecutive month after December 1973 -

1. continue to meet the requirements for Medicaid eligibility that were in effect under the State's plan in December 1973 for institutionalized individuals, and
2. remain institutionalized; and

2. are determined by the State to continue to need institutional care.

Reevaluation for public institution eligibles is required every twelve months.

Individuals who no longer meet these criteria will be evaluated against current Medicaid eligibility criteria(i.e. Section 3000).

Section 12202 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), PL 99-272, provides for the preservation of categorical Medicaid eligibility to disabled widows and widowers who:

became entitled to receive SSA benefits between the ages of 50 and 59; and

lost SSI benefits in 1984 due to an increase in SSA widow's or widower's benefits due to elimination of a benefit reduction factor that had previously applied, hereinafter referred to as the Reduction Factor increase.

The State must provide Medicaid to the above individuals if he or she:

1. was entitled to SSA for December 1983;
2. was entitled to and received a widow's or widower's SSA disability benefit for January 1984;
3. became ineligible for SSI after January 1984 due to the SSA benefit increase resulting from elimination of the Reduction Factor;
4. has been continuously entitled to a SSA disabled widow's or widower's benefit since SSI benefits were terminated due to the Reduction Factor increase;
5. would be eligible for SSI if the amount of the 1984 Reduction Factor increase and any subsequent cost-of-living adjustments were disregarded; and
6. applied for Medicaid benefits between July 1, 1986 and June 30, 1988 and was found eligible and certified for Medicaid benefits during that period (the end date for the application period for this group was extended from June 30, 1987 to June 30, 1988 by the Omnibus Budget Reconciliation Act of 1987). If an individual applied during the specified application period, but was denied, then that individual can reapply later and, if found eligible, can be certified at that time.

If the Medicaid case was closed for any reason after initial application between July 1, 1986 and June 30, 1988, it may later be reopened following a redetermination of eligibility.

The AABD guidelines in the MS 3000 section will be followed in redetermining eligibility. An individual who was denied during the specified application period and later approved, or an individual with a closed case which is later reopened, will have a Medicaid begin date effective the date of the new application. If retroactive coverage is requested, coverage may be given retroactively up to three months prior to the date of application.

The budget section on the DCO-57 will show all current income in the corresponding fields. In the unearned exclusion field, enter the total of the 1984 Reduction Factor increase, all COLA's received since January 1984, the $20 general exclusion and any other applicable SSI exclusions. Enter a "Y" in the MU field and the current SSI SPA in the MNIL field. The net income, after disregards and exclusions, will be entered in the Net Countable field. Only those individuals with net income under the SSI SPA will be eligible. If there is an ineligible spouse, deem according to MS 2111.1, and compare the resulting income to the couple's SSI SPA.

Cases will be maintained in Categories 11, 31, or 41, as appropriate.

Reevaluations will be done on a yearly basis.

The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) provides for preservation of Medicaid benefits for disabled widows and widowers who meet the criteria in MS 2046.1.

In order to be determined Medicaid eligible, these individuals must be:

Applications will be registered on WIMA in categories 31 and 41.In determining eligibility, the AABD resource limits and policy in the MS 3000 section will apply.

Income eligibility determination will be made by disregarding ALL current SSA income, regardless of type of benefit, when the benefit began, or amount of benefit. Any other income (RR Retirement, VA, private pension, etc.) will be considered in the budget. After the $20 and other applicable SSI Exclusions (Re. MS 3348) are deducted from income, the resulting net income will be compared to the current SSI/SPA (Re: SSI Chart at Appendix S). If the income is under the current SSI/SPA, the individual will be eligible for Medicaid.

Cases will be certified on WASM in Categories 31 or 41, using the closed SSI case number. All current income, including SSA, will be entered in the appropriate fields. In the unearned exclusion field, enter the total of all SSA income to be disregarded and the $20 and other SSI exclusions. Enter a "Y" in the MU field and the current SSI/SPA in the MNIL field. Net income, after all disregards, will be entered in the Net Countable Field.

Begin date of eligibility will be the application date, unless retroactive coverage is needed, in which case coverage may be given back to three months prior to the date of application.

Reevaluation will be conducted annually using the eligibility determination procedures in MS 2046.2.

Section 5103 of the Omnibus Budget Reconciliation Act of 1990 requires that Medicaid benefits be protected for a new group of disabled widows/widowers and for disabled surviving divorced spouses who lose their SSI due to receipt of SSA benefits based on a less restrictive definition of disability than was used prior to OBRA of 1990.

Individuals found eligible under these provisions will be entitled to the full range of Medicaid benefits.

An individual may receive Medicaid under these provisions, if he or she:

The Social Security Administration will determine which individuals are potentially eligible, based on their disability and marital status, and will refer those individuals to DEMS for eligibility determinations under these provisions.

Upon receipt of a Medicaid application (EMS-777), the County Office will register the application in Category 31 or 41. Other forms to be completed at the application interview are the EMS-86, EMS-87, EMS-662, EMS-707, and EMS-769.

The resources of a widow/widower or disabled surviving divorced spouse cannot exceed the current LTC limits for an individual. Resources are determined and verified according to LTC guidelines.

It is possible that some of the individuals referred by SSA will have remarried and will have a spouse in the home. In that case, the spouse will be considered an ineligible spouse, and the deeming of income rules at MS 2111.1 will apply in determining eligibility. The resulting net income will be compared to the couple's SSI/SPA for eligibility. Resources will be compared to the couple's resource limit.

In the event SSA refers both members of a married couple for eligibility determination, the SSA income of both individuals will be disregarded, along with the SSI exclusions, before comparing their net income to the SSI/SPA for a couple in the eligibility determination. The couple's resource limit will apply.

If approved, the application will be certified in Category 31 or 41 on the EMS-57. The action type "B" will be used and the old SSI closed case number will be utilized.

The disregarded SSA income, the $20.00 SSI exclusion, and other SSI exclusions, if any, will be totaled and entered in the Unearned Exclusion Field with "Y" in the MU Indicator Field. Net income, after all disregards and exclusions, will be placed in the Net Countable Income Field.

If certifying an eligible couple, each will be entered on a separate EMS-57, with separate case numbers. On the EMS-57 of each, a unit size of "2" and their combined income will be entered. The combined SSA disregards and SSI exclusions (only one $20 exclusion) will be entered in the Unearned Exclusion Field, and a "Y" entered in the MU Field. The couple's SSI SPA will be entered in the MNIL Field, and their net income in the Net Countable Field.

When there is only one eligible member of a couple, a unit size of "2" will be entered and the couple's SSI/SPA will be entered in the MNIL Field. The couple's combined income, after deeming, exclusions and disregards, will be entered in the Net Countable Field. The Unearned Exclusion and MU Field should be utilized as above.

The begin date of eligibility will be the date of application, unless retroactive coverage is needed. Retroactive coverage may be given up to three months prior to the date of application.

Reevaluations will be conducted on an annual basis. All factors of eligibility will be reestablished. Completion of the EMS-777, EMS-662, EMS-707, and EMS-769 are necessary for each reevaluation.

If an individual certified under these provisions becomes eligible for or entitled to Part A Medicare, case closure must be considered. Before closing the case, however, it should be determined whether or not the individual would be eligible for QMB benefits (Re. MS 2047).

In determining QMB eligibility, all SSA income will be counted in the budget, i.e., the SSA income cannot be given the disregard that is given in the disabled widow/widower or disabled surviving divorced spouse case. The QMB income and resource calculations and documentation may be made on a separate EMS-769. It will not be necessary to obtain a new application, EMS-777, unless it is time to make the annual reevaluation of the disability case.

If an individual is found QMB eligible, the existing disability case will be closed; and an application will be registered. The same case number will be used for the QMB case, which will be certified in Category 18 (if the individual is then age 65), Category 38, or Category 48, as appropriate.

The individual should be notified in advance by EMS-700 of closure of the disability case because of Part A Medicare eligibility or entitlement, but that the case will be reopened as a QMB with benefits limited to payment of Medicare premiums, deductibles and coinsurance. Closure of the disability case will be considered an adverse action, since QMB recipients are not entitled to the full range of Medicaid benefits.

Section 6 of Public Law 99-643, The Employment Opportunities for Disabled Americans Act, requires State Agencies to determine continuing eligibility for Medicaid benefits for individuals who lost their SSI on or after July 1, 1987, due to SSA Disabled Adult Children (DAC) entitlements or due to increases in their DAC benefits.

An individual who may be eligible for Medicaid in this categorically eligible group is one who:

• is age 18 or older,
• became disabled or blind before age 22,
• was receiving SSI based on disability or blindness, and
• lost SSI on or after July 1, 1987 due to a DAC entitlement or a DAC increase.

The Social Security Administration will notify the Agency of DAC cases through SDX, and County Offices will receive printouts entitled "SSI Recipients Terminated Due to DAC Increases" through system generation. Within 5 working days from receipt of the printouts, the County Office will notify the listed individuals that application will be needed to determine continuing benefits. Applications will be made on EMS-777's and will be registered in Categories 31 or 41, as appropriate.

In determining eligibility, the SSI resource limits will apply, and resource consideration will be made according to AADB guidelines in the MS.3000 section. No period of ineligibility will be imposed for a transfer of a resource for uncompensated value.

Income eligibility will be computed on the EMS-707. The income to be included in the budget will be the current income, less the DAC entitlement or increase that resulted in loss of SSI. Any income other than the DAC entitlement or increase will be counted. Examples: (1) If applicant previously had $446 SSI and was awarded $466 DAC, count "00" income; (2) if applicant had $400 DAC, $66 SSI and was awarded $66 DAC increase, count $400 DAC; (3) if applicant had $300 DAC, $100 VA, $66 SSI and was awarded $66 DAC increase, count $300 DAC and $100 VA. The $20 general exclusion and other SSI exclusions will also be deducted from current income, Net countable income will be compared to the current SSI SPA limits for eligibility.

Cases will be certified on WASM, using the closed SSI case number. In completing the EMS-57, enter all current income in the corresponding fields. In the unearned exclusion field, enter the total of the DAC benefit disregard, the $20 exclusion, and any other exclusions. A "Y" will be entered in the "MU" field, and the current SSI SPA in the MNIL. The net income, after disregards and exclusions, will be entered in the Net Countable field.

Begin date of eligibility will be the date of application, unless retroactive coverage is needed, in which case coverage may be given up to three months prior to the date of application.

Reevaluations of DAC cases will be made on a yearly basis. It will also be necessary to make a budget adjustment and income eligibility redetermination each January, as the annual SSA Cost of Living Adjustment must be counted as income.

Effective March 1, 1995, Section 201 of Public Law 103-296, the Social Security Independence and Program Improvements Act of 1994, mandated that States provide continuing Medicaid to drug addicts and alcoholics who lost their SSI, provided that they met certain requirements.

Public Law 104-121 repeals Section 201 of Public Law 103-296, and continuing Medicaid eligibility is no longer a requirement under the law.

Effective January 1, 1997 the Social Security Administration will terminate all SSI and Social Security Disability recipients who were receiving benefits because drug addiction or alcoholism was material to the finding of disability. They will no longer be considered categorically eligible as disabled individuals for Medicaid.

This revised disability criteria also applies to Medicaid recipients who were determined disabled by the Medical Review Team (MRT) due to their drug addiction or alcoholism.

Individuals whose disability status has been terminated due to the findings of SSA or MRT may apply for Medicaid at the county office. Unless the individual alleges a new and different disabling condition, he/she cannot be found eligible in a category in which disability is an eligibility requirement.

The Family Support Act of 1988 (Public Law 100-485), requires that certain AFDC families (Category 20) who lose eligibility April 1, 1990, or later, due to earned income must be given six (6) months of Initial Transitional Medicaid benefits without an application for such assistance.  These families may also qualify for an Additional 6 Months Transitional Medicaid Extension.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, extended this requirement to certain Medicaid families following replacement of the AFDC program with the TANF program. In Arkansas, families who lose eligibility for TEA Medicaid due to earnings are eligible for this extension.

Individuals approved for Transitional Medicaid will be eligible for the full range of Medicaid services, including services under the Children's Health Services Program.

In addition to the standard Medicaid eligibility requirements of citizenship, enumeration and child support enforcement, the following requirements must be met in determining eligibility for the Initial 6 Months TM Extension period:

1. The family must have become ineligible for TEA Medicaid due to increased wages or increased hours of employment (Re: MS 2061.3).
2. The family must have received TEA Medicaid in at least 3 of the 6 months immediately preceding the first month of TEA Medicaid ineligibility. Retroactive months count for this purpose (Re: MS 2061.4).
3. The family members must have been residents of Arkansas in the last month of TEA Medicaid eligibility, and must continue to reside in Arkansas.
4. There must be an dependent child under age 18 in the home (Re: MS 2061.6).

In addition to the eligibility criteria stated above, the following eligibility requirements must also be met in the Additional 6 Months TM Extension period:

5. The family must have received TM in each month of the Initial 6 Months TM Extension period.
6. There must continue to be a dependent child under age 18 in the home.
7. The parent (or non-parent specified relative) must have met the reporting requirement of the 1st 6 months and must meet the reporting requirements in the 1st and 4th months of the Additional TM Extension period (Re: MS 2061.7 and MS 2062.1).
8. The parent (or non-parent specified relative) must continue to be employed and receive earnings in each month preceding the 2nd and 3rd report periods of the additional TM extension period, unless good cause exists.

9. 9. The average monthly gross earnings of the eligible members (less paid child care costs) cannot exceed 185% of the Federal Poverty Level (Re: FPL Chart at Appendix F).

Resources, deprivation, and unearned income are not eligibility factors for TM.

A re-referral to OCSE is not required.

The Tea Medicaid case closure must be due solely to increased wages or increased hours of employment. If a TEA Medicaid family becomes ineligible due to earnings and for another reason in the same month, the family will be ineligible for Transitional Medicaid. For example, if the absent parent of all the TEA Medicaid children returns home and the caretaker parent becomes employed in the same month, the family will not be eligible for TM since earned income is not the sole reason for ineligibility. If, however, the TEA Medicaid family began receiving unearned income and earned income (of the caretaker parent) in the same month, a budget will be worked without the earned income. If the TEA Medicaid case remains eligible without the earned income and the inclusion of the earned income is the sole reason for TEA Medicaid closure, this requirement for TM has been met.

The increased earnings must be of the child's parent (or non-parent specified relative) who was included in the TEA Medicaid case as an eligible member in the last month of eligibility. The client’s declaration of earnings will be accepted to determine continued Medicaid eligibility when the TEA cash assistance case closes due to employment. If the family is converted to TM, based on self-declaration, verification of earnings will be required at the first quarterly report. If at the first quarterly report the caseworker determines that the family should have remained in TEA Medicaid, the case will be converted back to TEA Medicaid.

When it is determined that the family is ineligible for TEA Medicaid, and eligible for the Initial 6 Months Transitional Medicaid Extension, the AFDC Service Representative will manually issue Form DCO-123 to notify the family of their AFDC case closure; and to inform them of their eligibility for Transitional Medicaid and of the reporting requirement in the Initial 6 Months Transitional Medicaid Extension Period.

The TEA Medicaid case will be closed using a "CM" action type and action reason code 008 through 014, 031, or 033 on WACE. The earnings that resulted in TEA Medicaid ineligibility will be entered in the Case Budget segment. The Transitional Medicaid case will be keyed to the WATM screen, using Form DCO-125, and the TEA Medicaid case number.

The Initial 6 Months TM Extension will begin with the first month following the last month of TEA Medicaid eligibility. The begin date will be entered in the Transitional Medicaid Begin Date on WATM. Individuals included in the budget group in the last month of TEA Medicaid eligibility will be entitled to the Initial 6 Months TM Medicaid Extension. Night Edit will convert the case to Category 25 for all open members if the income keyed, when calculated by the system, shows the case to be ineligible for TEA Medicaid. The case will convert to critical error status and remain in Category 20 if the system calculations show the family remains TEA Medicaid eligible.

The family must have received TEA Medicaid in at least 3 of the 6 months immediately preceding the first month of TEA Medicaid ineligibility in order to qualify for TM.  Eligibility for retrocative TEA Medicaid can count toward the 3 months. This requirement must always be met. For example, after receiving TM for 4 months or longer, if the parent (or non-parent specified relative) loses employment, receives TEA  Meicaid for two months, than loses TEA  Medicaid eligibility again due to employment, the family will not be eligible for TM, as they did not receive TEA Medicaid in 3 of the last 6 months immediately preceding the first month of TEA Medicaid ineligibility.

If a family received TEA in another state at any time during the 6 months immediately preceding the first month of TEA ineligibility, this period can be used to determine eligibility for TM.

The family will not be eligible for Transitional Medicaid if it is determined that the family was ineligible for TEA Medicaid at any time during the 6 months immediately preceding TEA Medicaid ineligibility due to fraud (under current policy, only a court can make a determination of fraud).

The family members must be residents of Arkansas at the time they became ineligible for TEA Medicaid, and must continue to reside in Arkansas throughout the Transitional Medicaid period. Residence is not affected by temporary absence from the state (e.g., on vacation). The TM case will be closed if the family moves out of Arkansas. Subsequently, if the family returns to Arkansas after the TM case has been closed, the TM case cannot be reopened. The family will have to make an application, and eligibility will be determined in another category.

"Dependent Child" is defined, for TM purposes, as a child who is under age 18 who was living in the home in the last month of TEA Medicaid eligibility, and whose presence in the home helped establish TEA Medicaid eligibility.  As a condition of TM eligibility, there must be an dependent  child in the home in each month of TM. Eligibility for TM will terminate at the end of the first month in which the family ceases to include an dependent child. If the only dependent child leaves home and later returns after the TM case has been closed, the TM case may not be reopened, even if a portion of the 12 month TM period remains.

On the 6th workday from the end of the 3rd month of the Initial 6 Months Extension Period, the system will generate a notice and report form, DCO-124, to the family to be returned to the County Office by the 5th day of the 4th month. The parent (or non-parent specified relative) must report the household composition, the amount of gross earnings received, the amount of child care paid, and other circumstances which existed in the first 3 months of the Initial 6 Months TM Period. The DCO-124 will inform the family of its option for an additional 6 months period of TM which will be, in part, dependent upon the return of the DCO-124 report form in the 4th month of the Initial 6 Months TM Extension Period.

Upon receipt of a complete DCO-124, the County will key a "Y" in the "Report Received by County" field on WATM and will enter the date the report was received. This must be keyed to WATM no later than the 7th workday from the end of the 4th month. The earnings will be keyed into the budget section, but continuing eligibility is not based on the amount of earnings received in the first 3 months of the Initial Extension Period. If there is any unearned income in the budget fields, it should be removed with zeros (00s). Zeros should also be entered in the deduction fields. The only entries needed in the budget fields are gross earned income and child care. The system will compute the net earned income.

If the DCO-124 has not been received in the County Office by the 5th day of the report month (or the following workday if the 5th falls on a non-workday) or, if an incomplete DCO-124 is received, the following procedures will be used:

1. Notice DCO-126 and Form DCO-124 will be manually issued to the parent (or non-parent specified relative) no later than the 1st workday following the 5th day of the report month. The DCO-126 will advise the parent (or non-parent specified relative) that the DCO-124 must be returned in 10 days, or eligibility will not be granted for the Additional 6 months TM Extension period.
2. If the client returns an incomplete DCO-124, the caseworker will mail the incomplete form back with the DCO-126 and advise the client, in the space provided on the DCO-126, which questions must be completed or what verification is required. The client will also be advised that failure to return the completed DCO-124 in 10 days will result in ineligibility for the Additional 6 Months TM Extension Period.

A "complete" DCO-124 is defined as one in which each "Yes or No" question is answered, the explanations related to a "Yes" response are completed, and required verification is attached. Part I, Household Information, will be considered complete if sufficient information is shown to determine household composition.

If the county has not keyed a "Y" to WATM by the 7th workday from the end of the month, the system will close the case with a Medicaid end date effective the last day of the 6th month and will send a closure notice to the family. If the client returns a complete report form after the 7th workday from the end of the 4th month and good cause for an untimely report is established, or the County failed to key a "Y" by the 7th workday from the end of the month, the County will reopen the case on WACE (action type "B", action reason "096" and key a "Y" to WATM in the "Override Indicator" field, a "Y" in the "Report Received By County" field, and enter the date the report was received. The original Med Begin Date will be rekeyed and the Med End Date zeroed out. When the County reopens a case in this situation, it will not be necessary to register a new application.

NOTE: Good Cause for untimely reports (DCO-124): An untimely DCO-124 is one which is received after the 10 day notice period specified on the DCO-126. The client must establish good cause for an untimely report in order for the report requirement to be met. The determination as to whether good cause exists for returning an "untimely" report will be left to the judgment of the Service Representative, with approval by the County Supervisor or his/her designated representative. Some examples of situations which might result in good cause are hospitalization, out of town, client's new address had not been keyed by County which resulted in the client not receiving the report form, etc.

In the event the County Office is not informed by an TEA Medicaid recipient of increased earnings in a "timely" manner, eligibility for Transitional Medicaid will be determined from the month the family actually became ineligible for TEA Medicaid.

If the County Office is informed of an TEA Medicaid family's increase in earnings as late as the 5th day of the 4th month of TEA Medicaid ineligibility, eligibility will be determined for TM in each of the months succeeding the last month of TEA Medicaid eligibility. If the eligibility requirements in the Initial 4 Months TM Extension period (MS 2061.2 1-4) are not met, no additional benefits will be authorized. If the eligibility requirements in the Initial 4 Months Extension period (MS 2061.2 1-4) are met, continuing TM benefits will be authorized. The County will manually issue Form DCO-124 to the family, if it is later than the 3rd month of TEA Medicaid ineligibility. This report must be returned to the County by the last day of the 4th month of the Initial TM Extension Period in order for the family to qualify for the Additional 6 Months TM Extension period.

If the earned income is reported or discovered after the 5th day of the 4th month of TEA Medicaid ineligibility, eligibility for the Initial TM period will be determined (for purposes of an overpayment only) but the family will not be entitled to receive any Additional TM benefits.

In addition to continuing to meet each eligibility factor listed in MS 2061.2 1-4, the eligibility criteria specified in MS 2061.2 5-9 must also be met for the Additional 6 Months of TM.

The family must have received TM in each of the 6 months of the Initial Transitional Medicaid Extension Period. If the TM case is closed at any point during the Initial 6 months Transitional Medicaid Extension period (e.g., no eligible child in the home or moved out of Arkansas) the family will not be eligible for the Additional 6 Months TM Extension period.

On the 6th workday from the end of the 6th month of the Initial 6 Months Extension Period, the system will generate a notice and report form, DCO-124, to those families who met the eligibility factors in the Initial 6 months Extension Period. This report should be returned to the County Office by the 5th day of the 1st month of the Additional 6 Months TM Extension Period (the 7th month). The parent (or non-parent specified relative) must again report the household composition, the amount of gross earnings received, the amount of child care paid, and other circumstances which existed in the last 3 months of the Initial TM Extension Period.

Upon receipt of a complete DCO-124, the caseworker will determine the client's continued eligibility for TM and, if eligible, the County will document the case.

If a complete report form, DCO-124, is not returned by the 5th day of the 1st month of the Additional 6 Months Extension Period (the 7th month), or the following workday if the 5th falls on a non-workday or, an incomplete DCO-124 is received, the following procedures will be used:

1. Notice DCO-126 and Form DCO-124 will be manually issued to the parent (or non-parent specified relative) no later than the 1st workday following the 5th day of the report month. The DCO-126 will advise the client that the DCO-124 must be returned in 10 days or the case will be closed.

2. If the client returned an incomplete DCO-124, the caseworker will mail the incomplete form back with the DCO-126 and advise the client, in the space provided on the DCO-126, which questions must be completed or what verification is required. The client will be advised that failure to return the DCO-124 in 10 days will result in case closure.

If a complete DCO-124 is not received by the 7th workday from the end of the 1st month of the Additional 6 Months Extension Period (the 7th month), the County will close the case on WATM and WACE with a Medicaid End Date effective the last day of that month. If the client returns the report form after the 7th workday from the end of the month, the case has been closed, and good cause is established, the County will reopen the case on WACE, WAFM and WATM ("B" action type, "096" action reason, no new application necessary). The original Med. Begin Date will be entered, and the End Date will be zeroed out.

On the 6th workday from the end of the 3rd month of the Additional 6 Months Extension Period (9th month), if the case remains open, the system will generate a notice and report form, DCO-124, to the family to be returned by the 5th day of the 4th month of the Additional Extension Period (10th month).

Upon receipt of a complete DCO-124, the caseworker will determine the client's continued eligibility for TM and, if eligible, the County will document the case.

If a complete report form, DCO-124, is not returned by the 5th day of the 4th month of the Additional 6 Months Extension Period (the 10th month) (or the following workday if the 5th falls on a non-workday) or an incomplete DCO-124 is received, the following procedures will be used:

1. Notice DCO-126 and Form DCO-124 will be manually issued to the parent (or non-parent specified relative) no later than the 1st workday following the 5th day of the report month. The DCO-126 will advise the client that the DCO-124 must be returned in 10 days or the case will be closed.

2. If the client returns an incomplete DCO-124, the caseworker will mail the incomplete form back with the DCO-126 and advise the client, in the space provided on the DCO-126, which questions must be completed or what verification is required. The client will be advised that failure to return the DCO-124 in 10 days will result in the case closure.

If a complete DCO-124 is not received by the 7th workday from the end of the 4th month of the Additional 6 Months Extension Period (the 10th month), the County will close the case on WATM and WACE with a Medicaid End Date effective the last day of that month. If the client returns the report form after the 7th workday from the end of the month, the case has been closed, and good cause is established, the County will reopen the case ("B" action type, "096" action reason, no new application necessary). The original Med. Begin Date will be reentered, and the Med. End Date will be zeroed out.

NOTE: There are no automatic system closures in the Additional 6 Months Extension Period, except at the end of the 12th month.

In order for extended benefits to continue in the second 6-month period, the parent (or non-parent specified relative) must continue to be employed and receive earnings in each month preceding the 2nd and 3rd reports unless good cause exists.

Examples of good cause for loss of employment are illness, involuntary layoff, etc.

The family's average monthly gross earnings (less paid child care costs necessary for the parent, or non-parent specified relative, to maintain employment) cannot exceed 185% of the Federal Poverty Level (Re: FPL Chart at Appendix F).

To compute average monthly gross earnings:

1. Total for each month the earnings received by all eligible family members in each of the 3 reporting months (unearned income will be disregarded);
2. Subtract, from each month's total, the amount of child care paid in that month that was necessary for the parent (or non-parent specified relative) to maintain employment (use the actual child care paid);
3. Add the net results from each of these months; and
4. Divide the result by 3.

This figure is the family's average monthly gross earnings.

EXAMPLE: A family of 4 has earnings and paid child care for the reporting period as follows:

Minor children entering the household, who were not in the budget group at the time the group became TEA Medicaid ineligible, will not be eligible for Transitional Medicaid and will not be added to the case. If an excluded child has earnings, they will not be considered in computing the family's average gross monthly earnings. The Case Manager will determine eligibility for this child in another category, counting only the child and the child's parent(s) in the unit, and considering only their income.

Minor children, who were in the home and included in the TEA Medicaid case during the last month of TEA Medicaid eligibility, who later leave the home, will be dropped (a 10 day notice will be given). If he/she subsequently reenters the home while the family is receiving TM, he/she will be added to the Transitional Medicaid case. Any earnings that this child may have will be considered in computing the family's average gross monthly earnings.

The return of an absent parent to the home during Transitional Medicaid is not, in itself, a reason for closure (i.e., deprivation is not an eligibility factor for Transitional Medicaid). The absent parent who returns, if he/she was not in the budget group at the time of the TEA Medicaid case closure, will not be eligible for Transitional Medicaid and will not be added to the case. Any earnings of the returning parent, however, will be used in computing the family's average gross monthly earnings.

If the only child in the home becomes eligible for SSI, the parent(s) (or non-parent specified relative) will remain eligible for Transitional Medicaid as long as the SSI child is under age 18. However, the County will receive a Systems Action Report notifying them that the case has been closed. The caseworker will reopen the Transitional Medicaid case for the adults(s) by using a "B" action type and "096" action reason. The Transitional Medicaid Status on WATM will be changed to open status. The adult(s) must continue to meet all other eligibility requirements in order to remain eligible for Transitional Medicaid.

On the first workday of each month the system will search all Transitional Medicaid records for children who will reach the age of 18 that month. If the only child in the home is reaching age 18, the system will close the case and send a notice of case closure to the family. If there are other children under 18 in the home, the system will close only the 18-year-old and leave the remaining individuals open.

The Counties will receive a Systems Action Report that will inform them of Transitional Medicaid 18 year olds and cases closed by the system.

When the system has closed an 18 year old, or at any time a member or a case is found ineligible for Transitional Medicaid, the County Office will make a determination and document the case record as to whether or not the ineligible member(s) meets the eligibility criteria in any other Medicaid Category (e.g., PW, MN-SD, etc.). If it appears that a member or the case would be eligible in another category, an application and notice of potential benefits will be sent to the individual(s).

During the Additional 6 Months TM Extension Period (Second Six Months), a monthly report titled "Transitional Medicaid Cases" will be generated to the Counties to assist them in tracking the Transitional Medicaid cases. This report will list the Case Number, Casehead Name, Worker Number, Transitional Medicaid Begin Date, Current Month of Transitional Medicaid and the next month in which a Transitional Medicaid Report (DCO-124) is due.

At the end of the 12th month, the system will send a notice and close all Transitional Medicaid cases which remained open throughout both 6-month periods.

Found TEA Medicaid ineligible prospectively. Determined Transitional Medicaid eligible:

• Form DCO-123 manually issued to family.

Initial 6 months Extension Period

• 1st month of TEA Medicaid ineligibility.

• Notice/Report Form DCO-124 system generated to casehead on the 6th workday from the end of the month.

• Casehead must return DCO-124 with income and child care verification by the 5th day of the month. County completes DCO-125 and keys "Y" to WATM by the 7th workday from the end of the month. If the "Y" is not keyed, the system will generate a notice and close the case with a Medicaid End Date effective the last day of the 6th month.

• Notice/Report Form DCO-124 system generated to the casehead on the 6th workday from the end of the month.

Additional 6 months Extension Period

• Casehead must return DCO-124 with income and child care verification by the 5th day of the month. If family eligible, County documents case. If family ineligible, County must key closure to WACE and WATM with a Medicaid End Date equal to the last day of the 7th month.

• Notice/Report Form DCO-124 system generated to the casehead on the 6th workday from the end of the month.

• Casehead must return DCO-124 with income and child care verification by the 5th day of the month. If family eligible, County documents case. If family ineligible, County must key closure to WACE and WATM with a Medicaid End Date equal to the last day of the 10th month.

• System closes.

Three months of extended Medicaid will be authorized when a TEA Medicaid case is closed due to child support income (Action Reason 071) provided the case was open for at least three of the six months immediately preceding the first month of ineligibility. The three months will begin with the month following the first month in which the case became ineligible due to child support income. The TEA Medicaid ineligibility may have been caused in whole or in part by the child support income. Only those persons who were included in the budget in the last month of TEA Medicaid eligibility will be entitled to the three months of extended Medicaid.

The Arkansas Medicaid Program provides coverage of inpatient psychiatric care at the Arkansas State Hospital and George W. Jackson Center for eligible individuals under age 21 (up to age 22 if the individual is an inpatient at either hospital at the time of the 21st birthday). Individuals between the ages of 21 and 65 are not Medicaid eligible while institutionalized at either State Hospital.

Individuals age 65 and older, if eligible in a Medicaid category, may receive Medicaid coverage while institutionalized in a state hospital, but Medicaid will not pay for their inpatient psychiatric care, i.e., Medicaid will not pay the state hospitals a per diem rate for their daily care.

Individuals under age 21 who are already eligible for Medicaid can be covered for inpatient psychiatric care services at the State Hospital or the George W. Jackson Center without making an application.

Individuals under age 21 who are not eligible for Medicaid when they enter one of these facilities will be referred to the Agency for determination of eligibility. Referrals will be made to the County DHS Office in the individual's county of last residence or parent's residence. Individuals age 65 or over will be referred to the Pulaski-South County DHS Office or the Craighead County DHS Office.

Individuals admitted into the Arkansas State Hospital or the George W. Jackson Center from an in-home or noninstitutional setting will be evaluated against the following criteria:

The County Office is responsible for investigation and follow-up on each referral received from the State Hospital. An initial investigation will be made on all referrals to determine whether the patient is already eligible for Medicaid.

When it is determined that the patient is Medicaid eligible, a notice of the patient's eligibility status will be forwarded to the State Hospital by interagency memorandum. The notice will include the following items (if known): the recipient's name, his ten digit Medicaid ID Number, his aid category, date of birth, SSN, and Medicare Claim Number and/or other health insurer information. Correspondence will be mailed to: Director, Social Work Dept., State Hospital, 4313 W. Markham, Little Rock, AR 72201. No other action will be required for known Medicaid eligibles.

If a referred patient is not Medicaid eligible, the County Office will take steps necessary to secure and process an application for assistance in accordance with the requirements specified in MS 2071.

The State Hospital will be responsible for reporting when the patient is discharged. Discharge from the State Hospital by itself may not make the patient ineligible for Medicaid. The County Office will treat reported actions in accordance with the policies applicable to the category.

Public Law 97-35, Section 2176, the Omnibus Budget Reconciliation Act of 1981, allows states the option of providing home and community based services, as an alternative to institutionalization, to a limited number of individuals with a developmental disability who would otherwise require an ICF/MR Level of Care. 

The Omnibus Budget Reconciliation Act of 1987 (OBRA), Public Law 100-203, and Section 1916 (c) of the Social Security Act, mandates that specialized services be provided to mentally retarded/developmentally disabled (MR/DD) individuals who are residing in nursing facilities when it is believed that these individuals have been inappropriately placed.

The DDS Alternative Community Services Waiver Program was implemented in Arkansas on September 1, 1989, as a program designed to meet the needs of individuals who meet the ICF/MR level of care and who experience various health and social problems, thereby preventing unnecessary institutionalization and reducing health costs.

Individuals found eligible for the Waiver Program will receive the full range of Medicaid benefits, in addition to the Waiver services listed below.

Waiver services include:

• Case Management

• Consultation Services

•  Respite Care Services

• Supported Living Services

  o  Supported Living

  o  Transportation

  o  Community Experiences

• Environmental Modifications/Adaptive Equipment

• Specialized Medical Supplies

• Supplemental Support Services

• Supported Employment Services

• Crisis intervention

Respite care services can be provided in a recipient's home, other place of residence, or temporary placement within the community such as an intermediate care facility for the mentally retarded (ICF/MR) or a DDS licensed community group home.

Waiver applicants must meet the following eligibility requirements:

9. Cost Effectiveness - The average cost of services to the individuals in the community must be less than the average cost of services to individuals in an ICF/MR facility.

10. ICF/MR Level of Care - Individuals must be determined by the Division of Developmental Disabilities to require an ICF/MR level of care.

11. Must receive Waiver services. Medicaid only cannot be provided to an individual who is otherwise eligible for a Waiver program but who is not receiving (or will not receive) Waiver services. Prior to certification of a Waiver case, it must be assured that there are Waiver services available in the area where the individual lives and that the individual will receive Waiver services within a month of certification.

SSA Disability Determination - Applicants currently receiving SSI (or SSA) on the basis of a disability will be considered disabled. If a disability determination was made by SSA within the past year but the SSI or SSA benefits were terminated for nondisability reasons, documentation from SSA will be obtained for the case record. The applicant will be considered disabled based on the previous SSA disability determination.

1. Application Process

                    The DDS worker will obtain a completed DCO-777 from each applicant

                    or the parent/guardian/representative of the applicant UNLESS the

                    applicant is a current Medicaid recipient residing in an ICF/MR and nursing           

                    home facility OR opened in a TEFRA case.  Forms to be completed 

For current Medicaid recipients, who are residing in ICF/MR and Nursing Home facilities, refer to procedures in MS 2075.6.

When a TEFRA recipient completes ACS-102 Freedom of Choice form requesting DDS waiver services, an additional application is not required as eligibility for Medicaid has been established.  However, form DCO-727, Disposal of Asset Disclosure, must be completed as the transfer of resource provision applies to DDS Waiver individuals (MS 2075.1#8).  The DDS worker must also determine the disability status of the TEFRA recipient (MS 2075.2).  If a reexamination of disability is required, forms DCO-106, DC0-107, DCO-108, and DHS-4000 will be required and disability redetermined prior to approval. For further guidance on approving the DDS waiver and closing the TEFRA case, refer to MS 2075.5.

For other Medicaid categories (e.g. ARKids, AFDC-MN, etc) form DCO-777 will be completed along with all the required forms necessary to process the application for DDS Waiver services.

Upon receipt of completed applications, the Waiver Application Unit (WAU) will route the DCO-777s, or copies of the DCO-777s, to the Medicaid Income Eligibility Unit (MIEU), where they will be registered in Category 11, 31, or 41 (Exception:  Applications by SSI recipients need not be registered).

A DDS Medicaid Eligibility worker will have 45 days in which to process an application, or 90 days if a disability determination is needed.  It will be the responsibility of the DDS Medicaid Eligibility worker to verify and document each eligibility requirement.

2. Begin date of eligibility

                     With date specific eligibility, the beginning date of eligibility for Waiver recipients

                     will be the day of the month in which the Medicaid Waiver eligibility has been

                     finalized by the DDS worker.  However, the beginning date of eligibility for an

                     ICF/MR resident who leaves a facility can be no earlie than the date his/her   

                     facility residence was terminated.

3. Retroactive Eligibility

4. Appeals and Hearings

After the initial eligibility determination has been made, all income of the DDS Waiver recipient will be disregarded, i.e., DDS Waiver recipients will not be required to make a contribution to the cost of their care.

When submitting approval for the Waiver Program, the Action Reason-Approved Waiver will be used on WAIV ANSWER interface screen and Action Reason-Approved Medicaid will be used on WASM ANSWER interface screen. If a single member closed case is reopened, the case number assigned to the closed case will be used for the Waiver case.  Register the application in ANSWER using the closed case to ensure that the closed case number will be issued.  

When the Budget Unit characteristic of Waiver-Nursing Home is selected, the WAIV ANSWER interface screen will display the number "2999" in the WVNO field to identify clients who have been moved from an ICF/MR facility to enter the Waiver Program. The ICF/MR case must be closed before the Waiver case is opened, (ICF/MR case must be closed and allowed to edit over 72 hours before the Waiver case is opened).  Waiver certification cannot be made on the same day of the ICF/MR closure.

When the Budget Unit characteristic of Waiver-Community is selected on the WAIV ANSWER interface screen, the number “2900" will be displayed in the WVNO field to identify clients who have been living in the community prior to acceptance in the Waiver Program.

On the WAIV ANSWER interface screen the DDS Waiver recipient's total gross income will be displayed. 

If an applicant is currently open in a Medically Needy case all eligibility factors - including disability, if not previously established - will be determined prior to Waiver certification. The Medically Needy case will be closed or the individual dropped from the case prior to approval for the Waiver services.

If an individual found eligible for the Waiver program is currently certified in a Medically Needy Spend Down case, a Waiver certification will not be made until the Spend Down case has expired.

An open TEFRA child found eligible for the Waiver program will be certified in Category 41 after closure of the Category 49 TEFRA case.

Eligibility determinations may be made for applicants who request Waiver services and who are currently residing in an ICF/MR facility, when there is a plan to move them to a community setting. The approval request from DDS Waiver Unit is included in the file.  The Waiver Services and Medicaid Income Eligibility files are separate.

If an eligibility determination is made before an applicant is discharged from the ICF/MR facility, the Waiver case cannot be opened before the individual leaves the facility. 

For Medicaid eligible DDS Waiver applicants currently residing in ICF/MR Facilities, the following actions must be completed.

• Upon notification that an individual in an ICF/MR facility is requesting DDS Waiver services, DDS staff (Intake Unit or HDC Admission Coordinator), will meet with the individual or the individual’s guardian/legal representative and complete ACS-102 Freedom of Choice form.  Along with the ACS-102, the DDS staff will gather the following documentation to complete the Waiver packet:

1.      DHS-4000 – Release of information

2.      Current intellectual and adaptive assessments with scoring, written  

          report and credentialed signature within Waiver prescribed timeframes

3.      DHS-703 – Physician’s diagnosis (current within 1 year)

4.      Completed Areas of Needs form

5.      Current Social History

·        If the individual and/or his guardian are ready to select a provider, a provider choice form will be completed.  DDS staff will also obtain a copy of the DHS-704 (Eligibility) form from the individual’s file at the facility.

·         If the individual has not chosen a provider, the Waiver Unit Program Manager will assign a DDS Waiver Specialist to meet with the individual and/or his guardian to provide assistance in choosing a provider from the available choices.

·        Form ACS-102 and the DHS-704 will be submitted by the DDS staff to the DDS Waiver Application Unit along with notification of the request for waiver services for further processing and distribution.

·        The WAU will send the ACS-102 and DHS-704 to the DDS Medicaid Income Eligibility Unit for Waiver eligibility determination.

·        Once a determination of eligibility has been made, the DDS MIEU will email form DCO-3330 to the WAU advising eligibility status under the waiver category.

·        Once a choice of a provider has been selected, plan of care submitted and approved, and discharge date (determined by the ICF staff in cooperation with the receiving waiver provider) scheduled, the Waiver Application Unit will submit copy of the form DHS-702 to the DDS MIEU requesting the Medicaid case to be approved in waiver category upon date of discharge.

·        The Medicaid Income Eligibility Unit will forward a copy of the DHS-702 in email to the DCO Medicaid worker of the applicant (copying County Supervisor and County Administrator) and request he/she close the applicant on the WNHU screen.

·        Allow up to 72 hours edit; open up on WAIV screen, submit 3330 to Waiver Application Unit verifying waiver approval and start date as well as send DCO-700 to individual or guardian/legal representative advising of approval.

For individuals in a nursing facility, the following procedures will be followed:

·         The DDS Intake Specialist and/or Admission Coordinator will notify and submit the waiver packet to the DDS WAU.  

·         The individuals discharging from a nursing facility, the DDS Psychological Examiners will review current and past (if applicable) psychological evaluations to establish that the ICF/MR level of care requirement is met.  

·         The Psychological Examiner will complete the DHS-704 on eligible/ineligible individuals and submit to WAU.  

·         Once the ICF/MR Level of Care has been determined, the WAU will then disperse ACS-102 and DHS-704 to the MIEU for eligibility determination.  

·         WAU will submit DHS-702 verifying discharge date and request approval in waiver category.

If an eligibility determination is made before an applicant is discharged from the ICF/MR facility, the Waiver case cannot be opened before the individual leaves the facility.  The 45 (or 90) day time frame for processing applications must be followed.

To certify the DDS waiver case, close the LTC vendor portion of the case, but do NOT close Medicaid.  72 hours after closure of the vendor portion of the case, the Waiver portion of the case may be opened.  

When the client has left the facility, DCO worker will close the ICF/MR case in ANSWER with a Nursing Home STOP DATE effective the date the individual left the facility. A MED END date should not be entered in ANSWER.  After 72 hours if an individual who left an ICF/MR facility is to live in a community setting, the DDS worker will key the Waiver certification in ANSWER.  The WAIVER START DATE cannot overlap, so it will be the day after the client left the ICF/MR facility. The address will be changed in ANSWER.  It is not necessary to rekey or change the MED BEGIN DATE; the original date shown on the screen will remain.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193) replaced the Aid to Families with Dependent Children (AFDC) program with the Temporary Assistance for Needy Families (TANF) program. In Arkansas, the TANF program is known as Transitional Employment Assistance (TEA).

Low-income families and children who receive cash assistance are no longer automatically entitled to Medicaid. Certain individuals may be Medicaid eligible in the TEA category if their net income and countable resources do not exceed the AFDC income and resource limits which were in effect on July 16, 1996, and if there is deprivation of parental support. An individual need not be receiving TEA cash assistance to be eligible for Medicaid in this category.

Individuals approved for TEA Medicaid will be eligible for the full range of Medicaid services, including services under the Children's Health Services Program.

2086 Eligibility Requirements

Note: When there is a non-parent payee (e.g., grandmother, aunt, etc.) who is in need of Medicaid coverage, but not cash assistance, the payee can be added to Medicaid, with his or her income and resources considered in the budget.

Stepparents will not be budgeted with their stepchildren.

An adult caretaker can be eligible for Medicaid even if the deprived child is not eligible. The caretaker must have a deprived child in his/her care who is dependent, but for whatever reason, not eligible for Medicaid (e.g., a child receiving SSA whose parents are deceased, the child has insurance, they don’t want to include the child due to child support requirements, etc.).

Income is determined and verified as specified at TEA 2300-2353.2 with the following exceptions:

1. Income available only to a stepparent will be disregarded in the eligibility determination of the stepchild. Eligibility for the parent can be determined in TEA related Medicaid only if the stepparent has no countable income. If the stepparent has countable income, eligibility for the parent will have to be determined in a separate category with the stepparent's income deemed to the parent using the 100% standard of need (Re. FA 2377.1 and Appendix T).

2. When determining eligibility for TEA Related Medicaid, a $50.00 disregard will be applied to Child Support Income per month.

The following TEA cash assistance eligibility factors are not required for TEA related Medicaid eligibility:

Initial eligibility for TEA related Medicaid will be determined at the same time that eligibility for TEA cash assistance is determined. Applications for TEA cash assistance is not a requirement for TEA Medicaid. A family may apply and be considered for TEA Medicaid without applying for TEA cash assistance. Initial applications may be made on the DCO-180, Application for Transitional Employment Assistance. Other forms needed for new applicants are the DCO-96, DCO-86, DCO-662, and DCO-7. If additional information is needed, the county worker will also complete Form DCO-002 and give it to the applicant during the initial interview.

The county office worker will have a maximum of 30 days from the date of application to dispose of the application by one of the following actions: approval, denial, or withdrawal.

When all eligibility requirements have been met, the county office worker will take necessary steps to enter the case to the automated system (using action reason 101). The begin date of Medicaid eligibility will be the date of application, unless retroactive coverage is needed. Retroactive coverage may begin up to three months prior to the application date. Retroactive coverage should always be considered in TEA Medicaid, as retroactive months count toward the 3 of the last 6 month rule in Transitional Medicaid (MS 2061.4).

The county worker will complete the following tasks when denying an application:

Cases will be reevaluated every twelve months. Medicaid reevaluations should be scheduled to coincide with the TEA cash assistance reevaluation, if applicable to the household.

Recipients are required to report changes within ten days after the change occurs. If a reported change will result in adverse action, a ten day advance notice via Form DCO-700 will be given, if required (Re. MS 7840). All changes will be documented in the case record.

When a recipient goes to work, the county office worker will ask all information necessary to calculate income (e.g., number of hours working per week, place of employment, wages per hour and how often paid). If written verification from the employer is not provided, the client’s declaration of earnings will be accepted and the budget will be computed to determine if the client is still eligible for TEA Medicaid or should be moved to Transitional Medicaid. The earnings will be verified at the next reevaluation or at the first quarterly report.

If a TEA Related Medicaid case closes due to Child Support Income, the worker should determine if the household is eligible for the 3 months of extended Medicaid as specified in MS 2063.

If income from earnings exceed the income limit for TEA Related Medicaid, the case will be converted to Transitional Medicaid, if all TM eligibility requirements are met (Re. MS 2061.2).

The State is required to provide retroactive eligibility, for up to three full months prior to the date of application, to applicants who:

1. received services in the retroactive period; and
2. were eligible in the month the services were received.

Retroactive eligibility will be provided to applicants who were otherwise eligible in the month services were received, regardless of whether they were ineligible at other times during the retroactive period. Retroactive eligibility is separate and apart from current eligibility, i.e., applicants not eligible for the current period may be eligible for the retroactive period. Retroactive eligibility determinations are required for all categories, except AAS/ACS, DDS/ACS, QMB, SMB, QDWI, and PW-PE Retroactive coverage for Newborns will not be given prior to the date of birth.

An application for retroactive eligibility may be made on behalf of deceased persons and eligibility will be provided if they were eligible when the services were received.

For cases in which an applicant has not resided in Arkansas for three full months prior to the date of application, the retroactive period begins with the date the individual established residency in Arkansas. The "previous state" is responsible for the retroactive period prior to the time the applicant established residency in Arkansas. The County Office is responsible for providing the "previous state" with information necessary to determine eligibility for its portion of the retroactive period.

Services for the retroactive period are subject to the same restrictions as services for the current period (i.e., utilization review, benefit limitations, medical necessity, etc.). Prior authorization cannot be a condition of payment for services received during the retroactive period. However, such services are subject to the same Title XIX Utilization Review standards as all other services financed under the State's Title XIX program. The State is not required nor obligated to pay for services which have been retroactively determined by Utilization Review to be unnecessary.

For cases in which an applicant has made partial or full payment for services received during the retroactive period, the state will make payment to the servicing provider if: 

1. the services were necessary and the applicant was eligible when the services were received; and 

2. the provider is willing to refund the payment to the applicant and bill the State for the services.

The Service Representative will orally make information on retroactive eligibility available to all new applicants at the time of application.

The eligibility determination for retroactive Medicaid for AFDC is the same as the eligibility determination for current AFDC, except that the $30 and 1/3 earned income exclusions will not be given. The applicant(s) should have alleged medical expenses for the retroactive period.

The County Office should be aware that eligibility for the retroactive period cannot be assumed merely on the basis of current eligibility. For example, a woman who gives birth to her first and only child in the month of application and is determined eligible for current AFDC would not be eligible for retroactive AFDC Medicaid because there would not be a dependent child in the family unit during the retroactive period. Also, a parent and child/children who are abandoned, etc., in the month of application and are determined eligible for current AFDC would not be eligible for retroactive Medicaid because the children would not meet the deprivation of parental care and support requirement for the retroactive period. If an applicant being approved for AFDC does not meet all of the AFDC requirements in the retroactive period, then it must be determined if the applicant would be eligible in the retroactive period in any other category of Medicaid.

The County Office will indicate each month/year of retroactive AFDC Medicaid eligibility on the EMS-56 (when authorized in conjunction with current AFDC eligibility).

The AFDC case record should contain sufficient documentation to reflect whether or not eligibility requirements are met for the retroactive eligibility period.

Procedures for authorizing retroactive eligibility only, (i.e., "Fixed" eligibility) are outlined in MS 2160.

The begin date of the retroactive period will be entered on the EMS-56 at certification (when authorized in conjunction with current PW eligibility). Documentation of the retroactive eligibility determination should be made in the case record.

Procedures for authorizing retroactive eligibility only, (i.e., "Fixed eligibility) are found in MS 2160.

If application for retroactive PW coverage is made after termination of a pregnancy and coverage after the month of delivery (or after the end of the postpartum period for a SOBRA PW) is also requested, a separate application must be made in the appropriate category to provide coverage for the month(s) following the expiration of the PW coverage.

Retroactive determinations may not be made for Category 62 (PW-PE).

The eligibility determination for retroactive U-18 is completed in the same manner as the eligibility determination for current U-18. The applicant should have alleged medical expenses for the retroactive period.

The County Office will indicate the begin date of retroactive eligibility on the EMS-56 when authorized in conjunction with current eligibility.

The retroactive eligibility determination will be documented in the case narrative.

Procedures for authorizing retroactive eligibility only, (i.e., "Fixed" eligibility) are outlined in MS 2160.

For any month that an individual was in an LTCF during the retroactive period, the eligibility determination for retroactive LTC is the same as the eligibility determination for current LTC.

The County Office will indicate the begin date of retroactive eligibility on the EMS-57 when authorized in conjunction with current LTC vendor payment.

The County Office should be aware that eligibility for retroactive Medicaid based on LTC criteria can only be determined for applicants who were institutionalized prior to the month of application. Applicants who first qualify for LTC in the month of application will have to be determined eligible for retroactive Medicaid in another category, e.g., Medically Needy. A separate application will be required for the retroactive Medically Needy determination with authorization made on a separate EMS-57.

The County Office is notified of SSA Retroactive Blindness and Disability Determinations for SSI Recipients on Form EMS-109A. The EMS-109A identifies the month(s) to be considered for retroactive eligibility determination.

The DCO-109As will be retained in an alphabetical file for a period of three years unless the County Office receives notification of alleged medical expenses for the retroactive period. Notification of alleged medical expenses may be by means of:

1. data processing printout (sent periodically as SSA makes information available); or
2. direct contact by recipient.

When the County Office has been notified of alleged medical expenses of AB or AD SSI recipients, but has not received an DCO-109A, the AB or AD SSI recipient will be referred to SSA to secure verification of blindness or disability. If difficulty is encountered in securing the DCO-109A, the Central Office Client Assistance Section may be able to assist the County Office.

The County Office will also receive notification of AA SSI recipients who have alleged medical expenses for the retroactive period by the same means as described above. The County Office will need to make retroactive eligibility determinations on these AA SSI recipients only if they reached age 65 prior to the month of application with SSA.

Once notification of alleged medical expenses and verification of age, blindness or disability for the retroactive period have been received, the County Office will contact the SSI recipient to make an appointment for the retroactive eligibility determination.

Eligibility for AA, AB or AD SSI recipients will be determined against LTC criteria using MS 3340-3348.1 and MS 3330-3339.8 for income and resources, respectively, with the exception of income and resource deeming, which is determined in MS 2111 and MS 2112, respectively. The County Office will recognize the SSA application date for purposes of determining the retroactive period. Applications for retroactive eligibility by SSI recipients will be secured on Form DCO-777. Income eligibility will be determined on Form DCO-707 by completing Sections 1, 2 and 5. Countable income determined in Section 2 of the DCO-707 will be compared with the SSI income standards for individuals or couples to determine income eligibility (Re: SSI Chart at Appendix S).

NOTE: Individuals (or couples) living in the household of another may be considered to be in the "A" Living Arrangement when it is documented that they pay an equal share of the total household expenses.

Resource eligibility will be determined by verifying and evaluating the resources, if any, of the recipient.

Retroactive Medicaid eligibility for SSI recipients is authorized on the single member screen, WASM, by completing an Other (0) action on form EMS-57 and entering the begin date of eligibility in the Retroactive Medicaid Months Field. The begin date cannot be more than three months prior to the SSI application date. The EMS-57 should contain only minimum entries to identify the recipient and update the record (i.e. Recipient Name, Medicaid 1.D. No., Action Date, Action Type, Worker No., and the retroactive month(s) authorized).

NOTE: If the SSI case is closed at the time that the county determines retroactive Medicaid eligibility, the county will not be able to key eligibility for the retroactive period to ACES. When this happens, the county office will send a memorandum requesting the retroactive coverage along with a copy of a completed EMS-57 to the Medical Eligibility Unit, Slot 1223, P. O. Box 1437, Little Rock, AR 72203, so that retroactive coverage may be keyed from the central office.

When the applicant/eligible resides with his ineligible spouse or ineligible parents (if the eligible is a blind or disabled child), deeming of income from the ineligible spouse or parent(s) is required. Different procedures are provided for deeming of income from the recipient's ineligible spouse and for deeming of income from ineligible parent(s). These procedures are explained below for use in Retroactive Medicaid Determinations of SSI Recipients.

1. From unearned income, deduct the $20.00/mo. general exclusion (carry over any unused balance of the exclusion and deduct from earnings);
2. From earned income deduct the $65.00/mo. work expense allowance plus one-half(1/2) the remaining balance;
3. Total remaining earned and unearned income to arrive at countable income.

7. Compare the countable income, after deeming, to the SSI SPA for a couple. If countable income is less than the couple's SPA, the applicant is eligible. If countable income is equal to or greater than the couple's SPA, the applicant is ineligible.

NOTE: The following examples reflect January 1, 1994 - December 31, 1994 amounts.

Example - Deeming of Income from an Ineligible Spouse

An applicant has gross earned income of $285.00/mo. and unearned income of $140.00/mo. His ineligible spouse has gross earned income of $170.00/mo. and unearned income of $300.00/mo. and his ineligible child has no income. Deemed income is determined as follows:

1. From the applicant's earned income deduct the work expense allowance, $65.00 plus one-half (1/2) the remaining balance (i.e., $285.00 - $65.00 = $220.00 divided by 2 = $110.00).

From the applicant's unearned income deduct the general exclusion (i.e., $140.00 - $20.00 = $120.00). Add the earned and unearned income amounts ($110.00 + $120.00 = $230.00).

Since the applicant's total countable income is less than the individual SPA (i.e., $230 as compared to $446.00) complete #2 -#7.

For purposes of determining retroactive medical eligibility, a stepparent's needs and income will be disregarded.

1. Determine the gross monthly income of the ineligible parent(s) by type, earned and unearned less income excluded from deeming (Refer to MS 2111.5 to determine income excluded from deeming).
2. From the ineligible parent(s)' income deduct a living allowance for each ineligible child in the home (i.e., those not receiving SSI as blind or disabled children). Any income of the child is used to reduce this allowance unless it is excluded as student earned income. Refer to MS 2111.5, #10 to determine whether any of the student earned income is used to reduce the living allowance). The living allowance is deducted from unearned income first, and any unused balance is then deducted from earned income.
3. After deduction of living allowance(s) from income, the next step in the deeming determination from ineligible parent(s) will be as follows:

1. From unearned income, deduct the $20.00/mo. general exclusion (carry over any unused balance of the exclusion and deduct from earnings);
2. From earned income, deduct the $65.00/mo. work expense allowance plus one-half (1/2) the remaining balance;
3. Total remaining earned and unearned income;
4. From total remaining income, deduct a living allowance for the ineligible parent(s) equal to the SSI SPA.
5. Remaining income (if any) is deemed to the child as unearned income. It is subject to the $20.00/mo. general exclusion in the child's countable income determination.

4. If parental income is deemed to more than one eligible child, prorate the deemed income equally to each child.

Examples - Deeming of income from parent(s) to a child. (Examples reflect 1/1/94-12/31/94 figures)

Example #1. A child has gross unearned income of $35.00/mo. His ineligible parents have gross earned and unearned income of $900.00/mo. and $223.00/mo., respectively. There is one ineligible child. Deemed income is determined as follows:

1. The ineligible parents have gross monthly earned and unearned income of $900.00 and $223.00, respectively. Proceed to #2.
2. From the ineligible parents unearned income, deduct the living allowance for the ineligible child (i.e., $223.00 - $223.00 = -00.00; Since remaining income is earned only, step 3.a. will be completed.

2. From remaining income, deduct the ineligible parents living allowance equal to the couple's SSI Standard Payment Amount  (i.e., $417.50 - $669.00 = $00.00).
3. $00.00 is deemed to the child as unearned income. This amount would be added to the child's own income for his eligibility determination.

Example #2. A child has gross unearned income of $130.00/mo. His ineligible parents have gross unearned income of $800.00/mo. There is one ineligible child. Deemed income is determined as follows:

1. The ineligible parents have gross monthly unearned income of $800.00. Proceed to #2.
2. From the ineligible parents income, deduct the living allowance for the ineligible child 
   (i.e., $800.00 -$223.00 = $577.00). Since remaining income is unearned only, step 3.b. will be completed.
3.       b.    1.   From remaining income, deduct the general exclusion
                             (i.e.,$577.00 -$20.00 = $557.00),

2. From remaining income, deduct the ineligible parents' living allowance
   (i.e., $557.00 - $669.00 = $0.00),
3. $0.00 is deemed to the child as unearned income. This amount would be added to the child's own income for his eligibility determination.

Example #3. A child has gross unearned income of $35.00/mo. His ineligible parents have gross earned and unearned income of $685.00/mo. and $300.00/mo., respectively.

1. The ineligible parents have gross monthly earned and unearned income of $685.00 and $300.00, respectively. Proceed to #2.
2. There are no ineligible children.

   3.    c.          1.   From unearned income deduct the general exclusion 
                                (i.e., $300.00 - 20 = $280.00).

Where there is a blind or disabled child living in the home with his parents and one is categorically eligible (i.e., acceptable evidence exists that proves that the parent would qualify as aged, blind or disabled except for income), income of the ineligible parent is deemed first to the categorically eligible spouse and then to the eligible child. Deemed income to a blind or disabled child under these circumstances is determined as follows:

Where a blind or disabled child is in the home with parent/parents who is/are eligible except for excess income (i.e., acceptable evidence exists that proves that the parent/parents would qualify as aged, blind, or disabled except for income), only income above the parent(s)' SPA is deemed to the child. Deemed income is determined as follows:

The items listed below are excluded from income of the ineligible spouse or ineligible parent(s) before determination of deemed income.

When an applicant/eligible resides with his ineligible spouse or ineligible parent(s) (if the applicant is a blind or disabled child), deeming of resources from the ineligible spouse or parent(s) is required. The resource limits given in MS 2112.1 and MS 2112.2 are the current resource limits.

Note: Pension funds owned by an ineligible spouse or ineligible parent(s) are excluded from deeming. This includes any IRA, Keogh, or money held in a retirement fund under a plan administered by an employee or union.

The applicant and his ineligible spouse are permitted a couple's countable resource limit of $3,000 (Allow SSI Exclusions); there is no actual deeming.

For purposes of resource deeming, a stepparent living in the home with an eligible child is not considered a parent. Do not deem a stepparent's resources to a stepchild.

Under current SSA regulations, an SSI application will not be completed for an applicant who dies before income and resource eligibility is determined and for an applicant who is not survived by an eligible spouse. Therefore, the County Office will have the responsibility for the income and resource eligibility determination for the month of application and up until death in addition to the retroactive period. An individual responsible for the medical debt of the deceased may make the application. Individuals who have been denied SSI for reasons other than disability may also apply for retroactive eligibility. In either case, the eligibility determination will be the same as the determination for eligible SSI recipients. The County office will still need an EMS-109A from SSA on applications for AB or AD.

Applications for deceased individuals, or individuals denied by SSI, will be registered on WIMA in the Aged, Blind, or Disabled categories (Categories 11, 31, or 41 respectively).

Deceased individuals or individuals denied by SSI who qualify for retroactive eligibility will be certified for fixed eligibility by Form EMS-57 in the appropriate category (Aged - 11, Blind - 31, or Disabled - 41).

Case records for SSI retroactive eligibility will be retained in closed files for a three-year period.

Applicants in any Medicaid category may qualify for "Fixed" eligibility (retroactive and/or current) under certain conditions. The State is required to provide "fixed" eligibility to applicants who:

1. received medical services in the eligibility period (retroactive and/or current); and

2. were eligible when the services were received;
3. died before eligibility was determined; or
4. became ineligible following the month of application, but before eligibility was determined.

The County Office will be responsible for the eligibility determination for all applicants who qualify for "fixed" eligibility.

The County Office will certify an individual for fixed eligibility on the EMS-56 or EMS-57 by showing a "begin date" and an "end date" on the appropriate form. Action type will be "AF" for a new case, or "BF" for a reopened case.

Residency regulations are intended to assure uniform application of residency rules and to assure that no otherwise eligible individual is denied Medicaid because no State recognizes him as a resident.

State residency determinations are as follows:

1. An individual placed in an out-of-state institution is a resident of the State making arrangement for placement regardless of the individual's indicated intent or ability to indicate intent;
2. An individual receiving State Supplementation of SSI is a resident of the State making said payments;
3. A noninstitutionalized individual under age 21 whose eligibility is based on blindness or disability is a resident of the State where he is living;
4. A noninstitutionalized individual under age 21 whose eligibility is determined on a basis other than blindness or disability is a resident as determined by AFDC requirements;
5. A noninstitutionalized individual age 21 or over is a resident of the State where he is living,

1. with the intention to remain permanently or for an indefinite period of time, or
2. which he entered with a job commitment or seeking employment.

6. An institutionalized individual under age 21, or age 21 or over and incapable of indicating intent, is a resident of the State where the institution is located, unless he is proven to be a resident of another State through application of the following determinations:

1. An institutionalized individual under age 21, or age 21 or over who became incapable of indicating intent before age 21, is a resident of the State of:

1. his parents or legal guardian, if one has been appointed, at the time of his placement; or
2. the parent applying on his behalf if the parents reside in Separate States and a legal guardian has not been appointed;

2. An institutionalized individual who became incapable of indicating intent at or after age 21 is a resident of the State where he first became incapable of indicating intent. If this cannot be determined, the State of residence is the State which first determines the individual to be incapable of indicating intent.

NOTE: For purposes of State residency - an institution is a Title XIX Long Term Care Facility, and

1. an individual is considered to be incapable of indicating intent to re-reside in a State if:

Determinations specifically prohibited for State residency are as follows:

Medicaid regulations provide for written agreements between States to resolve cases of disputed residency. These agreements may specify criteria for residency other than the aforementioned determinations provided:

1. they do not stipulate criteria which result in loss of residency in both States or criteria which are prohibited by regulation, and
2. they stipulate procedures for providing Medicaid to individuals whose cases are involved in disputed residency.

As the State of Arkansas enters into written agreements with other States to resolve cases of disputed residency, the County Office will be notified. The notification will identify the State(s) and the criteria of the agreement(s).

The County Office will contact the Medical Eligibility Unit when either of the following situations occur: