The CAO must determine whether an individual is eligible for Healthy Horizons categorically needy benefits before considering NMPF, Healthy Beginnings, SSI-related NMP, or MNO MA.
NOTE: The individual who meets eligibility requirements for Healthy Beginnings and for Healthy Horizons must choose one coverage group of the MA program before eligibility is determined for any other family members. If the individual chooses Healthy Horizons, the Healthy Horizons individual is not included in the MA eligibility determination for the remaining members receiving or applying for NMP or MNO. If the individual chooses Healthy Beginnings, the Healthy Beginnings individual is treated according to the requirements of the MA program the remaining members are receiving or applying for.
Reminder: An individual enrolled in Healthy Horizons is automatically enrolled in Buy-In. If the individual chooses Healthy Beginnings and has income within Buy-In limits, the individual must be manually accreted into Buy-In.
If an elderly or disabled individual does not qualify for Healthy Horizons categorically needy benefits, the CAO must determine whether the individual can qualify under NMP spend-down.
NOTE: The CAO must consider eligibility for NMP under the SSI Pickle Amendment rules if the individual was receiving both Social Security (RSDI) and Supplemental Security Income (SSI) benefits when he became ineligible for SSI. (See Section 387.6, Extended NMP-Special Circumstances.)
If an elderly or disabled individual does not qualify for NMP, the CAO must determine whether the individual is eligible for Healthy Horizons cost-sharing benefits or for MNO spend-down, depending on the individual’s needs.
If the individual does not qualify for NMP or MNO, the CAO must determine whether the individual can qualify for SLMB or QI benefits.
A child born to a disabled woman who is receiving MA on the day of the child’s birth is automatically eligible on the date of birth and remains eligible for one year.
NOTE: This applies only if ongoing eligibility for MA has been established. This does not apply to women who are presumptively eligible. (See Section 318.13.)
Medical expenses are not considered for Healthy Horizons eligibility; so, there is no patient payment or spend-down provision.
Healthy Horizons categorically needy benefits may be approved retroactively if the applicant or recipient has an unpaid, covered medical expense from before the date of application. (See Chapter 338, Section 338.3 Retroactive Medical Assistance Eligibility.)
The CAO must authorize Healthy Horizons, SLMB, or QI as follows:
1. Authorize benefits effective on the date the signed application is date-stamped by the CAO or, if it was submitted by a provider, on the earliest date it was signed. Use the categories and program status codes listed in Chapter 305, Category.
NOTE Applicants or recipients in the same household who are identified by the same program status code may be in the same budget group.
2. For continuing eligibility, CIS/e-CIS posts a renewal date that is 12 months from the start date. Modify the renewal date, if it is required.
3. For continuing eligibility, if an individual is also eligible for Buy-In, see Chapter 388, Buy-In, and “Using IEVS – Chapter 10, Exchange 7 – Buy-In” for enrollment procedures.
4. Enter insurance information, including Medicare coverage, in the third-party liability (TPL) screens in CIS/e-CIS.
NOTE: If benefits are SLMB with no MA coverage or QI, do not enter medical resources in CIS/e-CIS.
5. Send a notice to the applicant letting him or her know of the eligibility determination. (See Chapter 377, Notices.) If he or she is eligible for continuing benefits, the notice should inform the individual the date eligibility will begin. If the individual is eligible for Buy-In of Medicare premiums, a notice will be generated by CIS/e-CIS telling the individual that DHS has sent a request to the federal government for Medicare Buy-In enrollment.
Updated February 14, 2012, Replacing June 20, 2008