Operations Memorandum - Medical Assistance
OPS020408

4/30/02

SUBJECT: Medical Assistance for Workers with Disabilities (MAWD)
TO: Executive Directors
FROM: Mary Brugger, Acting Director, Bureau of Operations

Purpose

To issue questions and the corresponding answers on MAWD.

Background/Discussion

Staff Development Training sessions and County Assistance Offices have submitted questions on MAWD. These questions and the corresponding answers are being issued by this Operations Memorandum. The questions are divided into the following areas:

Attached are the MAWD Questions and Answers.

Next Steps

  1. Review this Operations Memorandum and attachment with appropriate staff. 

  2. Contact your Area Manager if you have questions. 

  3. This Operations Memorandum becomes obsolete upon receipt of the Medical Assistance Eligibility Handbook pages.

Attachment


QUESTIONS AND ANSWERS ABOUT MAWD

Medicaid for Other Family Members

QUESTION #1

At our trainers meeting, I think we brought up the issue of whether the MAWD eligible individual is to be considered a "recipient" when determining eligibility for other Medicaid applicants. This is a rather important issue when evaluating eligibility for other family members in TANF-related or GA-related categories under NMP and MNO.

QUESTION #2

If someone is found eligible for MAWD, are his income and resources used to determine eligibility for other members of his family who are applying for other MA benefits?

QUESTION #3

In Healthy Horizons once a person is found eligible for Medicaid in an HH category they are pulled from the computation for Medicaid for other family members. Will this apply to MAWD eligibles?

QUESTION #4

Once authorized for MAWD, is the individual considered an MA recipient?

QUESTION #5

Would we deem the MAWD recipient's income to other household members per the deeming chapter? Or would the MAWD recipient be considered an MA recipient and there would be no deeming? Would it make a difference what the other household members' (spouse or children) MA category would be?

RESPONSE TO QUESTIONS #1 TO #5:

When evaluating NMP or MNO for other family members do not count the income or resources of the MAWD eligible individual.

When evaluating Healthy Beginnings for other family members, follow the Healthy Beginnings Family Members procedures in MAEH 318.2 and the Healthy Beginnings income and resource procedures in MAEH 318.

When evaluating Healthy Horizons for other family members, follow the Healthy Horizons Family Members procedures in MAEH 319.3 and the Healthy Horizons income and resource procedures in MAEH 319.

Remember: Resources are excluded for families with children under age 21 when evaluating other Medicaid benefits.

MAWD Eligibility Requirements

QUESTION #6

If a 16-year old child were financially qualified for both CHIP and MAWD, would the CHIP application be rejected on the basis that he is eligible for a Medicaid program?

RESPONSE:

Yes.

QUESTION #7

"Legally admitted alien" -- does this include temporary aliens (student visa, family of foreign officials, etc) who are normally excluded from on-going Medicaid programs?

RESPONSE:

No. MAWD uses standard Medicaid eligibility and verification requirements. Refer to MAEH 322.

QUESTION #8

If a person was receiving MAWD benefits in another state, does that make them eligible for benefits in Pennsylvania?

RESPONSE:

No, each state has different MAWD requirements, income and resource limits. The individual must meet Pennsylvania's requirements for MAWD.

QUESTION #9

Will a person qualify for PI (Worker with a Medically Improved Disability) based on the receipt of PW (Workers with a Disability) in another state from which he has moved to Pennsylvania?

RESPONSE:

No. In order to qualify for PI, a person must have received PW in Pennsylvania.

QUESTION #10

There are a number of people over age 65 who are already working and receiving Social Security benefits– any change to age limits envisioned?

RESPONSE:

This is in the Ops. Memo 02-01-01, page 1 "…at least 16 years of age but less than 65." Individuals age 65 or older are NOT eligible for MAWD.

QUESTION #11

A number of comments about amount of resources and income in the household, but no mention of the number of hours working to qualify or amount of money earned per week/month/year to qualify? No mention of self-employment and amounts/hours, etc. to qualify.

RESPONSE:

Please refer to the Ops. Memo 02-01-01, page 1. For the Workers with a Disability Group, there is no minimum number of hours of employment. For Workers with an Improved Disability, individuals must be employed at least 40 hours a month and earning at least minimum wage. For self-employed individuals, the Department will use gross monthly receipts divided by 40 hours to meet the work requirement.

QUESTION #11A

Must the self-employed client make a profit be considered "employed"?

RESPONSE:

No. To qualify for Workers with a Disability Group, the self-employed individual must provide documentation of self-employment activity, including, but not limited to tax records, self-employment records/ledgers that show information such as work activity, earned income, expenses and taxes paid. Self-employment is verified by documentation that the individual paid taxes, including FICA, state, Federal and local taxes and they have paid and filed taxes on a quarterly basis.

The intent of MAWD coverage is to help people with disabilities return to the work force without losing medical coverage, therefore, self-employment does not include receiving cash for doing occasional work efforts such as running errands, shopping, household chores or babysitting.

QUESTION #12

If the client's income/resources are low enough that they would be eligible for SSI/ SSDI, do they have to go that route? Remember in MAWD, the MRT is ignoring Step 1 of the sequential evaluation process - this is different than what the MRT does for PJ/PS.

RESPONSE:

The MAWD applicant does NOT have to apply for SSI/SSDI. However, prior to authorizing MAWD, which has a premium, evaluate Medicaid eligibility for other benefits and review with the applicant. The individual chooses which Medicaid benefit best meets his/her needs.

QUESTION #13

Is additional information on the type of self-employment needed in the case?

RESPONSE:

Yes. Please specify in CIS Case Comments the type of self-employment (small business, working as a contractor for another individual, etc), what type of work (such as bookkeeping, cleaning) as both employers and self-employed individuals are contacted to determine if other health insurance is available.

MRT Referral/Disability/DAP

QUESTION #14

PMS 8485-305 states that if average monthly earnings exceed $700 the individual is considered to be engaged in "substantial gainful activity". DAP workers have interpreted this to mean that a referral to the MRT is not appropriate as the individual would not be considered disabled.

Is this interpretation correct in light of the MAWD objective?

RESPONSE:

Not for MAWD. MRT has been advised not to take earnings into consideration when determining disability for MAWD applicants. MRT will only consider the person's medical condition. Remember, MAWD applicants and recipients are not being referred to the Social Security Administration to apply for SSDI or SSI benefits.

See Responses to Questions #17, #18 and #19, included in this section.

QUESTION #15

MAEH 319.2 contains the following as one definition of "disabled": "He had previously received Social Security or SSI disability benefits, and been found disabled by SSA or the MRT, and his disability certification is still valid. If he had been receiving SSI or disability RSDI and benefits were terminated for a reason other than disability status, the disability condition is still valid if his condition has not changed. If his condition has changed, a re-evaluation of his disability by the MRT is necessary." This language is also used in the draft Ops. Memo. The question is: If the individual lost SSI or RSDI because he was earning a monthly average of $700 or more, were benefits terminated for a reason other than disability status? Essentially, the SSA has determined the individual to be engaged in "substantially gainful activity" (SGA) and therefore has terminated benefits. However, if this individual is unable to maintain this level of earnings at anytime within 3 or 5 years of benefit termination, benefits will be reinstated without a new evaluation of his disability.

RESPONSE:

Yes. The individual's medical condition continues to meet the Social Security Administration's definition of disabled. It is the individual's medical condition that must remain unchanged for MAWD.

In the situation you presented, earnings terminated SSDI, not a change in the individual's medical condition.

QUESTION #16

If a client is not eligible for MAWD until they are certified as disabled by MRT, then who pays for the MRT review?

RESPONSE:

The Department pays for the MRT review. The CAO has no responsibility in this area.

QUESTION #17

A person applies for MAWD and meets all eligibility criteria but cannot verify that he is disabled. He is not currently receiving SSDI. He states that he is disabled and is willing to apply for SSDI. Often it takes a long time for SSA to determine disability (maybe up to a year). We cannot authorize MAWD until we verify the applicant is disabled according to SSA criteria. Should we refer this person to MRT (as well as to SSA through DAP), which makes the determination in a shorter period of time and therefore we will be able to authorize MAWD sooner?

RESPONSE:

The individual applying for MAWD must meet the SSA's definition of disabled. If the individual is not a current or past recipient of SSDI or past recipient of SSI whose condition has not changed, then he/she is referred to MRT who will make the determination of disability.

The MAWD applicant is NOT required to apply for SSDI or SSI as a condition of MAWD eligibility and for this reason should not be referred to SSA or DAP for a determination of disability. The MRT referral will be used for this purpose.

QUESTION #18

Our CAO has a concern about those individuals who would be referred to MRT for verification of disability. Cases that exceed the SGA are not to be referred to MRT. However, the SGA test does not take into account net income after allowable deductions. Our understanding is that SGA is a gross figure. Policy Clarification MA-4854-305 addressed this issue by advising that applicants with income over the SGA were to be referred to SSA for a disability determination. While the potential for these kinds of cases is low, it often occurs with an individual with a recent debilitating illness who is making a great effort to stay in the workforce, even if at a reduced capacity, hoping their health will improve over time or trying to make it to retirement age.

RESPONSE:

For MAWD, SGA is NOT considered. For MAWD, the applicant can be working and be earning well beyond the SGA amount and still be eligible. The Medical Review Team does not consider employment in these cases, they move beyond SGA and focus on the disability criteria.

See responses to Questions #14, #17 and #19, included in this section, for additional information.

QUESTION #19

If an individual loses their SSI or SSDI because of earnings from wages - SSA determines that they are engaging in Substantial Gainful Activity if their income exceeds SSA's SGA income limit. Per SSA, at that point they are considered to no longer have a disability. But what if they actually still have the physical or mental impairment? Would they be eligible for MAWD because they had previously received SSI or SSDI?

RESPONSE:

See responses to Questions #14, #17 and #18 included in this section.

QUESTION #19A

Would we have to submit an MRT referral?

RESPONSE:

This would depend upon the length of time between the SSI/SSDI termination and the application for MAWD. If termination of SSI/SSDI benefits occurred within the last 12 months, an MRT referral is NOT required. If benefits were terminated more than 12 months ago, an MRT referral is required. Anytime the disability is questionable, refer to MRT.

QUESTION #20

Our understanding is that we cannot submit for a MRT certification if the individual's income exceeds SSA's SGA income limit.

RESPONSE:

See responses to Questions #14 and #18 included in this section.

QUESTION #21

Definition of disability -- too disabled to continue present or former job? Too disabled to work anywhere? Whose definition do we use -- G.P., specialist, or one of the legion of M.D.'s who fill out our 635's and 1663's?

RESPONSE:

Refer to Ops. Memo 02-01-01 under the Disability heading. The individual must meet the SSA's definition of disability. For additional information see responses to Questions #14, 17, 18 and 19 included in this section.

Financial Eligibility (Income and Resources)

QUESTION #22

In other Medicaid eligibility evaluations, resources used to pay medical expenses are not counted. The Ops. Memo 02-01-01directs the CAO to use the "SSI-related methodology in MAEH 340 to determine countable resources." The statement regarding resources used to pay medical expenses is in Chapter 340, under the General Policy Section 340.12.

May this be applied in MAWD? 

RESPONSE:

Yes, General Resources procedures in MAEH 340.12 are applicable to MAWD. Resources used to pay medical expenses are not counted in the MAWD resource eligibility determination.

QUESTION #23

If a 16-year old child was not eligible for PS-95 due to his own income and we considered him for MAWD, would any of his parent's income/resources be considered in determining his eligible for MAWD?

RESPONSE:

No.

QUESTION #24

Are there any issues about counting child support for the disabled child who is applying for MAWD?

RESPONSE:

Child Support is countable income if it is the income of the MAWD applicant (i.e., the disabled child is the applicant).

QUESTION #25

Do we count the parent's income and resources for the disabled adult child who gets SSDI based upon his parent's earnings?

RESPONSE:

No.

QUESTION #26

Someone may be eligible for MAWD and for Healthy Horizons. In this case, is one preferable over the other? HH doesn't have a premium, but if the person becomes ineligible for SSA as "Medically improved" MAWD would allow continuing as a PI.

RESPONSE:

The applicant/recipient chooses the Medicaid benefit that best meets his/her needs.

In this situation, the choice of coverage depends on the type of HH benefits. HH (PS/90) and MAWD are eligible to receive categorically needy Medicaid benefits in HealthCare Benefits Packages #1 (under 21), #2 (age 21 up to 65 with no Medicare coverage) and #8 (age 21 up to 65 with Medicare coverage.)

HH (PL-Medicare cost sharing) does not receive categorically benefits so MAWD may be a better choice because it provides full Medicaid coverage.

This may also be the situation regarding individuals who are eligible for SLMB only.

The following factors need to be considered in this situation:

Premium Payment -- If an individual is eligible for coverage other than MAWD, it needs to be explained that Medicaid coverage exists at no cost to the applicant/recipient. Individuals need to be advised of the "no cost" coverage as most individuals will probably choose to receive coverage at "no cost".

PI eligibility -- An individual who is PW is not automatically eligible for PI. The individual must meet the employment/working criteria of at least 40 hours per month and earning at least minimum wage.

Due to the premium, the possibility that an individual may not meet all of the PI criteria, when an individual is eligible for categorically needy HH Medicaid coverage, HH may be the best choice for the individual. Keep in mind that if an individual with disabilities, who is working, becomes ineligible for HH due to income and resource requirements the individual should be reviewed for MAWD.

Always review the applicant's options for Medicaid benefits.

QUESTION #27

In cases where monthly income differs substantially, can MAWD be authorized based on financial eligibility using earnings in the 2nd or 3rd month after application? This would be pertinent especially in cases of MRT delay lasting a month or more. Or does financial eligibility for MAWD have to be established in the month of application?

RESPONSE:

No. MAWD financial eligibility is determined using income received in the month of application. If the individual's income decreases and will remain reduced for the remainder of the premium payment period, he/she can request that the premium be reduced based on the reduction in income. This should be explained to the applicant/recipient at application, reapplication and when the premium is reviewed.

Premium and Good Cause

QUESTION# 28

The Ops. Memo on page 5, under Premium Payment Method states, "The applicant/recipient is required to sign a form authorizing payroll deduction."

What form is to be signed?

RESPONSE:

The PA 4 WD, Authorization for Payroll Deduction, has been developed for this purpose. The CAO will be able to order the PA 4 WD through AIRS and should mail or give one to the MAWD eligible individual who indicated payroll deduction as his/her choice for premium payment on the application.

This form is only signed when the applicant selects payroll deduction.

QUESTION #29

Regarding the "Initial Payment Voucher", if benefits are authorized on or after the 10th of Month Two for Month One, how is the client notified of the premium due for Month Two since authorization is completed on the same day or after the voucher for Month Two is generated by Central Office?

RESPONSE:

For Central Office to generate a system premium statement, the CAO data entry deadline is the last calendar day of the month. If the CAO does not data enter the MAWD authorization by the last calendar day of the month, the CAO must include the premium amounts for both the month of application and the following month on the Initial Payment Voucher.

QUESTION #30

Can the monthly premium be paid in advance (e.g., the premium for the period 2/02 through 7/02 is $30. The client wants to pay $180 in February and avoid the monthly payments)?

RESPONSE:

No, advance payments are not permitted.

QUESTION #31

If someone applies for retroactive MAWD only and we cannot authorize until he makes the premium payment would there be a problem because the system would not show an active Medicaid case when the premium is received by Central Office and they go to post the payment and issue the alert?

RESPONSE:

When the IMCW provides the client with the Initial Payment Voucher that contains the premiums for each retroactive month, the IMCW MUST include the individual's social security number on the voucher. This allows Central Office to send the CAO an alert (Alert #182).

QUESTION #32

Where can we find the form that the client signs to authorize payroll deduction?

RESPONSE:

See response to Question #28 included in this section.

QUESTION #33

Must the reason for loss of employment or the medical condition be verified to establish Good Cause?

RESPONSE:

Yes.

QUESTION #34

What documentation/verification, if any, is needed to establish that the individual is seeking new employment? How long can this be used as meeting the Good Cause criterion?

RESPONSE:

Documentation/verification that the individual is seeking new employment includes, but is not limited to, a statement from a community agency with whom the individual is working to locate employment or a statement from the MAWD recipient as to his/her efforts to secure employment.

Good Cause is limited to a maximum of two (2) months in any six-month premium payment period. The two months need not be consecutive.

QUESTION #35

MAWD client has job terminated through no fault of his own in March. He does not make the March premium payment due March 31. IMCW gets an alert on April 20. Good Cause is granted for April and May with a review of the situation set for the end of May. ISSUE: Client still owes the premium for March. What is the time frame for him to make this payment? Do we close the case if he doesn't pay it within a certain time?

RESPONSE:

The client has until the end of the Good Cause period (in your example 5/31) to pay the MAWD premium for March. On the 11th day of the next month (in your example 6/11), check the WEB site to verify if the March premium payment has been received. If it has not been received, send a PA 162-A to close MAWD the last day of June. Always check the WEB site prior to closure.

QUESTION #36

If an individual did not pay the premium for January and requested Good Cause in February for two months, is the individual still responsible for the premium payment for January? After the two month Good Cause period, how long can the case remain in open status if the January premium is not paid?

RESPONSE:

See response to Question #35 included in this section.

QUESTION #37

If individual does not pay January premium, requests Good Cause in February and is granted Good Cause for February and March, what is the process for follow-up for January premium? Is a PA 162A sent at the close of the Good Cause period to close benefits? (Send PA 162A in beginning of April for closure at end of April.)? Allow a one-month grace period and if payment not received in April begin closing process in May?

RESPONSE:

See response to Question #35 included in this section.

QUESTION #38

Regarding an instance in which someone lost his job and Good Cause is established, at what point do we close the case because he does not meet the "Employment" requirement for the MAWD benefit? It looks like we must discuss the eligibility factor of employment at the 12-month reapplication. Prior to that, as long as he is trying to get a job we could keep the case active and reduce his premium. If this is the case, and the premium is based on his unearned income only, there would be no reason to grant Good Cause.

RESPONSE:

Good Cause is limited to a maximum of two (2) months in any six-month premium payment period. The two months need not be consecutive. By the 15th day of the month following the end of the Good Cause period, the individual must meet the "Employment" requirement. If the individual is not meeting the "Employment" requirement by the 15th, send a PA 162-A to close MAWD on the last day of the month citing that he/she is not meeting the "Employment" criteria to receive MAWD.

QUESTION #39

Clarify Good Cause. How many Good Cause periods are allowed? If an individual receives Good Cause due to loss of employment, can Good Cause be extended for 2 more months, indefinitely? (The individual is not meeting the work requirement.)

RESPONSE:

Good Cause is limited to a maximum of two (2) months in any six-month premium payment period. The two months need not be consecutive. Good Cause CANNOT be extended indefinitely.

QUESTION #40

Is it the IMCW's responsibility to find out if the employer participates in payroll deduction?

RESPONSE:

No.

QUESTION #41

May an individual make a partial payment of their premium? Will a partial payment (if allowed) be treated the same as a full payment? (Meaning compliance)

RESPONSE:

Individuals are required to pay the premium in full each month.

QUESTION #42

Is there a phone number on the voucher for clients to call to report problems, questioning payment amounts, etc.?

RESPONSE:

No, there is no phone number on the voucher for the client to call and report problems. The individual should contact their IMCW. The IMCW should try to resolve the issue using the WEB site. If the IMCW cannot resolve the issue, refer the situation to the CAO liaison who will contact Central Office to resolve issues on premium payments.

QUESTION #43

Suggest a form be developed for six-month review. Suggested wording: Your monthly premium amount needs to be reviewed. Please send income verification for the month of MM/YYYY by MM/DD/YYYY. Income includes but is not limited to: Earned: Unearned: . This income will be used to calculate your premium for the following six- month period. If you have any questions, please contact……

RESPONSE:

This suggestion is under consideration. Thank you.

QUESTION #44

The premium payment may be suspended for a period up to two months if the CAO grants Good Cause for the loss of employment beyond the individual's control. If in the third month the MAWD recipient has not regained employment is the CAO to close with proper notice?

RESPONSE:

See responses to Questions #35, #38 and #39 included in this section.

QUESTION #45

Payment Methods: Twice a month? Ok with payroll deduction, but what happens with babysitting jobs or similar? Would the payment from a payroll deduction come from the individual's first pay of the month?

RESPONSE:

If the MAWD recipient is paying the premium directly, he/she is to mail in one check for the full amount of the monthly premium.

Central Office makes arrangements with the employer when payroll deduction is the selected premium payment method.

QUESTION #45A

For retroactive coverage, would all months requested for coverage have to be paid at once or can an individual pay for the months as they can afford them?

RESPONSE:

Retroactive MAWD premiums must be paid in full at one time.

Retroactive Coverage

QUESTION #46

The Ops. Memo 02-01-01 on page 8, under Retroactive Medicaid Coverage states, " The application will be held for 30 days, or until payment is received for the premiums for the retroactive period."

Does "held for 30 days or until payment is received" mean the earlier of these two possibilities? Retroactive Coverage (Cont'd.)

RESPONSE:

Yes, the earlier of the two possibilities. The MAWD application for retroactive coverage is held for a maximum period of 30 days if the premium is not received earlier. If the CAO is notified via an alert that payment is made within the 30-day period, authorize retroactive MAWD coverage immediately. If the payment is NOT received by the end of the 30-day period, reject retroactive coverage under MAWD using the PA 162 RM, citing non-payment of the premium as the reason.

QUESTION #46A

When does this 30-day count begin? The date of application or the date the decision on retroactive eligibility is made? Because the CAO has 30 days in which to make the eligibility decision, the period could expire before the client is notified of the premium payment amount if the count begins with the date of application.

RESPONSE:

The 30-day count begins the date the decision on retroactive eligibility is made.

QUESTION #47

Can someone apply for retroactive MAWD only (and not for ongoing)? If so, is there a special way to complete data entry?

RESPONSE:

Yes, an individual may apply for retroactive MAWD only. The CIS Daily Status on MAWD, D1143, gives instructions for data entry of retroactive coverage under MAWD. Please refer to the Daily Status.

QUESTION #48

If someone applies for retroactive MAWD only and we cannot authorize until he makes the premium payment would there be a problem because the system would not show an active Medicaid case when the premium is received by Central Office and they go to post the payment and issue the alert?

RESPONSE:

When the IMCW provides the client with the Initial Payment Voucher that contains the premiums for each retroactive month, the IMCW MUST include the individual's social security number on the voucher. This allows Central Office to send the CAO an alert (Alert #182). 

QUESTION #49

In determining retroactive eligibility we use the actual (not weekly x 4) income received during the retro-month. Correct?

RESPONSE:

Yes, you are correct. Use the actual income received in each month of requested retroactive coverage.

QUESTION #50

An individual requests 3 months of retroactive coverage only. They worked during the first and third month but did not work the middle month because of illness and a hospital stay. Can they be authorized this month?

RESPONSE:

No. The individual must meet all the MAWD requirements in each of the retroactive months.

Eligibility for retroactive coverage under other Medicaid benefits should be explored.

QUESTION #51

Retroactive coverage may be authorized if the applicant has allowable medical expenses. Does "allowable" mean NMP covered?

RESPONSE:

"Allowable" means unpaid, categorically needy (NMP) covered medical services.

QUESTION #52

Retroactive coverage may be authorized if the applicant has allowable medical expenses, is eligible and pays the premium for the retroactive months. Retro MA is not authorized until the premium(s) is paid. Information at MAWD training states that the application will be held for 30 days, or until payment is received for premiums for the retroactive period. This wording is confusing. Is the application held indefinitely waiting for the retroactive premium payment?

RESPONSE:

See responses to Questions #46 and #46A, included in this section. 

QUESTION #52A

When is ongoing eligibility authorized in this case?

RESPONSE:

On page 7 of Ops. Memo 02-01-01 under Retroactive Medicaid Coverage, the NOTE states: " If an applicant applies for both retroactive and on-going benefits, do not hold authorization of on-going benefits. Authorize on-going benefits prior to receipt of the premium for retroactive periods (provided that all proper verification is received).

Application

QUESTION #53

Can we use other application forms or only the PA 600 WD as the application form for MAWD?

RESPONSE:

As indicated on page 2 of the Ops. Memo, "When an applicant has already completed a PA 600, but is only eligible for MAWD, the PA 600 application can be used to determine eligibility for MAWD. The IMCW must then obtain the additional necessary documentation for MAWD from the client before authorizing MAWD benefits."

QUESTION #54

PA 600 WD lists auto -- but no question regarding auto insurance company or a block for this information. TPL is required for Medicaid. Will a block be added to the application for this information? Also for other health insurance it asks for the insurance company address…the required information for TPL is the claims address. Will this be corrected to add a block for this entry?

RESPONSE:

Auto insurance must be data entered on TPL for MAWD as it is for other Medicaid benefits. For future printings the necessary corrections will be made to PA 600 WD.

QUESTION #55

Are separate applications required for SLMB/QMB/MAWD?

RESPONSE:

No, one application is sufficient.

QUESTION #56

If all family members are listed on the MAWD application and wish to apply for other benefits, will the PA 600 WD suffice as an application?

RESPONSE:

Yes, the PA 600 WD will suffice. However, the IMCW must secure the required information and verifications necessary to establish Medicaid eligibility for other benefits. Be sure to document in the case narrative.

QUESTION #57

Is a face-to-face interview required for a MAWD application?

RESPONSE:

No.

Time Frames (Applications/Reapplications)

QUESTION #58

Applicant applies for MAWD on 2/26. He meets all eligibility requirements. His income for the month of application (Feb) is used to compute eligibility. He has indicated that he wants MAWD to begin on 3/1. The six-month period would run from 3/1 through 8/31. In August a review of income would occur and the premium would be computed for the next six-months, 09/1 through 2/28. In February a complete R/I would be completed. Is the determination of the six-month period correct? Are we correct with the timing of the 6-month review and the complete redetermination?

RESPONSE:

You are correct in your determination of the initial six-month premium period, 3/1 through 8/31. You are also correct with the timing of the six-month review, 9/1 through 2/28. Since your effective date is 3/1, your redetermination due date will be 3/1 of the next year.

QUESTION #59

For MAWD, on the client's choice to begin coverage in the 2nd month, do we need a new application after authorization for a change back to the 1st month of application? Is it considered a retroactive authorization if Medicaid has been authorized (ex. For 4 months) and the recipient requests coverage for the month of application? Does this require verification of a premium payment prior to authorization?

RESPONSE:

No, a new application is NOT required. This does not meet the definition of a retroactive month, but it does require verification of a premium payment. If this does occur, please call the CIS Hotline for data entry instructions.

QUESTION #60

MAWD states eligibility period for MRT referral is the 1st day of the calendar month in which MRT decision is received or the month of application. Does an applicant certified by the MRT have the option of choosing a date in between the application date and the MRT receipt as the begin date for their MAWD coverage? (Ex. Application completed in February, MRT received in April, applicant requests eligibility begin in March.)

RESPONSE:

As indicated on the PA 600 WD, the applicant's choice is either the 1st day of the month of application or the 1st day of the calendar month that the MRT decision is received. The client has NO other choices.

QUESTION #61

The Ops. Memo 02-01-01 states that MAWD cannot be denied if the individual is cooperating with the verification process. Suppose a MAWD applicant is cooperating to secure verification of his income, but at the end of 30 days, he still has not been able to secure verification of income. What does the CAO do?

RESPONSE:

At the end of the 30-day period, the CAO will authorize MAWD without verification if the individual is cooperating in the verification process. Be sure to document his cooperation in the verification process in the case narrative.

QUESTION #62

Why are the only months allowed for the benefit period to begin either the application month or the MRT month? Example: Individual applies in January and is MRT certified in March. Does not want MA for January but wants Medicaid to begin in February. Can Medicaid be authorized in February?

RESPONSE:

MRT has advised the Department that the disability certification should not take longer than one month for MAWD applicants. CAOs should work with MRT to process as quickly as possible.

QUESTION #63

Can redetermination be extended to three years?

RESPONSE:

No. Redeterminations will be required annually.

CIS Data Entry/IEVS

QUESTION #64

Are the CAOs permitted to request IRS information through IEVS on the non-applicant spouse of the MAWD applicant/recipient?

RESPONSE:

Follow current IEVS procedures concerning non-applicant legally responsible relatives.

QUESTION #64A

Can the CAO put the non-applicant spouse in CIS as an NL so that IEVS requests will be done automatically?

RESPONSE:

Follow current IEVS procedures concerning non-applicant legally responsible relatives.

QUESTION #65

Must the top part of the CADISB screen be filled out? (i.e., disability description, c/m code, begin date, etc)? Maybe for MAWD the only fields that must be filled out are Disab/Incap Code and the fields at the bottom of the screen.

RESPONSE:

The top part of the CADISB screen is to be completed for MAWD as well as the Disab/Incap Code and the fields at the bottom of the screen. Refer to the CIS Daily Status on MAWD, D1143, for comprehensive instructions.

QUESTION #66

How specific must one be about listing the employer's address on CAEMPL screen since this is the screen that Central Office uses to get the employer's address for payroll deduction information? E.g., sometimes "payroll office" does not use the same address as the client's worksite (McDonald's K-Mart, etc.).

RESPONSE:

On CAEMPL, data enter the name and complete address of the individual's worksite location. The telephone number of the local worksite is also needed.

QUESTION #67

Should applications remain in AP when waiting for an MRT certification?

RESPONSE:

Applications should remain in AP until disposition (authorization or rejection).

QUESTION #68

The CAEMPL screen must have a complete address so that Central Office can establish payroll deduction if this is the method chosen. Do we enter the local employer address? Or must we enter the address of the payroll company?

RESPONSE:

See response to Question #66.

QUESTION #69

Are TPL entries to be made for premium payment amounts?

RESPONSE:

No.

Healthcare Benefits & Medicaid Coverage

QUESTION #70

Under medical benefits for those over 21, the Ops. Memo 02-01-01 lists Benefit Packages 2 and 8. Both these have an asterisk under prescription benefits, indicating that there would be limitations. Could someone give us some guidance on this? A big concern for potential applicants in this program will be "Can I get my blood pressure, or heart medicine through this program." What's the answer? How limited are the prescription benefits?

RESPONSE:

CAOs can order Health Care Benefits Packages MA 447 through AIRS, which has more information than the MAEH. The limit on prescriptions in Benefit Packages 2 and 8 is "Excluded medications for symptomatic relief of cough and cold." For specific medical services, the individual must check with their provider. Validation of covered services is via the EVS system. Because of Managed Care coverage and different Healthcare Benefits Packages, an IMCW cannot answer specific questions.

QUESTION #71

If the client is already working and has coverage through his employer, which coverage will be primary and which one will be secondary? Will HIPP buy the coverage through their normal process?

RESPONSE:

Medicaid is always the payer of last resort. Yes, HIPP will do an evaluation to determine whether or not it is cost effective to pay for this insurance coverage.

QUESTION #72

Will the client only be purchasing ACCESS coverage or can they have an HMO?

RESPONSE:

Refer to the Ops. Memo 02-01-01, in the "Medicaid Benefits" section. It states "Individuals residing in HealthChoices counties will be enrolled in HealthChoices." Also clients in a county with voluntary HMO options may be enrolled in an HMO.

Miscellaneous

QUESTION #73

Can the Healthy Horizons income calculation be changed to match Healthy Beginnings and MAWD, namely weekly times 4 to determine gross monthly income?

RESPONSE:

This suggestion will be taken under consideration. Thank you.

QUESTION #74

Are MAWD clients categorically eligible for Food Stamps?

RESPONSE:

No, MAWD clients would have to meet Food Stamp requirements.

QUESTION #75

Are MAWD clients entitled to SPALS under appropriate RESET Programs?

RESPONSE:

Yes, if eligible for and receiving Food Stamps. If a MAWD client also meets Food Stamp eligibility requirements and is enrolled in the FS/RESET Program, then a MAWD client would be eligible to receive appropriate special allowances. Receiving MAWD does not qualify a recipient to receive any RESET SPALS. MAWD is a Medical Program -- eligible persons may receive appropriate special allowances for Medicaid recipients.

QUESTION #76

Every Supervisor in our CAO thinks that 3000 clients is probably a gross understatement of the number of potential clients.

RESPONSE:

Estimates are based upon population and experience that other states have had with this program.

QUESTION #77

There is an inconsistency between the MAWD brochure (Pub. 476) and the MAWD policy regarding non-resident property. The MAWD brochure (Pub. 476) seems to contradict MAEH Chapter 340 for resource methodology by stating "countable assets do not include homes or automobiles". CAO staff is following MAEH 340 to determine eligibility, but would like clarification on this issue.

RESPONSE:

Continue to determine eligibility using MAEH 340. The MAWD brochure (Pub. 476) will be corrected in future printings.