This manual letter lists new and revised material for the Health Care Programs Manual. Unless otherwise noted, new and revised instructions are effective October 1, 2012.
This manual letter includes revisions to the Emergency Medical Assistance (EMA) program. Manual Letter #54 also includes updates relating to Railroad Retirement Benefits, Medical Assistance (MA) for 1619(a) and 1619(b), MA eligibility for foster care children, maximum Supplemental Security Income (SSI) payout amounts, Medicare referrals, and the Medicare Buy-In.
Chapter 3 - Eligibility Groups and Bases of Eligibility
Clarifies policy relating to MA for foster care children and MA for 1619(a) and 1619(b). Revisions to this chapter also include changes to EMA.
Chapter 4 - Social Security Administration (SSA) Benefits
Updates policy related to Railroad Retirement Benefits, Medicare referrals, and the Medicare Buy-In. Also, updates maximum SSI payout information.
Chapter 6 - Client Responsibilities
Adds information about Railroad Retirement Benefits.
Chapter 12 - Certification of Disability
Adds information about Railroad Retirement Benefits.
Chapter 3 - Eligibility Groups and Bases of Eligibility
l Section 03.25.20 - Medical Assistance for Children in Foster Care.
Clarifies that automatic MA eligibility for a child in foster care should not be terminated during a temporary absence from foster care if the child continues to be IV-E eligible. A child may continue to be IV-E eligible during a temporary absence from foster care placement. MA eligibility continues for the child as long as he or she remains eligible for IV-E eligibility continues.
l Section 03.30.30 - Medical Assistance for 1619(a) and 1619(b).
Clarifies when and how to verify 1619(a) and 1619(b) status. The changes to this section also clarify that people who receive Railroad Retirement benefits and SSI can have a status of 1619(a) or 1619(b). Also, adds that 1619(a) status may still exist if a person receives SSI and has counted income above the Substantial Gainful Activity (SGA). A status 1619(b) may still exist if a person’s SSI stopped due to earned income.
l Section 03.45.05 - Emergency Medical Assistance (EMA).
Clarifies that a client may be eligible to receive coverage under EMA outside an emergency room or hospital if an authorized care plan submitted by their physician or dentist is approved by DHS. The client’s physician or dentist can submit an EMA Plan Certification Request (DHS-3462) in situations in which a client’s medical condition requires further care outside the emergency room or hospital, such as a long-term care facility or long-term care service through one of the home and community based waiver services, to prevent the client’s condition from becoming an emergency within 48 hours. The changes to this section also clarify that DHS review agents will contact the MMIS User Help Desk regarding a decision to authorize EMA coverage beyond an emergency room or hospital under an authorized care plan. The MMIS User Help Desk will then notify the client’s worker who will continue coverage for the client for the designated time frame or until the next renewal. If further services are needed, the authorized care plan will have to submitted and authorized at least annually.
Additionally, adds to the list of people eligible for EMA: people ineligible for federally funded MA due to immigration status or date of entry who meet all other MA program requirements and people receiving services from the Center for Victims of Torture who are on state-funded MA without a spenddown who have a medical emergency.
Chapter 4 - Social Security Administration (SSA) Benefits
l Section 04.05 - Railroad Retirement Benefits.
Clarifies who should be referred to apply for Railroad Retirement Benefits, including children, current and past spouses, and widows of railroad employees. Also explains that railroad retiree benefits are based on the number of years of service. The section was reorganized to prioritize the newly added information.
l Section 04.15 - Supplemental Security Income (SSI).
Removes a reference to an obsolete SSA form, SSA-1610, which was previously used to contact the SSA regarding agency inquiries. The change to this section also includes an update of the maximum SSI payout amounts effective January 2012.
l Section 04.30 - Verification of RSDI and SSI Benefits.
Removes a reference to an obsolete SSA form, SSA-1610-U2, which was previously used to contact the SSA regarding agency inquiries. Also, refers workers to Section 03.30.30 for verification of 1619(a) and 1619(b) status.
l Section 04.45.10 - Referrals to Medicare.
To help workers more easily identify who should be referred to Medicare and who should not be, the referral to Medicare subsection was separated into two separate subsections. Additionally, clarifies that people who receive railroad retirement benefits must apply for Medicare through the Railroad Retirement Board.
l Section 04.45.15 - The Buy-In.
Adds an explanation of what the Buy-In is and how it works. Clarifies qualifications for the Buy-In and worker actions needed to allow the Buy-In to work correctly. The changes to this section also include clarification of what the Buy-In pays for based on the client’s qualifications.
The changes to this section also explain that the Social Security Administration may consider a person who turns 65 on the first day of the month to be eligible for Medicare the first day of the preceding month; however, the Buy-In cannot enroll these clients until the month of their actual birthday when they can be enrolled in a Medicare Savings Program.
Chapter 6 - Client Responsibilities
l Section 06.15 - Applying for Other Benefits.
Adds a reference and link to HCPM Section 04.05 - Railroad Retirement Benefits under the Applying for Other Benefits - MA subsection.
Chapter 12 - Certification of Disability
l Section 12.10 - State Medical Review Team (SMRT) Disability Determinations.
Adds certifying disability for people applying for Railroad Retirement Board disability benefits as one of the functions of SMRT.