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Effective: December 1, 2006 |
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03.10.05ar1 - Multiple Bases of Eligibility (Archive) |
Archived: June 1, 2008 |
Some people meet the criteria for more than one basis of eligibility for Medical Assistance (MA). The choice of basis will determine whether the person’s eligibility is determined under Method A or Method B. Countable income and assets may be different depending on the eligibility method.
Many of these applicants and enrollees have the right to choose their basis of eligibility. Assist clients in making an informed choice. However:
l People must use a Method B basis of eligibility for the Medicare Savings Programs, regardless of which method they choose for MA.
l People must also use a Method B basis of eligibility for the waiver programs.
The choice of basis may determine the delivery system through which an enrollee receives health care services. In managed care counties, many clients must receive services through managed care organizations.
Note: Do not change an enrollee’s basis of eligibility based on a request from a managed care organization (MCO) (or other third party) unless that person is the enrollee’s authorized representative.
Some of the situations in which an applicant or enrollee meets the criteria for more than one basis of eligibility include:
l A disabled adult with dependent children who is eligible for MA as a parent/caretaker may also meet the criteria for a disabled basis of eligibility.
Example:
Flora is disabled and eligible for Medicare, and lives with her five-year-old son, Tito. She chooses a parent/caretaker basis of eligibility for MA because she has certain assets that may be excluded under Method A only.
Action:
Determine Flora’s MA eligibility using Method A (parent/caretaker), but her eligibility for the Medicare Savings Programs must be determined using Method B (disabled).
l A disabled child who is eligible for MA as an auto newborn or as a child under 21 may also meet the criteria for a disabled basis of eligibility.
l A person age 65 or older who is the caretaker of a dependent child meets the criteria for a parent/caretaker basis as well as an age 65 or older basis.
Example:
Gerald, age 66, is the caretaker for his 10-year-old grandson. He has a parent/caretaker basis as the relative caretaker of a dependent child. He also has an MA basis as a person age 65 or older. Gerald is employed.
Action:
If Gerald chooses the parent/caretaker basis, determine his countable income using Method A disregards and deductions. If he chooses the age 65 or older basis, use Method B disregards and deductions.
Note: If Gerald applies for the elderly waiver (EW), he must use his Method B basis of eligibility.
People under age 65 who are certified disabled are not required to enroll in managed care regardless of the basis of eligibility they choose.
l If they choose a basis other than disabled, they may enroll voluntarily.
l If they choose the disabled basis, they may not enroll.
Note: People age 65 or older who use a disabled basis must enroll in managed care unless they are excluded for another reason.
If a client under age 65 requests to be excluded from managed care due to a disability, help the client gather information for a disability determination if needed. Refer people who are undecided about their choice of service delivery to a managed care presentation or to managed care staff.
Example:
Amy receives MA as a parent/caretaker. She wants to continue receiving services through her family physician who is not a health plan provider. The State Medical Review Team (SMRT) has certified that Amy is disabled.
Action:
Inform Amy that she may choose her MA basis as either a parent/caretaker or as a disabled adult. Regardless of which basis she chooses, she may choose to be excluded from managed care enrollment. If she wants to enroll in managed care, she must use the parent/caretaker basis.
Example:
Tara is certified disabled by the Social Security Administration (SSA) . She receives MA under a disabled basis using Method B. She has a spenddown and is excluded from managed care enrollment. She calls to report that she is pregnant.
Action:
Explain the pregnant women basis of eligibility. Tara chooses this basis because she will not have a spenddown with the higher income limit for the pregnant women basis. She may remain excluded from managed care because of her disability certification.
For more information, see: