SECTION 7 QUALIFYING UNDER SPECIAL CIRCUMSTANCES
03.01.600. INDIVIDUALS WHO MAY QUALIFY FOR HEALTH CARE ASSISTANCE THROUGH SPECIAL CIRCUMSTANCES
03.01.602. EMERGENCY MEDICAL CONDITION
03.01.603. MINOR PARENT (MP) LIVING WITH PARENTS
03.01.604. RESIDENT OF ELIGIBLE INSTITUTION
03.01.605. – 03.01.699. (RESERVED)
03.01.600. INDIVIDUALS WHO MAY QUALIFY FOR HEALTH CARE ASSISTANCE THROUGH SPECIAL CIRCUMSTANCES.
The individuals listed in Subsections 601 through 603 of these rules may gain eligibility in any Title XIX Medicaid or CHIP A coverage group. Individuals described in section 604 of these rules may gain eligibility in any Title XIX or CHIP A or CHIP B coverage group. (7-1-04)T
A newborn child whose mother is receiving Title XIX Medicaid or CHIP A at the time of the child's birth is eligible for Title XIX Medicaid for one (1) year. Other nonfinancial criteria are not applied until a renewal is made. (7-1-04)T
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NEWBORN CHILD OF A MEDICAID ELIGIBLE MOTHER |
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Resides with Medicaid Eligible Mother |
The newborn child remains eligible for up to one (1) year from birth as long as he resides with his mother. His mother must remain eligible for Title XIX Medicaid or CHIP A or would be Medicaid eligible if still pregnant. A woman is considered receiving Title XIX Medicaid or CHIP A at the time of the child's birth if her Medicaid application date is before the birth of the child. |
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Idaho Residents |
The newborn and his mother must be residents of Idaho. If residence is lost and the child returns to Idaho and reapplies for Medicaid before his first birthday, he does not regain his status as a newborn of a Medicaid eligible mother. |
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Newborn Waived Criteria |
A newborn child of a Title XIX Medicaid or CHIP A eligible mother is not required to provide an SSN or application for an SSN. The newborn is not required to provide a declaration of citizenship. |
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Newborn's Continued Eligibility |
If a child gets Medicaid as a Newborn Child of a Title XIX Medicaid or CHIP A Eligible Mother, and there are no other eligible participants on the case, an application for the child must be filed no later than her first (1st) birthday. If other members of the family receive Medicaid on the same case, there is no need to file a new application to continue Medicaid coverage for a newborn after the first birthday. The child's eligibility should be redetermined at the end of the family's annual eligibility period. If the certification period ends before the newborn's first birthday, the child remains eligible through the month of her first birthday, as long as she meets the requirements outlined in 03.01.601. |
Handbook Table Newborn Child of a Medicaid Eligible Mother (7-1-04)
03.01.602. EMERGENCY MEDICAL CONDITION.
Individuals who do not meet citizenship requirements may receive medical assistance under any Title XIX coverage group or the CHIP A coverage group for medical services necessary to treat an emergency medical condition, including labor and delivery. Emergency medical conditions have acute symptoms of severity, including severe pain. The Bureau of Medicaid Policy and Reimbursement determines if a condition meets criteria of an emergency condition. Medical assistance is limited to the period of time established for the emergency condition. For undocumented individuals with emergency conditions, the SSN requirement is waived because an SSN cannot be issued. Individuals must be otherwise eligible for medical assistance. (7-1-04)T
Non-Citizen Emergency Medicaid
Participants in CHIP B and the Access Card programs are not eligible for
Emergency Medicaid.
A non-citizen requesting coverage for labor and delivery does not qualify for:
-Prenatal care
-The 60-day postpartum coverage
A child requesting coverage of a medical emergency does not qualify for
12-month continuous eligibility. A child does not have to meet the disability
criteria to receive assistance for an emergency medical need.
Processing Emergency Medicaid Applications
Step 1: Register the application for the coverage
group the non-citizen would be eligible for if they met the citizenship
criteria.
Step 2: Complete the eligibility determination.
Step 3: At CLPA; code the non-citizen with an IA
participation code.
Step 4: Enter the appropriate non-citizen entry data
on CLPI for the non-citizen.
Step 5: Enter rejection code R03 on CLPA for the
individual or on AFPI for the entire family. Notice X203 or X222 will be
generated automatically.
Step 6: If the applicant meets all eligibility
criteria except citizenship continue. If the applicant fails to meet all
eligibility criteria except citizenship mail the X203 or X222, the application
action is complete.
Step 7: Submit a completed Non-Citizen E-Med & AIM
Eligibility form (Attachment A) to the Medicaid Care Manager (CM) identifying an
application for emergency medical assistance with the participants’ medical
records including:
-Admission record with admission date and time
-Physician delivery notes
-Discharge summary with discharge date and time
Step 8: CM makes emergency medical determination. If
approved, CM builds AIM eligibility segment.
Step 9: CM mails or faxes a copy of the Non-Citizen
E-Med & AIM Eligibility form with the emergency determination information to the
SRS.
Step 10: Approvals - SRS orders, enters the
approved dates of service and mails the X131 to the applicant. Denials -
SRS orders and mails the X231 to the applicant.
Step 11: SRS notifies the hospital of the action if
the hospital initiated the application.
Process to Obtain Approval of Labor and Delivery E-Med coverage:
Step 1: SRS determines non-citizen eligible for
Medicaid except for citizenship criteria.
Step 2: SRS submits a completed Non-Citizen E-Med &
AIM Eligibility form HW0913 to the Medicaid Care Manager (CM) identifying an
application for emergency medical assistance with the participants’ medical
records including:
-Admission record including admission date and time
-Physician delivery notes
-Discharge summary including discharge date and time
Step 3: CM makes emergency medical determination. If
approved, CM builds AIM eligibility segment.
Step 4: CM will mail or fax a copy of the Non-Citizen
E-Med & AIM Eligibility
form HW0913 with emergency determination information to the SRS.
Step 5: Approvals - SRS orders, enters the
approved dates of service and mails the X131 to the applicant. Denials -
SRS orders and mails the X231 to the applicant.
Step 6: SRS will notify the hospital of the action if
the hospital initiated the application.
NOTE: Form HW0600 is no longer in use. Please destroy
any copies you may have. Form HW0914 is no longer used for non-citizen Emergency
Medicaid.
Submit the HW0913 with the documentation to:
Division of Medicaid
3232 Elder
Boise ID 83705
(7-1-04)
When do I complete a HW 0914
request?
A HW 0914 should be submitted if a participant’s eligibility segment can not be
passed electronically. A HW 0914, approved by your Supervisor
must
be submitted to the EPICS Helpdesk for the following
situations.
-Participant applies and is added to an ongoing case for the wrong
month. Example: Participant was added to a case for 12/03, they should have
been added as of 11/03. Eligibility has been processed for the participant.
EPICS will not send an electronic update to cover the participant for a month
prior to their application. Submit a HW 0914.
-Retro medical for a PW pregnant woman does not pass the correct Medicaid code
to AIM. Submit a HW 0914.
-Immediate medical attention or medication is needed by the participant.
Example: There is a problem with the EPICS/AIM interface.
Things to check before
submitting a HW 0914 Request:
-Check and make sure that the Medicaid benefit is not on HOLD at ISHI.
-Cycles are scheduled for specific days during the month. EPICS cycles are
posted in the EPICS calendar on the Self Reliance Home Page.
EPICS Calendar
-Review the case record for keying accuracy. Review the Budget Spill Inquiry
Screen to determine if a participant’s eligibility processed correctly. Medicaid
Budget Spill Instructions
HW0914 Processing:
-All HW 0914 requests must be reviewed by the SRS/supervisor to determine if
keying is an issue.
-A HW 0914 must not be used to back date closures. If a
participant is not eligible for a month where eligibility was granted then the
SRS must write up an overpayment.
-Submit the HW 0914 as an attachment to the Email request. Include the
participants name in the subject line of the email. (HW0914 will not be
accepted by fax or by mail.)
-On the HW 0914 form include a brief description of the reason why you are
submitting the request. Example: Retro medical request for a pregnant woman,
wrong program code interfaced.
(7-1-04)
03.01.603. MINOR PARENT (MP) LIVING WITH PARENTS.
A minor parent (MP) who lives with her parents may be eligible for Medicaid for herself and her child. A MP is a child under the age of eighteen (18) who is pregnant or has a child. The MP's parent(s) are not required to apply. The MP's parent(s) income is deemed to the MP. The MP must meet financial and non-financial criteria. The MP's parental income is deemed as shown in Subsections 603.01. through 603.04. (7-1-97)
01. Standard Disregard. From earned income, subtract the standard work disregard of ninety dollars ($90). (7-1-97)
02. Child Care Costs. From earned income, subtract child care costs up to the maximums in Section 362. (4-11-06)
03. Unearned Income. To earned income, add the amount of unearned income. (7-1-97)
04. Parental Family Deduction. From the total income, subtract an amount equal to the AFDC Need Standard or the FPG for the MP's parent's family size. This deduction is determined by the MP's coverage group. In calculating the family size, exclude the MP and her children. (7-1-97)
MINOR PARENT DEEMING
Minor parent deeming applies to AF-related programs and FPG programs. The minor
parent may apply for Medicaid for herself and her child.
If the minor parent applies for AF-related Medicaid, use the AF-related need
standard for her parent's household size to determine deemed income budgeted
against her Medicaid eligibility.
If the minor parent is applying for FPG programs, use 100% of the FPG total
allowance for her parent's family size to determine deemed income budgeted
against her Medicaid eligibility.
If the minor parent is married, parental deeming does not apply.
(7-1-04)
When determining the parent's family size, do not count the minor
parent or her unborn child or children in the parent's family. Do not count
step-parents or unrelated persons
(7-1-04)
03.01.604. RESIDENT OF ELIGIBLE INSTITUTION.
A resident of an eligible institution can get Title XIX Medicaid, CHIP A or CHIP B. Non-financial and financial criteria must be met, and the individual must meet conditions of Title XIX Medicaid, CHIP A or CHIP B. Eligible institutions are medical institutions, intermediate care facilities, child care institutions for foster care, or publicly operated community residences serving no more than sixteen (16) residents. (7-1-04)T
See
Appendix B for institutions and eligibility.
Medicaid for inmates who are inpatients:
http://infonetdhw/welfare/CircLetters/Letters/01_22_Inmate_Inpatient_CL.doc
(7-1-04)