Procedures

Screen for eligibility for all classes of Family Medicaid and for PeachCare for Kids®.

If the AU is ineligible for all Family Medicaid COAs and PeachCare for Kids® based on income or resources, proceed with FM-MN.

Follow the steps below to establish FM-MN eligibility:

Step 1 Accept the Medicaid application from the A/R and establish the six-month renewal period. Obtain a written statement of choice when a bill that could potentially be paid by Medicaid is used to meet SD for an ongoing month. Medically Needy Option Statement . Step 2 Determine the AU and BG. Refer to Chapter 2600, Family Medicaid Assistance Units and Budget Groups. Step 3 Establish each budget month of the renewal period. Step 4 Determine the countable resources of the BG for the budget period and compare to the FM-MN resource limit for the BG size to determine resource eligibility. Step 5 Determine if a TPL resource exists that will pay for all or any portion of the medical expenses. Step 6 Complete a FM-MN budget using the prospectively budgeted income and expenses of the BG. Refer to Section 2671 , Family Medicaid Medically Needy Budgeting. Step 7 If the net countable income of the BG exceeds the MNIL for the BG size, the amount of the excess is the SD. Explain to the applicant/member the SD process. Step 8 Determine whose expenses are allowed as deductions from the SD. Step 9 Obtain itemized copies of bills for unpaid medical expenses and those paid during the budget period for the individuals determined in Step 8. Step 10 Determine which medical bills may be applied to the SD. Step 11 If a TPL exists, determine how much the TPL has paid or will pay toward these bills and subtract the TPL payment(s) from the bill(s). Use only the remaining amount toward meeting the SD. Step 12 Sort medical bills in ascending (oldest to most recent) chronological order. Step 13 Deduct from the SD the allowable prior medical bills (bills that were incurred prior to the budget period). If the SD is met using prior medical expenses, approve FM-MN Medicaid for the AU members on the first day of the budget period. Complete the following actions: Approve FM-MN Medicaid for the AU members beginning the first day of the budget period. Notify the AU. Notification includes the BAD, the ending date of eligibility and the Medicaid numbers for each AU member. Provide to the AU a Form 962 for any/all approved months that can not be entered in the system. Fax form 962 to HP to be manually updated. If the SD is not met using prior medical expenses, proceed to Step 14. Step 14 Deduct allowable medical expenses incurred during the budget period in ascending (oldest to most recent) chronological order. Rank bills incurred the same day as follows: incurred by BG members not included in the AU; incurred by AU members but not covered by Medicaid (noncovered expenses such as over-the-counter medications or bills payable to non-Medicaid providers); incurred by AU members payable to a Medicaid provider, the lowest dollar amounts first. If the SD is met, proceed to Step 15. If the SD is not met, skip to Step 16. Step 15 If the SD is met by bills ranking order 1 or 2 (as described in Step 14), Form 400, First Day Liability is not required, as the AU has no FDL. Complete the following actions: Approve the AU members for Medicaid to begin on the day in which the bill that brought the SD to zero (the break-even bill) was incurred. Notify the AU of the BAD and the ending date of eligibility and the Medicaid numbers for each AU member. Provide to the AU a Form 962 for any/all approved months that can not be entered into the system. Fax form 962 to HP to be manually updated. If the SD is met by bills in ranking order 3 (as described in Step 12), Form 400, First Day Liability is necessary. Complete the following actions: Issue a Form 400 for the break-even bill showing the dollar amount of the FDL as the client liability Issue Form 400 with a client liability of zero for all other bills incurred on the BAD that were not used to meet the SD. Do not issue Form 400 for bills incurred on the BAD that were applied to the SD prior to the break-even bill as no portion of these bills is payable or reimbursable by DCH and are the total responsibility of the client. Report to the client and DCH the amount of the break-even bill used to meet the SD as the FDL. If a manual Form 962 is used, indicate the BAD as the “Eff Date” and the last day of the budget period as the “End Date”. Complete the “First Day Liability” field, indicate Form 400 is required (Y) and whether the breakeven bill was for a pharmacy (Y or N). For group medical practices, clinics, or other provider names that do not include the name of a specific physician or clinician who performed the medical service, include the name of the individual in addition to the group name. Notify the AU of the BAD, FDL, the ending date of eligibility and the Medicaid numbers for each AU member. Provide the AU a Form 962 for any/all approved months that cannot be entered into the system. Fax form 962 to HP to be manually updated. Step 16 If the SD is not met, place the case in suspense status until medical expenses adequate to meet the SD are incurred. Step 17 Subtract from the SD any medical expenses incurred during the budget period as they are provided by the AU, according to the date incurred. When medical expenses equal the SD for cases in suspense status, complete the following actions: Determine actual income already received during the budget period. Recalculate the SD using the actual income and any income anticipated to be received in the remainder of the budget period. Step 18 If the recalculated SD is met, approve the AU for FM-MN, completing actions outlined in Step 13. Step 19 If the recalculated SD (see Step 15) is not met, place the case in suspense status and notify the AU of the amount of the SD for each budget period month remaining in the renewal period. Step 20 Subtract from the SD any medical expenses incurred during the budget period as they are provided by the AU, according to the date incurred. If there is a question as to whether or not the medical expense can be used, mail or fax to DCH at: P.O. Box 38420 Atlanta, Georgia 30303 or Fax: 404-656-4913 If the SD is met, approve FM-MN according to procedures outlined in Step 15. Step 21 If the SD is not met during the one-month budget period, continue the case in suspense until enough bills are incurred to meet the SD in another budget period. A renewal of the case must be completed every six months for continued eligibility.

SD that remains in suspense status should be closed with the correct closure codes to refer to the Federally Facilitated Marketplace (FFM).