400.05.01 HEALTHIER MS WAIVER (HMW) ELIGIBILITY CRITERIA (COE-045)

The HMW is an 1115 waiver designed to cover individuals, specifically aged and disabled individuals without Medicare, who are not otherwise eligible for Medicaid. The HMW was implemented following the discontinuation of the optional State Plan covered Poverty Level Aged and Disabled (PLAD) category that had previously covered aged and disabled individuals in MS (with or without Medicare) whose income did not exceed 135% FPL. PLAD coverage existed from July 1, 1989, until December 31, 2005, at which time the PLAD group was terminated by legislative mandate. Since there was a need to cover aged and disabled individuals who did not have Medicare (due to the 24-month waiting period required under Medicare rules for a disabled individual), MS requested and was approved by the Centers for Medicare and Medicaid Services (CMS) to cover this population under an 1115 waiver effective January 1, 2006. Eligibility requirements under the waiver include the following provisions: • The individual must be age 65 or over or, if under age 65, must be disabled using the same disability rules as the Supplemental Security Income (SSI) program, • The individual cannot be covered by Medicare. • Income cannot exceed 135% of the FPL for an individual or couple. • Countable resources cannot exceed $4,000 for an individual and $6,000 for a couple. • All non-financial requirements for ABD Medicaid must also be met. Aged and disabled individuals eligible in the HMW can be determined eligible for the waiver in the retroactive period (up to 3 months prior to the month of application) and children under age 19 approved for coverage in the HMW are entitled to 12-months continuous Medicaid. HMW Excluded Services Excluded services under the HMW include the following: • Long term care services which include services in a nursing facility or ICF/IID, swing-bed services in a skilled nursing facility and HCBS waiver services. If a HMW applicant or recipient is in need of institutional care, determine eligibility using institutional rules for placement in the appropriate COE. • Maternity and newborn care. If a HMW applicant or recipient is pregnant, she must be evaluated for MAGI-related pregnancy coverage for the duration of her pregnancy and post-partum period, at which time HMW eligibility is re-evaluated as per Section 101.19.03 in Chapter 101. HMW Applicant/Recipient Has Previously Applied for Medicare If an applicant/recipient has previously applied for Medicare (A and/or B) and coverage was: • Refused (R), • Withdrawn (W) or • Terminated due to non-payment of premiums (T), Do not refer the individual to re-apply. A SVES or BENDEX query will display an R, W or T next to the HI (Hospital Insurance) Option Code or the SMI (Supplemental Medical Insurance) Option Code. The action to take is as follows: • If countable income is above 100% FPL – acceptance of Medicare Parts A/B for an applicant or recipient in the HMW is not required. • If countable income is at/below 100% FPL – transfer the individual to the QMB coverage group (or an alternate full-service coverage group) and notify the TPL Director of the Buy-In Program that the individual’s Medicare Part A and/or Part B must be opened or reopened. Include in the notification email the individual’s name, Medicaid ID, SSN and the effective date of QMB coverage, which can be no earlier than the QMB effective date of eligibility or the effective month of the transition from HMW to QMB (after allowing for adverse action). • If the HMW applicant or recipient has previously applied for Medicare and was denied Medicare, verify the reason for the denial to ensure the denial does not impact Medicaid eligibility, such as an unsatisfactory immigration status. Document the case record with the denial reason and the resulting impact on the case.